What will be covered. HCF Overview Trends Cases Predictions Questions

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1 Federal Bureau of Investigation Health Care Fraud Special Agent Leah C. Wynn Norfolk Division, FBI

2 What will be covered. HCF Overview Trends Cases Predictions Questions

3 WHY IS HEALTH CARE FRAUD SO IMPORTANT? 2007: $2.2 Trillion in health care spending But its not just about dollars and cents..many of the schemes put the public at risk

4 Mission of the FBI Health Care Fraud Program To identify, investigate, and assist in the prosecution of individuals and entities which: Defraud US Government Health Care Programs Defraud Private Health Care Insurers & Programs Defraud Consumers of Health Care Programs and Health Care Providers

5 Health Care Fraud Criminal Statutes 18 USC engage in a scheme or artifice to defraud a HC benefit program 18 USC false statements relating to a HC Benefit Program 18 USC theft or embezzlement in connection with a HC Benefit Program 42 USC 1320a-7b -anti-kickback act 42 USC 1320d-6 HIPAA medical privacy

6 WHERE DOES THE FBI GET INFORMATION? Complaints Witnesses Data analysis Current / former industry employees Task Forces Referrals

7 Schemes Services not rendered Services not necessary Kickbacks Upcoding Unbundling Product substitution Cost report fraud Substandard products Illegal Internet et prescription pt drug sales Prescription drug diversion Counterfeit pharmaceuticals Medical privacy

8 AMBULANCE SERVICES HOME HEALTH CARE TYPES OF CLINICS PHARMACY BILLING FRAUD FRAUD HOSPITAL LABORATORY FRAUDS DME PHYSICIANS

9 HCF TRENDS Pain Management Medical Identity Theft Staged Auto Accidents HIPAA Medical Privacy

10 PAIN MANAGEMENT

11 Cleveland, Ohio US v. Martinez Procedural based pain management Narcotics for injections trade Patient Deaths $59 Million billed to Medicare, Medicaid, OBWC, etc. Covert investigation First life sentence for HCF Resulting in Death (18 USC 1347)

12 SOUTHERN CALIFORNIA OUTPATIENT SURGERY CENTER FRAUD scheme involved private insurance beneficiaries receiving unnecessary surgeries patients were recruited on a national level losses to insurance industry estimated at $800 million

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14 Prescription Drugs Yesterday s drug dealers are now Committing today s health-care fraud

15 Obtaining prescriptions Illicit drugs vs. prescription drugs One ounce of marijuana costs roughly $20 but one 80 milligram pill of oxycontin is worth $80. If a script is for 30 pills, that has a street t value of $2,400!

16 INTERNET PHARMACY CASES Drug Dealing Risk to Public International

17 United States v. Bansal True joint investigation FBI, DEA, FDA, HHS, IRS, Postal, State and local Involved 20 subjects operating multiple internet pharmacy websites selling pharmaceutical drugs without a prescription Distributed schedule II, III, and IV drugs

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19 BANSAL ORGANIZATION AKHIL BANSAL BRIJ BANSAL ANDREW SHACKLETON

20 MAY 2004 It looks like they bought the legitimacy of our business, pat me on the f****** back for that one. -May 9, from Germein to Shackleton regarding an inquiry about whether the company was licensed to sell prescription drugs online.

21 April 17, 2006

22 CASE RESULTS 20 subjects indicted: distributing controlled substances without a prescription introducing misbranded drugs into interstate commerce money laundering All Subjects Convicted (except Australians not subject to extradition)

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24 The Scheme Ordered 1,000 Rx forms Used names and DEA # of 23 doctors Advertised on internet Charged consult and prescription fee 4,000 pills in 4-6 weeks 11 doc s name used 250 times

25 U.S. vs. Stowell Licensed 1970 Addiction Medicine and Psychiatry Numerous disciplinary actions Convicted by FBI in 1994 for HCF under the name of R R. Jeremy Stowell

26 The Scheme Prior criminal history, doc sneaks back into Medicaid program Writes prescriptions for known drug addicts Gives prescriptions outside of doctor/patient relationship

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35 Conclusion of Case Plea Agreement Health Care Fraud (Title 18 USC 1347) Distribution of Drugs (Title 21 USC 841) Sentenced 3.5 years and restitution

36 HIPPA

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38 Health Insurance Portability and Accountability Act of 1996 Public law Enacted August 21, 1996 The Privacy Rule addresses the use and disclosure of individuals health information

39 Health Insurance Portability and Accountability Act of 1996 Public law Enacted August 21, 1996 Appropriated $548 million to the FBI first 7 years and $114 million each year thereafter) for health care fraud enforcement

40 Health Insurance Portability and Accountability Act of 1996 Public law Enacted August 21, 1996 Creates and defines a "FEDERAL HEALTH CARE OFFENSE" applicable to both government sponsored and private health insurance programs

41 Title 18 USC 1347 Whoever knowingly and willfully executes, or attempts to execute, a scheme or artifice (1) to defraud ANY health care benefit program; or (2) to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, ANY health care benefit program

42 HIPAA Medical Privacy US v. Ramirez Clinic employee sold information of FBI Agent US v. Lewis Medical testing ti employee provided a list of law enforcement patient names to a methamphetamine dealer

43 FBI Subject caught on camera Seattle Division subject, a lab technician, was sentenced to 16 months and $9,000 restitution after being convicted of a HIPPA violation.

44 Medical Identity Theft Identities stolen by providers to meet regulatory requirements; Identities stolen by providers to submit fraudulent claims; Identities stolen by individuals to obtain treatment/prescriptions; Identities t es stolen by individuals dua to submit staged auto accident claims

45 Using Identities to Obtain Treatment By a crooked patient (Maybe the patient is uninsured) Medical ID Theft accounts for 3% of Identity Theft Crimes 2005 study by the Federal Trade Commission

46 Matthew Wiseman Beach nurse charged with stealing dead man's credit card By Aaron Applegate The Virginian-Pilot April 2, 2008 Michael Puopolo was found slumped over in his car in the parking lot of a BJ's Wholesale Club last week. He was pronounced dead at Sentara Bayside Hospital. Six hours later, a man in hospital scrubs used Puopolo's credit card at Best Buy to purchase a laptop computer, police said. On Tuesday, police arrested a Sentara Bayside nurse and charged him with the crime. Matthew J. Wiseman, 24, is facing one count of credit card theft and one count of credit card fraud, both felonies. He was working in the emergency room when Puopolo arrived, police said.

47 United States vs. Deborah Loving Company Audited Owner Created Fictitious Nurse Used information from another s application and job resume

48 Submitting Fraudulent Claims Phantom patients Provider steals an identity to submit claims without patient/client s knowledge Billing for the deceased

49 United States vs. Robert Leahey dba Xtra Care Home Assisted Living

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51 Staged Auto Accidents

52 STOLEN VIN SCHEME JASON THOMPSON AKA WALTER THOMPSON STEALS VIN 1997 BUICK LESABRE REGISTERED TO NOVA RESIDENT VICTIM to Santino Thompson BART'S CAR STORE ANDERSON INDIANA 2002 Lincoln LS claimant vehicle ALLSTATE INSURANCE POLICY PROGRESSIVE INSURANCE POLICY GEICO POLICY MICHAEL NICHOLAS Claim 12/27/2004 paid $3, MICHAEL NICHOLAS Claim 12/27/2004 paid $2, ROBERT LASKY Claim 01/03/2005 paid $3,929.41

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54 Print on paper handled by Allstate claimant, Roddale Fitzpatrick MATCHES PRINT OF MARCUS ANTHONY ROBERTSON, JR.

55 WHAT DOES THE FUTURE HOLD? More demand for data analysis More cyber issues More Medicaid investigations Organized crime International factors Medicare Part D investigations Identity / data theft

56 Report Medical Identity Theft or for the Office of Civil Rights at the Department of Health and Human Services. p g for your local FBI Field Office. (757) for the Norfolk Division. or IDTHEFT ( ) 4338) for the Federal Trade Commission.

57 Questions? Special Agent Leah C. Wynn (757)