DOJ, FBI Produce Record Health Care Fraud Case Load

From 1992 to 1999, federal attorneys more than quadrupled the number of convictions for criminal health care fraud, some of the most "expensive and difficult" cases to pursue, the New York Times reports. Similarly, between 1997 and 2000, the amount the government recovered from civil fraud cases grew by more than 50%. Jim Sheehan, a "leading expert in health care fraud" and chief of the civil division in the U.S. Attorney's Office of the Eastern District of Pennsylvania, said, "There is no doubt that the government has gotten more aggressive in both civil and criminal cases." Health care fraud "has become one of the most active areas in federal prosecutor's offices all over the country," the Times notes, adding that most offices have assigned a lawyer to pursue health care fraud exclusively and some have even created entire health care fraud units.

A Legacy of Clinton's Failed Reforms
One of "the few legacies of the Clinton administration's failed efforts to overhaul health care," the push to combat health care fraud came during 1993, when then-Attorney General Janet Reno told former President Clinton that "any health care reform act would need a strong fraud component." In addition, the Health Insurance Portability and Accountability Act of 1996 included a new fraud statute and money to investigate and prosecute such cases. Congress allotted the Federal Bureau of Investigation $47 million and the Department of Justice $22.4 million in 1996 solely to investigate and prosecute health care fraud, and provided additional money in 1999, 2000 and 2001. Besides funding, prosecutors have been "aided by relatively fresh cooperation ... [with] private insurance companies ... and a newly sophisticated group of whistle-blowers." With "their cash and resources," the agencies filed 506 cases in 1999, up from 83 in 1992, and obtained convictions in 263 cases, up from 59, the Times reports.

Too Heavy a Hand?
While the "strong efforts" to combat fraud have been praised, the Times reports that "some see the government's hand as too heavy and warn that well-meaning health care providers ... may be getting unfairly snagged." Keith Korenchuk, a Charlotte, N.C.-based health care lawyer, said that a "vast majority of health care centers are trying the best they can and don't understand the amazing complexity of these billing procedures. The government is creating a climate of fear in the health care industry." Various trade groups and lawyers also have begun to inquire whether the new Bush administration will continue the push against health care fraud. While such an answer is "not quite clear," Dennis Jay, executive director of the Coalition Against Insurance Fraud, said, "There are no indications that this administration is going to back off. But there is no sense that it is going to be as big a priority." However, the Times reports that most lawyers predict that "conviction rates are likely to rise further" as HIPAA is "increasingly tested" (Steinhauer, New York Times, 1/23).