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HEALTH CARE FRAUD
Protecting Your Pocketbook

07/20/07

Ken Kaiser, Assistant Director of our Criminal Investigative Division, briefs reporters.
Ken Kaiser, Assistant Director of our Criminal Investigative Division, briefs reporters.

"A billion here, a billion there, and pretty soon you're talking real money," the late Senator Everett Dirksen is supposed to have said.*

And so it is today with health care fraud, a burgeoning crime plague that's adding up in a big way, big-ticket scheme after big-ticket scheme, essentially costing you money every time you walk into a hospital or doctor's office or fill a prescription, whether you know it or not. The National Health Care Anti-Fraud Association estimates that this fraud collectively costs Americans between $60 billion and $100 billion a year. Ouch.

Our role in combating the problem? We're the primary investigative agency, with jurisdiction over federal programs like Medicare and Medicaid (both big targets) and private insurance programs, all the while working hand-in-hand with plenty of public and private sector partners. Locally, our agents team up with their investigative counterparts on health care fraud working groups, task forces, and strike teams to tackle the biggest scams. Nationally, we have a Health Care Fraud unit at FBI Headquarters that helps support and coordinate field investigations and leads field-wide initiatives.

An anniversary, of sorts. It was 15 years ago, actually, that we ran our first major health care fraud investigation—"Operation Gold Pill." It involved about a thousand "professional patients" getting prescriptions for medicine they didn't need and having them filled at pharmacies that

Joe Ford, Associate Deputy Director (left), and Sal Hernandez, Deputy Assistant Director in our Criminal Investigative Division, at the briefing.
Joe Ford, Associate Deputy Director (left), and Sal Hernandez, Deputy Assistant Director in our Criminal Investigative Division, at the briefing.

billed Medicare for much more than the cost. The patients then sold the medication at a discount to dealers, who turned around and hawked it on the street or repackaged it and sold it back to the pharmacies—a full circle of crime.

Fifteen years ago this month, as the investigation came to a head, hundreds of FBI agents and other law enforcement professionals fanned out across the nation, making more than a 100 arrests and seizing more than $30 million in cash and assets. By today's standards, that's pocket change. But soon, more resources came our way, and we were in the business of busting healthcare fraud full-time.

A million ways.... Today, the schemes are more complex, more time-consuming, and more costly than ever. "There's literally millions of ways to defraud health care," our Associate Deputy Director Joseph L. Ford told reporters this week. "They come up with new ways every day." Just a very few examples of what we see:

  • Hospitals, doctors, pharmacists, and other care providers submitting fake bills for services never rendered—or overcharge;
  • Service providers charging insurance for unnecessary and costly procedures;
  • Doctors selling prescriptions to patients for cash;
  • Companies billing insurance for expensive equipment but providing poor substitutes;
  • Crooked docs enticing patients to visit their offices for "free services" or gifts, then stealing their personal information and using it to file fake claims.

Your role. As with any white-collar fraud, we depend on alert and conscientious citizens for help. We encourage you to contact us if you come across any suspected abuse—either on the job or in your own personal lives. Please do yourself a favor and keep an eye on your explanation of benefits to make sure you're not getting billed for services or items you never received. And please safeguard your insurance card—and your patient information—just like you would a credit card. It's fodder for identity thieves, as well.

For more telling details on health care fraud, see our recent Financial Crime Report. And visit our Be Crime Smart webpage to arm yourselves with more facts about the latest scams and frauds.

* - The Dirksen Congressional Center questions whether he ever said this or anything similar; see its website for details. But it's such a good quote!