Mutual Matters

Nationwide Health Care Fraud Sweep Targets Opioid Providers

Posted by Emma Cecil, JD on Jul 14, 2017 2:49:55 PM

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On July 13, the Department of Justice (“DOJ”) announced charges against 412 individuals, including 115 doctors, nurses, and other licensed medical professionals, for their alleged participation in health care fraud schemes involving approximately $1.3 billion in false billings to health care programs. Spearheaded by the Medicare Fraud Strike Force, the takedown, which spanned 41 federal districts, is the result of a coordinated enforcement effort among multiple federal and state law enforcement agencies, including 30 Medicaid Fraud Control Units.

Although the defendants announced have been charged with various health care fraud-related offenses ranging from anti-kickback statute violations to money laundering and mail and wire fraud, this year’s takedown is of particular significance due to its aggressive targeting of those who participated in schemes involving the prescribing and distributing of opioids and other dangerous narcotics, including physicians who billed Medicare and Medicaid for illegally prescribed opioids. Of the 412 individuals ensnared in the bust, nearly a third have been charged with opioid-related offenses, making this the largest opioid fraud takedown, both in terms of the number of defendants and loss amount, in history. Moreover, HHS-OIG announced that as part of the takedown it has issued exclusion notices to 295 individuals, including 57 doctors, 162 nurses, and 36 pharmacists, for conduct involving opioid diversion and abuse.

DOJ’s heightened focus on opioid-related offenses and those who seek to profit from the opioid epidemic comes as no surprise in light of a recent OIG report finding that 1 in 3 Medicare beneficiaries received a prescription opioid in 2016, with as many as 500,000 beneficiaries receiving a “high amount” of opioid narcotics. Moreover, statistics show that the number of opioid-involved deaths remain on an upward trajectory. According to CDC data, overdose deaths involving prescription opioids have quadrupled since 1999, as have sales of these prescription drugs. While opioid deaths are on the rise, overdose deaths involving prescription drugs, rather than illicit drugs like heroin, saw only a moderate increase of 4% from 2014 to 2015.

Health care providers thus play a crucial role in reducing opioid abuse and addiction. Providers must ensure that they are appropriately prescribing opioids and that they have adequate safeguards in place to detect and prevent misuse and diversion. DOJ’s takedown and related press release make clear that physicians who over-prescribe controlled substances face serious consequences. Even in cases where the government elects not to pursue criminal charges, providers may have significant civil liability under the federal False Claims Act, which prohibits the submission of claims for reimbursement for medically unnecessary services and imposes treble damages and often crippling per-claim penalties.

More broadly, however, the crackdown serves as a sharp reminder that health care fraud remains a top DOJ priority. In light of current enforcement efforts, which show no signs of easing, all health care providers, not only those who prescribe opioid narcotics, must be more vigilant than ever when it comes to ensuring compliance with state and federal health care-related laws and regulations. 

For regulatory questions please contact Emma Cecil, senior regulatory attorney, at questions@magmutual.com.

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