Crime in Healthcare

Crime in Healthcare:

Medicaid and Medicare Fraud

Gerry Scoggin

Deborah Tillis-Kloch

18 June 2011

“In FY 2010, the Department of Justice (DOJ) opened 1,116 new criminal health care fraud

investigations involving 2,095 potential defendants. Federal prosecutors had 1,787 health care

fraud criminal investigations pending, involving 2,977 potential defendants, and filed criminal

charges in 488 cases involving 931 defendants. A total of 726 defendants were convicted for

health care fraud-related crimes during the year. Also in FY 2010, DOJ opened 942 new civil

health care fraud investigations and had 1,290 civil health care fraud matters pending at the end

of the fiscal year.”

Identifying the Problem

The preceding is a direct quote from the Department of Health and Human Services and The Department of Justice Health Care Fraud and Abuse Control Program’s annual report for fiscal year 2010 concerning its enforcement actions for that year. The results of those actions were the winning or negotiation of approximately $2.5 billion in health care fraud judgments and settlements, and the attainment of additional administrative impositions in health care fraud cases and proceedings. It is readily apparent from reports such as this that crime in healthcare, most notably in the form of fraud, is a massive and growing problem in the healthcare industry today

with an estimated annual cost in excess of $226 billion, most of which is ultimately shouldered by the American taxpayer through increased insurance costs and decreased federal benefits.

According to the Federal Bureau of Investigation (FBI), for many of its fifty-six field offices across the nation healthcare fraud is the number one white-collar crime.  During the latter part of the twentieth and into the first part of the twenty-first century the number of healthcare cases under investigation increased rapidly, with Medicare fraud being the primary healthcare fraud problem.  The chart below...