Fraud in health care and organized crime.

James F. Dube, JD  falSe ClaimS to mediCare and mediCaid are nothing new. Billions of dollars are being lost in Medicare and Medicaid programs to waste, fraud and abuse. Fraud has been characterized by the FBI as intentional deception or misrepresentation of facts to gain an illegitimate benefit. Abuse has been defined as unnecessary costs associated with actions and services that are inconsistent with accepted practices. There are countless schemes being perpetrated that take advantage of taxpayer dollars on both the state and federal levels. The schemes move from state to state and business to business in an attempt to avoid detection. They run for a limited time, referred to as a “rip-period.” New efforts aimed at helping those in need can also open the door to those seeking ways to take advantage of the system. The Global Medicaid Waiver in Rhode Island indeed will increase home health care and assist many people in a very positive way; however, it also undoubtedly will open up opportunities for fraudulent activity in that area. This article highlights some of the fraud risks in Rhode Island, as well as the state-level protections we have implemented to prevent it. Finally, we offer some recommendations to Rhode Island health care providers on how to avoid being ensnared in the local and federal law enforcement apparatus. To compound matters, it isn’t simply just individuals seeking to take advantage of the system. New organized groups are finding that health care fraud schemes are far less dangerous and more lucrative than other more dangerous crimes such as drug trafficking and the like. Health care fraud has grown over the years. As new people turn to crime, different schemes are uncovered. The fraud across the country is found in many different areas of practice. There are cases involving doctors, dentists, chiropractors, nurses, home health care aides, personal care attendants, nursing homes, ambulance companies, etc. If someone can think of a new way to perpetrate a fraud on our system, they give it a try. If successful, they keep on billing an already burdened system during a “rip-period,” then suddenly stop and move on to another scheme at a different location. On the state side, the single-state agency through which the Medical Assistance Program is administered is the Rhode Island Department of Human Services (DHS). The Rhode Island Department of Attorney General’s Medicaid Fraud and Patient Abuse Unit (MFCU) investigates many complaints and offenses. Among those, are allegations of fraud being perpetrated upon the system by individuals, corporations or other groups. The MFCU consists of two attorneys (Unit Chief / Director and Deputy Director), a case coordinator/paralegal, one chief investigator, one nurse investigator, one auditor, and five additional investigators. The MFCU handles both civil and criminal matters in the fight against fraud and abuse. Many investigations are opened through routine investigative efforts and complaints while others are started after billing anomalies are detected through data analysis and the use of various algorithms.