November 15, 2021
Health Care Fraud
Not a Victimless Crime
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Steve Lewis: American health care involves a lot of money.
According to the Centers for Medicare and Medicaid Services, nearly $12,000 per person was spent in 2019 on health care costs. That includes both what people paid out of pocket and what insurance companies paid.
But when you get sick and go to the doctor, you may not always be aware of how much the care you’re receiving really costs or what the billing processes look like after you leave your appointment. There’s actually a lot to it—and a lot of opportunities for dishonest people to commit fraud.
This is where the FBI comes in, because while health care fraud may seem victimless, it actually hurts everyone.
On this episode of Inside the FBI, we’ll hear from two of the FBI’s top health care fraud experts, who will define this kind of crime, break down how and why the Bureau works these cases, and explain how you can avoid becoming a victim yourself.
I’m Steve Lewis, and this is Inside the FBI.
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Monica Grover: Health care fraud isn’t the most traditionally exciting thing the FBI investigates. It’s not the stuff of gangster movies, rarely involves SWAT teams, and doesn’t usually make big headlines.
But it’s a crime that’s still shockingly common, involves a lot of money, and has a wider impact than you’d expect.
According to Greg Heeb, the FBI’s top health care fraud fighter, this kind of crime...
Gregory Heeb: ...takes on many different forms. What we typically look at in the FBI is fraud that targets both the public health insurance programs, ones that most people would commonly recognize—Medicare, Medicaid. We also look at fraud that targets private insurance plans.
Grover: So who’s committing these frauds? And what exactly are they doing?
Sometimes, it’s a medical provider billing multiple claims for one service—or billing for a service a patient never even received. In some cases, a scammer might steal your identity to use your health insurance.
During the COVID-19 pandemic, we’ve seen a number of individuals commit fraud related to PPE, testing, and vaccines—and telemedicine, also known as telehealth.
The use of telemedicine has risen during the pandemic, with many doctors taking virtual appointments for the first time. This option offers a lifeline to patients, but it also opens up more opportunities for fraudsters.
With telemedicine fraud, dishonest medical providers and companies usually conspire to order unnecessary equipment, medicine, or tests for patients.
Even though the patients might never receive the things prescribed, Medicare or private insurance companies still get big bills for them. And the doctors who sign off on these fraudulent orders typically get illegal kickbacks from the equipment or medicine companies, to boot.
Heeb: So, telemedicine doctors that were unscrupulous would make arrangements with certain laboratories, with other doctors in an exchange for signing off on prescriptions for very expensive medications or durable medical equipment or laboratory tests that required a doctor's orders.
They would sign off on these things and they would receive sometimes a kickback, which is illegal when you're talking about public programs, in exchange for signing off on things that there was no medical necessity for.
So, that's where telemedicine, as far as the FBI's concerned became an issue, is doctors that were receiving kickbacks and just working to facilitate large-scale health care fraud schemes.
Grover: So, while health care fraud didn’t start with the pandemic, the ease and speed with which doctors can prescribe prescriptions for anything, for patients anywhere, has made it a far easier kind of crime to commit.
The FBI also investigates prescription-related health care fraud, including medication abuse, prescription forgery, and drug diversion.
Drug diversion, which is the illegal use of prescription medication, is one of the most serious types of health care fraud we investigate because its real-life impacts on patients and communities make it the opposite of a victimless crime.
And a recent case that our Salt Lake City office pursued shows just how damaging drug diversion can be.
In 2014, officials in Utah discovered a group of patients infected with a rare strain of Hepatitis C. While this liver infection is caused by a virus that people typically catch by sharing needles, the patients in question had no known connection to each other. As a result, the state health department and various federal agencies set out to investigate.
They soon found a common denominator. All the patients were treated in the same emergency room in Ogden, Utah, by the same nurse: Elet Neilson.
Neilson happened to have that same strain of Hepatitis C.
According to FBI agent Todd Thompson, who worked the case:
Todd Thompson: She was diverting the patients' drugs for her own use, so when the patients would come into the emergency room suffering from pain, related to whatever injury or condition that they had, she was utilizing their pain medication, typically morphine or Dilaudid.
Grover: Thompson—who’d spent most of his career up until that point investigating health care fraud—said authorities believe the way Neilson took the stolen drugs likely led to her victims getting sick.
Thompson: What is suspected is that she would use a portion of their pain medication, injecting it into herself first, and then injecting the remainder into the patient.
Grover: The resulting blood-to-blood contact, he continued, theoretically exposed the patients to the virus that causes Hepatitis C.
The state and the hospital worked to track down every patient Neilson had come into contact with. They discovered that at least seven had contracted Hepatitis C.
While the condition is treatable, it’s also chronic. This means Neilson’s victims may have to live with their symptoms for the rest of their lives.
Thompson: Of course everybody reacted differently, but one of our patients stated that she lost hair, that it affected her mood. She had significant mood swings and went into depression and placed undue tension on her marriage relationship.
Another patient indicated that she was so depleted and lethargic because of the treatment that her business, which ironically was a drug and alcohol treatment facility that she had just opened, suffered to the point where she could no longer carry on.
Grover: Neilson pleaded guilty in September 2019 and was sentenced in January 2020 to five years in prison.
Thompson said this case, compared to other cases he’s worked, is one that's...
Thompson: ...more egregious to me in that it affected individuals on a very personal basis.
Grover: So, how does the FBI find and ferret out fraud in the massive health care industry?
Since most medical claims are paid out quickly to encourage timely care, our investigators usually use the “pay and chase” model.
Heeb: The money is usually out the door before we identify that the fraud has occurred. So, we're in a situation in law enforcement where we're basically going then to try to follow the money and identify the bad actors.
Grover: This, Heeb says, makes preventing health care fraud difficult. The good news is that we have a few crucial tools at our disposal.
One of these is data analytics, which can help us chase transactions that seem suspicious.
Another is tips from the public, partner agencies, and insurance providers, who help us know where to look.
Heeb: One of the things that we do in the FBI is focus on kind of abnormal patterns in billing. So, we would look and see, you know, is a particular doctor in a region of the country billing a particular code to receive reimbursement that is kind of outside of the norm of what's happening in every other place in the country, and trying to recognize regional differences and different, you know, health issues that may exist somewhere else. We try to take that stuff out of it, but that's really what directs us to what could potentially be health care fraud.
Grover: Once our health care fraud investigators spot a clue like that, they implement the typical suite of techniques you’d use in any case: witnesses, search warrants, and collaboration with partners like health insurance companies and other government agencies.
Heeb: So, a lot of times, an FBI special agent is teamed up with a criminal investigator from HHS-OIG—
Grover: that’s short for the U.S. Department of Health and Human Services Office of Inspector General
Heeb: —to go out and conduct the investigations, so, very, very close, very good working relationship with our partners there. That also includes in the realm of the prescription drug diversion investigations, we work very closely with the Drug Enforcement [Administration], as well, to further those cases.
On the private side of the house, we work very closely with our partners in the special investigations units, and most health care plans have a special investigations unit component, and they are really responsible for for identifying suspicious behavior, fraudulent behavior involved in their health plans, so we are in very close working partnerships with those folks.
Grover: No matter the crime, every dollar a fraudster steals is one less that’s available to pay for the care someone else needs—and the increase in costs is usually felt by the insured. That’s why it’s so important for the FBI to investigate these crimes.
Heeb: I think what everyone needs to keep in mind, it's that whether it's the private plans that we pay for or the public plans that so many Americans rely on for their health care, that if fraud continues unchecked in those areas, that at the end of the day, it's ultimately gonna cost us—as taxpayers, as employees who contribute to these plans—it's gonna cost us more.
And the costs take on many forms, as well. It could be increased contributions. I mean, many Americans struggled trying to pay their health care premiums as it is, so when those costs increase—and they often increase more than salaries increase—that American families feel the burden.
Grover: Heeb also stresses that if gone unchecked, health care fraud could have a catastrophic impact on government programs that people rely on.
Heeb: There's a possibility that when a lot of the workforce gets to the point where they retire and they're dependent on Medicare for their health coverage, it could potentially not be there if we, as the government and the FBI, don't address health care fraud.
Grover: So, now that you’re armed with information about what health care fraud is and how we tackle it, what can you do to protect yourself from this risk?
First, watch your cards—whether they’re for insurance, Medicare or Medicaid, or any other kind of medical or dental benefit. Once someone has that information, they can combine it with other data about you that’s out there and steal your identity.
Heeb: I think what a lot of people forget is, it's like a limitless credit card, specifically when you talk about a Medicare number. Once that number's in the hands of the wrong person, they can bill all kinds of things that you may never even know about.
Grover: Next, check your explanation of benefits. These are statements that your insurance company sends you in the mail or electronically that break down how much money they’ve spent on your care recently.
If you spot a charge for an appointment, procedure, or prescription you don’t recognize, that’s a red flag.
Heeb: The first call might be to the insurance company first to say, "Hey, this doesn't look right to me. Can you follow up and see whether this is accurate or not?" And they may be able to reach back out to the provider and receive clarification or even deny payment, so, it might not become an issue after that telephone call.
Grover: From there, if something is amiss, your insurance company will let us know. You can also always contact us directly with your tips at tips.fbi.gov.
Thanks for joining us as we learned about health care fraud and how you can help us prevent these crimes.
For more information, visit fbi.gov/healthcarefraud. And again, if you suspect that you might be a victim, you can report it to us online at tips.fbi.gov or contact your health insurance provider.
This has been another production of Inside the FBI. You can follow us on your favorite podcast player, including Spotify, Apple Podcasts, and Google Podcasts. You can also subscribe to email alerts about new episodes at fbi.gov/podcasts.
I’m Monica Grover from the FBI’s Office of Public Affairs. Thanks again for tuning in.
For more podcasting platforms please view our listing on transistor.fm or subscribe to episodes with email.
Health Care Fraud
Health care fraud is not a victimless crime. It affects everyone and causes tens of billions of dollars in losses each year. The FBI is the primary agency for investigating health care fraud, for both federal and private insurance programs.