[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]
ENFORCEMENT OF THE CRIMINAL LAWS AGAINST MEDICARE AND MEDICAID FRAUD
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON CRIME, TERRORISM,
AND HOMELAND SECURITY
OF THE
COMMITTEE ON THE JUDICIARY
HOUSE OF REPRESENTATIVES
ONE HUNDRED ELEVENTH CONGRESS
SECOND SESSION
__________
MARCH 4, 2010
__________
Serial No. 111-113
__________
Printed for the use of the Committee on the Judiciary
Available via the World Wide Web: http://judiciary.house.gov
U.S. GOVERNMENT PRINTING OFFICE
55-222 WASHINGTON : 2010
-----------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Printing
Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; DC
area (202) 512-1800 Fax: (202) 512-2104 Mail: Stop IDCC, Washington, DC
20402-0001
COMMITTEE ON THE JUDICIARY
JOHN CONYERS, Jr., Michigan, Chairman
HOWARD L. BERMAN, California LAMAR SMITH, Texas
RICK BOUCHER, Virginia F. JAMES SENSENBRENNER, Jr.,
JERROLD NADLER, New York Wisconsin
ROBERT C. ``BOBBY'' SCOTT, Virginia HOWARD COBLE, North Carolina
MELVIN L. WATT, North Carolina ELTON GALLEGLY, California
ZOE LOFGREN, California BOB GOODLATTE, Virginia
SHEILA JACKSON LEE, Texas DANIEL E. LUNGREN, California
MAXINE WATERS, California DARRELL E. ISSA, California
WILLIAM D. DELAHUNT, Massachusetts J. RANDY FORBES, Virginia
STEVE COHEN, Tennessee STEVE KING, Iowa
HENRY C. ``HANK'' JOHNSON, Jr., TRENT FRANKS, Arizona
Georgia LOUIE GOHMERT, Texas
PEDRO PIERLUISI, Puerto Rico JIM JORDAN, Ohio
MIKE QUIGLEY, Illinois TED POE, Texas
JUDY CHU, California JASON CHAFFETZ, Utah
LUIS V. GUTIERREZ, Illinois TOM ROONEY, Florida
TAMMY BALDWIN, Wisconsin GREGG HARPER, Mississippi
CHARLES A. GONZALEZ, Texas
ANTHONY D. WEINER, New York
ADAM B. SCHIFF, California
LINDA T. SANCHEZ, California
DEBBIE WASSERMAN SCHULTZ, Florida
DANIEL MAFFEI, New York
[Vacant]
Perry Apelbaum, Staff Director and Chief Counsel
Sean McLaughlin, Minority Chief of Staff and General Counsel
------
Subcommittee on Crime, Terrorism, and Homeland Security
ROBERT C. ``BOBBY'' SCOTT, Virginia, Chairman
PEDRO PIERLUISI, Puerto Rico LOUIE GOHMERT, Texas
JERROLD NADLER, New York TED POE, Texas
ZOE LOFGREN, California BOB GOODLATTE, Virginia
SHEILA JACKSON LEE, Texas DANIEL E. LUNGREN, California
MAXINE WATERS, California J. RANDY FORBES, Virginia
STEVE COHEN, Tennessee TOM ROONEY, Florida
ANTHONY D. WEINER, New York
DEBBIE WASSERMAN SCHULTZ, Florida
MIKE QUIGLEY, Illinois
Bobby Vassar, Chief Counsel
Caroline Lynch, Minority Counsel
C O N T E N T S
----------
MARCH 4, 2010
Page
OPENING STATEMENTS
The Honorable Robert C. ``Bobby'' Scott, a Representative in
Congress from the State of Virginia, and Chairman, Subcommittee
on Crime, Terrorism, and Homeland Security..................... 1
The Honorable Louie Gohmert, a Representative in Congress from
the State of Texas, and Ranking Member, Subcommittee on Crime,
Terrorism, and Homeland Security............................... 3
The Honorable John Conyers, Jr., a Representative in Congress
from the State of Michigan, and Chairman, Committee on the
Judiciar....................................................... 5
WITNESSES
Mr. Greg Andres, Acting Deputy Assistant Attorney General,
Criminal Division, U.S. Department of Justice, Washington, DC
Oral Testimony................................................. 7
Prepared Statement............................................. 9
Mr. Timothy J. Menke, Deputy Inspector General for
Investigations, U.S. Department of Health and Human Services,
Washington, DC
Oral Testimony................................................. 20
Prepared Statement............................................. 22
Mr. D. Mark Collins, Assistant Attorney General, Director of
Nebraska Medicaid Fraud Control Unit, President of the National
Association of Medicaid Fraud Control Units, Lincoln, NE
Oral Testimony................................................. 30
Prepared Statement............................................. 33
Mr. James Frogue, Vice President and Director of State Policy,
Center for Health Transformation, Washington, DC
Oral Testimony................................................. 50
Prepared Statement............................................. 53
APPENDIX
Material Submitted for the Hearing Record........................ 79
ENFORCEMENT OF THE CRIMINAL LAWS AGAINST MEDICARE AND MEDICAID FRAUD
----------
THURSDAY, MARCH 4, 2010
House of Representatives,
Subcommittee on Crime, Terrorism,
and Homeland Security
Committee on the Judiciary,
Washington, DC.
The Subcommittee met, pursuant to notice, at 10:05 a.m., in
room 2141, Rayburn House Office Building, the Honorable Robert
C. ``Bobby'' Scott (Chairman of the Subcommittee) presiding.
Present: Representatives Scott, Conyers, Pierluisi, Jackson
Lee, Gohmert, Poe, and Goodlatte.
Staff present: (Majority) Bobby Vassar, Subcommittee Chief
Counsel; Joe Graupensperger, Counsel; Veronica Eligan,
Professional Staff Member; (Minority) Caroline Lynch, Counsel;
Art Barker, FBI Detailee; and Kelsey Whitlock, Staff Assistant.
Mr. Scott. The Ranking Member has asked me to go on. He
will be here in just a moment.
The Subcommittee will now come to order. I am pleased to
welcome you today to the hearing before the Subcommittee on
Crime, Terrorism, and Homeland Security. Today we will discuss
enforcement strategies for fighting criminal fraud against
Medicare and Medicaid programs.
These two programs have provided immeasurable benefits to
the health of our Nation's citizens, particularly those who are
often the most in need of assistance. It is the continuing
responsibility of Congress to examine these programs to ensure
that our government is making the best possible effort to
reduce fraud, waste and abuse related to them.
Health care fraud, including fraud against Medicare and
Medicaid, is a serious problem. It has been estimated that
there is more than $60 billion of health care fraud against
public and private plans each year.
Criminals have devised a number of ways of defrauding these
programs, such as billing for services that were never rendered
either by using genuine patient information, sometimes obtained
through identity fraud, to fabricate entire claims or padding
claims with charges for procedures that did not take place;
billing for more expensive services or procedures than were
actually provided or performed, commonly known as upcoding;
performing medically unnecessary services solely for the
purpose of generating insurance payments.
Now, we have been advised by some that that is a result of
defensive medicine, but I think we are going to hear perhaps
that some of these unnecessary services are just for the
purposes of generating insurance payments.
Another is billing each step of the procedure as if it were
a separate procedure, known as unbundling. In recent years,
many of these schemes have been perpetrated in connection with
the sale of durable medical equipment, the provision of home
health, and infusion of certain expensive drugs for HIV
therapy.
Federal law provides statutes that prosecutors use to bring
charges against those who commit fraud against the Federal
health care programs. Some are specific to health care fraud.
Some are statutes with more general application such as the
prohibition against false statements to the government, which
are used by prosecutors to pursue many types of crimes.
I want to hear today how these statutory tools are being
used as a basis for investigating and prosecuting those who
defraud Medicare and Medicaid and how the statutes complement
Federal civil remedies for these frauds.
And we also need to know whether or not there is a need for
new laws--new criminal laws or whether the--we just need more
resources to enforce the laws that are on the books.
Frequently, our response to these kinds of situations are to
increase the penalties.
Now, that obviously is irrelevant if there has been no
investigation, no prosecution and no conviction. That is when
the penalties would kick in. Sometimes if you just had the
resources for the investigations and the prosecution, you could
pursue these crimes much more efficiently, and that increased
penalties would be irrelevant unless you would have done the
investigation.
Federal effort against these crimes has evolved over the
years in an effort to keep pace with the volume of these crimes
and the increasing sophistication of the criminals committing
them. For instance, irregularities in billing are more easily
detectable now with the ability to examine billing records
maintained in computer databases.
The Justice Department and HHS have increased monitoring of
this information to detect suspicious patterns in claims data
and adjust enforcement efforts accordingly. At the same time,
these agencies have been able to better identify and focus on
regional hot spots for this type of crime.
In 2007, DOJ and HHS established a Medicare strike force
team in Miami-Dade County in Florida. Next year, the strike
force--the next year, the strike force was established in Los
Angeles. And over the past year, these two agencies under the
HEAT program have expanded the use of task forces in Detroit,
Houston, Tampa, Brooklyn and Baton Rouge.
I understand that further expansion of the strike task
force concept is planned for later this year.
The pursuit of those who commit Medicaid--who defraud the
Medicaid program involves both State and Federal law
enforcement.
In 1977, Congress created a State Medicaid Fraud Control
Units, which are usually located in the offices of the State
attorneys general. They investigate and prosecute a variety of
types of fraud crimes primarily in connection with Medicaid
programs. We will hear from the director of one of those
control units today.
I hope this hearing will serve to highlight the continuing
need to examine and adjust our efforts to combat fraud against
Medicare and Medicaid. I look forward to hearing from all of
our witnesses today concerning how we can better prevent,
investigate and prosecute this time--this kind of fraud.
It is now my pleasure to recognize the Ranking Member of
the Subcommittee, the gentleman from Texas, Judge Gohmert.
Mr. Gohmert. Thank you. And I do appreciate us having this
hearing. I appreciate your leadership on this, Chairman Scott.
And appreciate the witnesses being here today.
One of the most famous bank robbers in history was William
``Willie'' Sutton. It is estimated Sutton robbed over 100 banks
beginning in the late 1920's, stealing an estimated $2 million.
He was one of the early faces on the FBI's Ten Most Wanted
list, and when he was asked, famously, why he robbed banks, he
said, ``Because that is where the money is.''
Well, whether Sutton really said that or not, if Sutton
were in this room today he would likely agree Medicare or
Medicaid systems are defrauded because that is where the money
is--and, I would submit, apparently from what I have been
reading of the testimony, easy money.
One individual convicted of health care fraud commented,
``Wow. I just won the lottery.'' From making $20,000 to $40,000
a day cheating Medicare.
In fact, in some areas of the country, the Medicare fraud
business is reported to have replaced the drug trade as the
biggest crime problem. With little effort and with the odds of
getting caught relatively low, the risk is--that criminal
investigations and prosecutions are not serious enough
deterrents to counter the relatively easy way that millions of
taxpayer dollars are stolen.
There are witnesses here today from the Department of
Justice, Department of Health and Human Services and Medicaid
Fraud Control Unit, all who have success stories to tell.
I also want to thank my friend Jim Frogue for being here.
And I appreciated getting and reading a copy of his book,
``Stop Paying the Crooks: Solutions to End the Fraud that
Threatens Your Healthcare.'' Newt Gingrich had a good forward
in that book. But I appreciate his efforts and appreciate him
being here today with the other witnesses.
In his testimony before the U.S. Senate on the topic of
health care fraud deterrence, Professor Malcolm Sparrow of
Harvard, the John Kennedy School of Government, identified the
rule for criminals as it relates to these frauds. ``If you want
to steal from Medicare, Medicaid or any other health care
insurance program, learn to bill your lies correctly. Then, for
the most part, your claims will be paid in full and on time
without a hiccup by a computer with no human involvement at
all.''
While the agencies represented by the witnesses before us
today have implemented enforcement and prosecution strategies
targeting regions that have been identified as high-risk areas
for these types of frauds, one representative from an
investigating agency was quoted as saying that his ``office
finds fraud everywhere it looks.''
In any event, to illustrate some of the topics that we will
discuss here today, I would ask permission to have a brief--and
it is actually cut down substantially from where ``60 Minutes''
played it, but with your permission, we would ask unanimous
consent to view a small segment of the program that was
produced by ``60 Minutes'' called ``Medicare Fraud: A $60
Billion Crime.''
Mr. Scott. All right. This ``60 Minutes'' story that
provoked--it was partly responsible for provoking this hearing,
so we would be, without objection, delighted to roll the tape.
[Begin videotape.]
Mr. Kroft. [``60 Minutes'' Correspondent] FBI Special Agent
Brian Waterman, who we rode with for several days, told us the
only visible evidence of the crimes are the thousands of tiny
clinics and pharmacies that dot the low-rent strip malls. You
don't even know they are there because there is never anyone
inside--no doctors, no nurses, and no patients.
Mr. Waterman. [FBI Special Agent] This office number should
be manned and answered 24 hours a day.
Mr. Kroft. This tiny medical supply company billed Medicare
almost $2 million in July and a half a million dollars while we
were there in August. But we never found anybody in, and our
phone calls were never returned.
Mr. Waterman. Say they are currently on the other line. Oh.
Well, do they want you to hold?
Mr. Kroft. Sometimes they don't even have offices. We went
looking for a pharmacy at 7511 Northwest 73rd Street that
billed Medicare $300,000 in charges. It turned out to be in the
middle of a public warehouse storage area.
Mr. Waterman. They have already told us that there is no
offices here, there are no businesses here. In fact, they are
not even allowed to have a business here.
Mr. Kroft. Waterman is the senior agent in the Miami office
in charge of Medicare fraud. And Kirk Ogrosky, a top Justice
Department prosecutor, oversees half a dozen Medicare Fraud
Strike Forces that have been set up across the country.
This one operates out of a warehouse at a secret location
in South Florida and includes investigators from the FBI,
Health and Human Services and the IRS.
Mr. Ogrosky. [DOJ Prosecutor and Healthcare Fraud Strike
Force Leader] There is a health care fraud industry where
people do nothing but recruit patients, get patient lists, find
doctors, look on the Internet, find different scams.
There are entire groups and entire organizations of people
that are dedicated to nothing but committing fraud, finding a
better way to steal from Medicare.
Mr. Kroft. Is the Medicare fraud business bigger than the
drug business in Miami now?
Mr. Ogrosky. I think it is way bigger.
Mr. Kroft. What changed?
Mr. Ogrosky. The criminals changed.
Mr. Waterman. Sophistication.
Mr. Ogrosky. They figured out that rather than stealing
$100,000 or $200,000, they can steal $100 million. We have seen
cases in the last 6, 8 months that involve a couple of guys
that, if they weren't stealing from Medicare, might be stealing
your car.
Tony. You are waking up every day making $20,000, $30,000,
$40,000, every day, almost literally, and you are like, ``Wow,
I mean, I just won the lottery.''
Mr. Kroft. Let's call this guy ``Tony.'' That is not his
real name and obviously not his real face. But before he was
ratted out by a friend and brought down by the FBI, he was
making Wall Street money running a string of phony medical
supply companies out of this building that were theoretically
providing wheelchairs and other expensive equipment to Medicare
patients.
How much money did you steal from Medicare?
Tony. About $20 million.
Mr. Kroft. $20 million?
Tony. Yes.
Mr. Kroft. Was it easy?
Tony. Real easy.
Mr. Kroft. And you are not exactly a criminal mastermind.
Tony. No. No, not really. It is more like common sense.
That is all you need here.
Mr. Kroft. Did you actually ever sell any medical
equipment?
Tony. No. No. Just have somebody in an office answering the
phone like we are open for business, and wake up in the
morning, check your bank account and see how much money you
made today.
Mr. Kroft. So you didn't have any medical equipment. You
didn't really have any clients either, did you?
Tony. No.
Mr. Kroft. All of it was fake.
Tony. All of it was fake, yes.
Mr. Kroft. And you would just fill out some invoices and
some forms and send them to Medicare and----
Tony. Yeah, that is it. And 15 to 30 days you will have a
direct deposit in your bank account. I mean, it is--it was
ridiculous. It is more like taking candy from a baby.
[End videotape.]
Mr. Gohmert. Thank you, Mr. Chairman. And again, appreciate
the opportunity to have this hearing. Appreciate your calling
it.
Mr. Scott. Thank you.
The Chairman of the full Committee is with us, the
gentleman from Michigan.
Do you have a statement, comment?
Mr. Conyers. Thanks, Chairman Scott, Judge Gohmert.
Now, this is an issue that everybody of every persuasion
can come together on. And I congratulate you for having the
hearing. And I would like to find out where the next step from
the ``60 Minutes'' clip goes.
I mean, to whom did this enterprising young man send
invoices to get the money? I mean, who sent the money to him?
And they are the ones that ought to be sitting at the second
panel here today to explain that, or removed from office, or at
least discontinuing what they are doing.
That is the back story to this hearing.
Mr. Scott. Well, we have one inspector general from the HHS
who might comment.
Mr. Conyers. Well, he better make more than a comment.
[Laughter.]
I will tell you that. No. No, this is simple. I mean, this
is not complex crime. It is not international drug smuggling.
This isn't undercover operations. I mean, this is just ordinary
household criminal law violations.
And it is a little bit shocking it takes two Federal
agencies at the top to combine to bust little guys like this
who just say it is really just simple, you send in the invoices
and then you check your bank account to see where the money
comes from.
I mean, I want to ask the witnesses this in advance. Could
you suggest a simpler crime that could be committed in the
United States than what this young fellow just told ``60
Minutes'' and everybody in America?
To be honest, the one thing we have got to worry about is
how many more people did he incentivize. I mean, people that
are sitting at home that just got laid off, or their company
moved out of the States, or their home is in foreclosure, and
they see this program--I mean, he doesn't need a wake-up call.
They just told him what he might do, and that it might
work, and that it--and it is working so successfully that we
have two agencies at the Federal level--can I ask you why the
Department of Justice can't get enough money from the Congress
to bust this simple, ordinary kind of racket?
The second question that I am going to ask is what about
the corporate crime that goes on here. We are talking about the
little guys--if there is an element of corporate activity in--
that we have to know about.
So I thank you, Mr. Chairman.
Mr. Scott. Thank you. And I thank you for your comments,
Mr. Chairman.
And thank you, Mr. Gohmert, for bringing that piece to our
attention.
Our first witness on the panel will be Mr. Greg Andres. He
is appointed acting deputy assistant attorney general in the
Criminal Division.
He is joined in the division on detail from the United
States--U.S. Attorney's Office in the Eastern District of New
York, where he has been an assistant U.S. attorney since 1999
and has served as chief of the Criminal Division since 2006. He
has been involved in several high-profile prosecutions
involving organized crime, terrorism and securities fraud
offenses.
Our second witness will be Mr. Timothy Menke. He is the
Department of Health and Human Services deputy inspector
general for investigations. He has over 20 years of Federal law
enforcement experience and has been with the Office of
Inspector General since 1996.
Our third witness will be Mr. Mark Collins. He joined the
Nebraska Attorney General's Office in September 2005 as
director of the Nebraska Medicaid Fraud Control Unit which had
just been created a year earlier. He also serves as the special
assistant U.S. attorney for the District of Nebraska for health
care fraud matters and is president of the National Association
of Medicaid Fraud Control Units.
And our final witness is Mr. Jim Frogue--did I pronounce
that right?
Mr. Frogue. Frogue.
Mr. Scott. Frogue, thank you--Mr. Jim Frogue, who is the
vice president and director of State policy for the Center for
Health Transformation. He is the center's chief liaison to the
State policy projects--the primary areas of focus--including
Medicare, Medicaid and fraud.
Previously, he was the director of Health and Human
Services task force at the American Legislative Exchange
Council, where he coordinated the development of market-
oriented health policies among State legislators.
Now, each of our witnesses' written statements will be
entered in the record in its entirety.
I would ask each of our witnesses to summarize your
testimony in 5 minutes or less. To help stay within the time,
there is a timing device at the table which will begin green
and go to yellow when you have 1 minute left. And when it turns
red, that signals that your 5 minutes has expired.
Mr. Andres.
TESTIMONY OF GREG ANDRES, ACTING DEPUTY ASSISTANT ATTORNEY
GENERAL, CRIMINAL DIVISION, U.S. DEPARTMENT OF JUSTICE,
WASHINGTON, DC
Mr. Andres. Thank you, Chairman Conyers, Chairman Scott,
Ranking Member Gohmert and distinguished Members of the
Subcommittee.
Thank you for the invitation to be here today. Thank you
for the opportunity to outline the Department of Justice's
efforts to root out, prosecute and prevent health care fraud.
Every year the Federal Government devotes billions of
dollars to provide health care services for our citizens, young
and old alike. Sadly, between 3 and 10 percent of that money
may be lost to waste, fraud or abuse.
We in the Department of Justice have a duty to protect
against fraud and the obligation to make sure that money
allocated for health care is not siphoned away by criminals.
This is a responsibility that we embrace.
And the Department of Justice has used criminal and civil
enforcement tools to prosecute health care fraud for more than
a decade. Today we are doing it better. Most importantly, we
are coordinating more effectively with our partners at the
Department of Health and Human Services.
The Health Care Fraud Prevention and Enforcement Action
Team, or HEAT initiative, is guiding this partnership in a
smart, strategic and targeted way and it is producing results.
On the criminal side, we are identifying hot spots with
unexplained billing patterns, and we are placing Medicare Fraud
Strike Forces in those cities to catch the most egregious
offenders.
We started in Miami and Los Angeles and expanded to Detroit
and Houston. And later we expanded further, this time to
Brooklyn, Baton Rouge and Tampa. Our strike force prosecutors
and agents have made arrests and earned convictions in a wide
variety of fraud schemes involving claims for services that
were unnecessary or that were never provided.
For example, in June of 2009 Federal prosecutors charged 53
defendants in Detroit relating to fraudulent billing schemes
involving physical, occupational and infusion therapy services.
These scheme involved $50 million.
Days later, Federal prosecutors indicted eight Miami-area
residents in connection with a $22 million scheme to submit
false claims to Medicare for home health services.
And about a month after that, July of 2009, Federal
prosecutors in Houston charged 32 defendants in schemes
involving more than $16 million in fraudulent Medicare billing.
Similar prosecutions have been brought in Los Angeles and
Brooklyn alike.
In all, since its inception, strike force prosecutors and
agents have charged more than 500 defendants who collectively
billed the Medicare program for more than a billion dollars.
They have secured more than 260 guilty pleas to date,
obtained prison sentences for 94 percent of defendants
convicted. These efforts have a tangible result in terms of
savings.
In the first year after strike force operations in Miami,
there is an estimated reduction of $1.75 billion in durable
medical equipment claims submitted.
The HEAT initiative also has a civil fraud enforcement
component. Using the False Claims Act and the Anti-Kickback Act
and Food, Drug and Cosmetic Act during fiscal year 2009, DOJ
civil lawyers have secured $1.6 billion in civil settlements
and judgments. They have opened 886 new civil health care fraud
matters and filed complaints or intervened in 283 civil health
care fraud matters.
The Civil Division's Office of Consumer Litigation
prosecutes drug and device manufacturers and responsible
individuals believed to be illegally promoting and distributing
misbranded and adulterated drugs or devices in violation of the
Food, Drug and Cosmetic Act.
The Civil Division also houses the Elder Justice and
Nursing Home Initiative to coordinate and support law
enforcement efforts to combat elder abuse, neglect and
financial exploitation.
Finally, the Special Litigation Section of the Civil Rights
Division ensures that the civil rights of persons who reside in
public, State or locally run institutions are fully protected.
In conclusion, the Department of Justice has made the
prosecution of health care fraud a priority. Resources are
dedicated to these activities and the President's budget seeks
additional funding to expand our enforcement efforts.
We look forward to working with Congress as we continue our
important mission to prevent, deter and prosecute health care
fraud. Thank you.
[The prepared statement of Mr. Andres follows:]
Prepared Statement of Greg Andres
__________
Mr. Scott. Thank you.
Mr. Menke.
TESTIMONY OF TIMOTHY J. MENKE, DEPUTY INSPECTOR GENERAL FOR
INVESTIGATIONS, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES,
WASHINGTON, DC
Mr. Menke. Good morning, Chairman Conyers, Chairman Scott,
Ranking Member Gohmert and distinguished Members of the
Subcommittee. I am Timothy Menke. I am the deputy inspector
general for investigations at the Department of Health and
Human Services Office of Inspector General.
I thank you for the opportunity to discuss OIG's health
care antifraud strategy, primarily focusing our law enforcement
activities to combat Medicare and Medicaid fraud.
OIG is an independent nonpartisan agency committing to
protecting the integrity of more than 300 programs administered
by HHS.
OIG employs more than 1,500 dedicated professionals,
including a cadre of nearly 400 highly skilled criminal
investigators trained to conduct criminal, civil and
administrative investigations.
Thanks to the hard work of our employees in fiscal year
2009, OIG's enforcement efforts resulted in 670 criminal
actions, 362 civil actions and nearly $4 billion in monetary
recoveries.
We work closely with the Department of Justice, our
Federal, State and local law enforcement partners, to include
State Medicaid Fraud Control Units with whom we are working
over 980 joint investigations.
OIG's partnerships extend to one of the Administration's
signature initiatives, the Health Care Fraud Prevention and
Enforcement Action Team, known as HEAT.
The HEAT initiative, established by Secretary Sebelius and
Attorney General Holder in 2009, brings together senior
officials from both HHS and DOJ with the goals of sharing
information, spotting fraud trends, coordinating prevention and
enforcement strategies, and developing new fraud prevention
tools.
OIG contributes its experience to HEAT by analyzing data
for patterns of fraud, conducting investigations, supporting
Federal prosecutions, as well as making recommendations to HHS
to remedy program vulnerabilities.
One of the investigative strategies promulgated by HEAT is
the Medicare Fraud Strike Force. The Medicare Fraud Strike
Force has changed the way health care fraud cases are
investigated and prosecuted.
Strike force cases focus on the development and
implementation of a technologically sophisticated and
collaborative approach. Strike force cases are data driven,
using technology to pinpoint fraud hot spots through the
identification of unexplainable billing patterns as they occur.
The majority of subjects in strike force cases are engaging
in 100 percent fraudulent activity, not providing any
legitimate services to program beneficiaries whatsoever.
Real-time access to data is critical to the success of the
HEAT strike force initiative. Over the last several months,
representatives from OIG, CMS and DOJ have explored ways to
improve access to CMS claims data.
Much of our attention has been focused on obtaining real-
time data. To date, we have established limited access to real-
time claims data, but we are continuing to work to improve our
access to this data.
It is also important that we expand our access to CMS
systems offering advanced analysis and query tools that can be
employed in mining a comprehensive national Medicare claims
database.
In addition to using data more efficiently, OIG is also
using data to take a more strategic approach in identifying
fraud. In 2009, OIG organized a cross-component data analysis
team to support work of HEAT. The data team includes OIG
special agents, statisticians, programmers and auditors.
Together, the team brings a wealth of experience in
utilizing sophisticated data analysis tools combined with
criminal intelligence gathered from special agents to more
quickly identify ongoing fraud schemes and trends.
OIG is also capitalizing on cutting-edge electronic
discovery tools to maximize investigative efficiency in the
processing and review of voluminous electronic evidence
obtained during the course of our health care fraud
investigations.
This technology is Web-based and has been made available to
OIG investigators to increase investigative efficiency and
effectiveness. OIG was the first Federal law enforcement agency
to implement this technology. It enables OIG to analyze large
quantities of mail or other electronic documents more
efficiently and to associate or link e-mails contained in
multiple accounts based on content or metadata.
Recently, OIG has expanded the use of this technology by
making it available to our external law enforcement partners
for use in joint investigations. This effort strengthens OIG's
relationships with partner law enforcement agencies and allows
for much greater collaboration.
Because the technology is Web-based and can be accessed
securely over the Internet, investigators can use this tool
from anywhere in the country.
By attacking fraud vigorously wherever it exists, we all
stand to benefit. Medicare trust fund resources will be
protected and remain available for their intended purposes.
Medicare dollars that have gone to fraudulent suppliers
will instead be available for legitimate businesses whose
purpose is to serve the critical health care needs of our
program beneficiaries.
And most importantly, we can assure that seniors and
persons with disabilities receive the necessary supplies and
care they need to stay healthy so as to enjoy enhanced well-
being and quality of life.
Thank you for the opportunity to discuss our law
enforcement efforts and strategies to protect the integrity of
Federal health programs.
And, Mr. Chairman, I would just like to add I brought a
couple of exhibits along that may assist in our discussion a
little bit later regarding fraud schemes. Thank you.
[The prepared statement of Mr. Menke follows:]
Prepared Statement of Timothy J. Menke
__________
Mr. Scott. Thank you.
Mr. Collins.
TESTIMONY OF D. MARK COLLINS, ASSISTANT ATTORNEY GENERAL,
DIRECTOR OF NEBRASKA MEDICAID FRAUD CONTROL UNIT, PRESIDENT OF
THE NATIONAL ASSOCIATION OF MEDICAID FRAUD CONTROL UNITS,
LINCOLN, NE
Mr. Collins. Thank you, Chairman Scott, Chairman Conyers,
Ranking Member Gohmert, Members of the Committee. I am Mark
Collins. I am director of the Nebraska Medicaid Fraud Control
Unit in the Nebraska Attorney General's Office and also
president of the National Association of Medicaid Fraud Control
Units.
As you all know, Medicaid is financed by both Federal and
State funds and administered by each State. And although most
taxpayer dollars go directly toward providing essential medical
care to the intended beneficiaries of the program, there is a
tremendous amount of money that is lost to fraud, waste and
abuse.
The Medicare and Medicaid antifraud and abuse amendments
enacted by Congress in the 1970's established the State
Medicaid Fraud Control Unit program and provided the States
with the incentive funding to investigate and prosecute
Medicaid provider fraud, and also to prosecute abuse and
neglect of patients in Medicaid-funded residential health
facilities, and to investigate fraud in the administration of
the Medicaid program.
Medicaid Fraud Control Units are law enforcement agencies,
and they are primarily responsible for monitoring each State's
Medicaid program. MFCUs have investigated and prosecuted some
of the largest and most sophisticated frauds ever committed
against the program.
And they also work to identify and implement systemic
reform initiatives in the administration of the Medicaid
program by advocating for legislation, exposing emerging trends
of abusive practices, and collaborating on technological
solutions and safeguards against fraud.
Since the inception of the National MFCU program in 1978,
the 50 Medicaid Fraud Control Units have obtained thousands of
criminal convictions and recovered hundreds of millions of
dollars in restitution.
Perhaps even more importantly, and more important than any
specific prosecution, these units have demonstrably deterred
the loss of many more hundreds of millions of dollars in
Medicaid overpayment.
The National Association of Medicaid Fraud Control Units,
which we call NAMFCU, was established in 1978 to provide a
forum for nationwide sharing of information concerning the
challenges of Medicaid fraud control.
NAMFCU fosters interstate cooperation on law enforcement
and Federal issues regarding MFCUs, conducts training programs
to improve the quality of Medicaid fraud investigations and
prosecutions, gives technical assistance to our association
members, and provides the public with information about the
MFCU program.
Beginning with the first global settlement case in 1992,
NAMFCU has effectively coordinated State-Federal investigations
of settlements, primarily involving pharmaceutical companies.
In the past decade, State MFCUs have seen a rapid increase
in both the number of fraudulent schemes targeting Medicaid
dollars and the degree of sophistication with which they are
perpetrated.
Typical fraud schemes included--will include billing for
services never rendered, double billing, misrepresenting the
nature of services provide, providing unnecessary services,
submitting false cost reports, and paying illegal kickbacks.
MFCUs continually adapt their investigative and
prosecutorial techniques to curtail and to anticipate new and
innovative methods of thievery.
The Office of Inspector General at the U.S. Department of
Health and Human Services provides oversight to State MFCUs.
One important feature of the MFCU oversight program is to
cultivate close and effective working relationships between
State and Federal agencies to combat fraud and abuse in the
Medicaid programs of all the various States.
All MFCUs work closely with the Offices of the United
States Attorney in their respective districts and with Federal
law enforcement agencies such as the U.S. Department of
Justice, the FBI, HHS OIG, the IRS and the Postal Service.
MFCUs actively participate in State-Federal health care
fraud task forces and working groups that operate in virtually
every State in the Nation.
The Federal False Claims Act contains qui tam provisions
that provide the authority and financial incentive for private
individuals or relators to enforce the act on behalf of the
government. Qui tam relators are often called whistleblowers,
and they are generally current or former employees of target
entities.
Twenty-five States currently have false claims statutes
with qui tam provisions. An increasing number of relators are
filing their cases with the States as well as with the Federal
Government, and this development has fostered a significant
increase in State-Federal investigative partnerships.
The National Association of Medicaid Fraud Control Units
encourages States to look beyond their individual State
perspectives and to participate in global cases. NAMFCU
coordinates these multistate investigations, often appointing
NAMFCU investigative and settlement teams.
And if settlements are reached, per NAMFCU protocol, then
all State recoveries are allocated to each State based upon
their actual damages. Multistate cases in which the MFCUs have
played a role have resulted in the recovery of over $5 billion
to the Medicaid program.
In an historic 2009 case against Pfizer, Pfizer and its
subsidiaries agreed to pay Medicaid and Medicare and other
Federal programs a total of $2.3 billion to resolve civil and
criminal allegations against kickback and illegal off-label
marketing campaigns.
As we have done for the past 30 years, State Medicaid Fraud
Control Units continue to play a national leadership role in
investigating and prosecuting health care fraud and resident
abuse and will continue to do so in the future.
Thank you for your time today and allowing me to testify
and would look forward to any questions that you may have.
[The prepared statement of Mr. Collins follows:]
Prepared Statement of D. Mark Collins
__________
Mr. Scott. Thank you.
Mr. Frogue. Thank you.
TESTIMONY OF JAMES FROGUE, VICE PRESIDENT AND DIRECTOR OF STATE
POLICY, CENTER FOR HEALTH TRANSFORMATION, WASHINGTON, DC
Mr. Frogue. Thank you, Chairman Scott, Chairman Conyers and
Ranking Member Gohmert. My name is Jim Frogue. I am vice
president of the Center for Health Transformation here in town.
Chairman Conyers, I would like to associate something you
said in your opening statement about who should be sitting up
here at perhaps your next hearing. People with street-level
knowledge of how easy it is to steal from Medicare and Medicaid
would make for a fantastic hearing at some point down the road.
I think you are exactly right with that point.
President Obama said in his speech to the joint session of
Congress on September 9th that there are hundreds of billions
of dollars in waste and fraud in our health care system.
Secretary Sebelius said at the National Summit on Health
Care Fraud on January 28th, ``We believe the problem of health
care fraud is bigger than government, law enforcement or
private industry can handle alone.'' And she is certainly right
about that.
Congressman Ron Klein of South Florida, which is a hot spot
for health care fraud, said at the same summit, ``Constituents
come to me repeatedly with fake billings and stories of
solicitations for their Medicare I.D. number.''
Senator Tom Coburn said at the White House Health Summit
last week he believes 20 percent of government health programs
are fraud. Senator Schumer from New York a few minutes later
associated himself with those remarks.
The scope of health care fraud is certainly vast. A Thomson
Reuters study in October of last year said it could be as much
as $175 billion a year.
The Government Accountability Office and HHS OIG have
literally issued hundreds of reports over the years warning how
big and how serious the problem is.
Law enforcement--the HEAT program, for example--does an
excellent job, but they are up against an unwinnable battle.
They are much like the mythical character Sisyphus trying to
push the rock up to the top of the hill, only to have it
collapse at the last minute. Law enforcement can't do it alone.
James Mehmet, who is the former inspector general of New
York Medicaid, said in 2005 that he thinks 40 percent--that is
four zero--40 percent of Medicaid claims in New York State
might be fraudulent or at least questionable. Now, that would
be up to $20 billion in one State's Medicaid program in 1 year.
Keep in mind that 1 percent of Medicare spending is $5
billion. So identification and prosecution of fraud schemes in
the tens or even hundreds of millions of dollars are very
significant and very worthy, but they barely scratch the
surface of how serious the problem is.
It should be worth nothing that the credit card industry is
a great example of pre-screening of payments, something that
Medicare and Medicaid don't do in any significant degree.
They actually check and make sure the vendor is legitimate
and the claims are legitimate before they pay the money. That
is a huge step in the right direction for Medicare and
Medicaid, and adopting that technology would be hugely--would
be hugely important.
One-tenth of credit card spending is fraud--one-tenth of 1
percent, I should say. And for an industry that is over $2
trillion, that is more money than Medicare and Medicaid, so
that would be an industry to learn from.
A few quick bullet points on what can be done to make the
difference. For one, although this sounds a little strange,
there is no constitutional right to be a Medicare supplier.
There is this attitude out there that if you fill out the
application properly you have the right to supply Medicare,
whether your services are needed or not. And I think there
needs to be significantly better screening.
One very easy solution is add the term--add the phrase
``under penalty of perjury'' to the CMS 855 form, which would
give prosecutors a much more important tool to go after people
for committing crimes.
Medicare and Medicaid should use private-sector standards
for establishing how many suppliers should be in a defined
area. California Medicaid has done this for almost a decade now
and it has worked very well.
Reduce the administrative red tape and lengthy appeals
process that suppliers get to exploit. Often supplies can drag
out for months their appeals process when they are trying to
get kicked out of the program.
The OIG identified 15--they did 1,500 unannounced site
visits back in 2008, found 491 either didn't have an actual
facility or were not staffed accordingly, so they revoked
billing privileges of 491.
Two hundred and forty-three of them appealed. Two hundred
and twenty-two, or 91 percent, were reinstated. And 111 of
those had their billing privileges revoked again.
Authorize demonstration projects whereby authentication of
new suppliers to Medicare fee-for-service is outsourced by and
to an entity not CMS. Perhaps OPM would be a good place to try
that.
Data-sharing across departmental jurisdictions, which has
been successful with the HEAT program, should be done with the
vigor that it has been done with the national security agencies
post-9/11.
Another one is open up Medicare claims data to audits
conducted by contingency-fee-based companies beyond the
standard four recovery audit collection companies. I think that
would bring a new set of eyes, a new set of techniques and some
fresh ideas to that particular--those series of investigations.
Create a Web site where payments to all Medicare suppliers
are posted for public access. We all have a right to know, as
taxpayers, where these dollars are going. If you are billing
Medicare, what you bill Medicare should be available to anyone
to see as soon as possible.
Perhaps more radical is consider a way to post claims
before they are even paid. In the spirit of President Obama's
idea that all legislation should be posted for 72 hours before
it is voted on, taxpayers should have a right to see what kind
of claims are being paid before they are actually paid.
This need not interfere with Medicare's prompt payment
promise already for providers, but it would be an interesting
way to take a look at some of the money being sent out.
And hold hearings about the governance of CMS and its
ability to be truly effective in fighting fraud and abuse. And
I think Chairqman Conyers' opening statement made a lot of
sense.
And it would be my privilege, Mr. Chairman, to work with
you and your staff to help identify some people who could
testify that would give you stories that would be quite
shocking.
With that, thank you very much. I look forward to your
questions.
[The prepared statement of Mr. Frogue follows:]
Prepared Statement of James Frogue
__________
Mr. Scott. Thank you. Thank you very much.
And I thank all of our witnesses for their testimony. We
will now ask questions under the 5-minute rule. And I would
like to start with Mr. Frogue.
Is there a difference in the public and private sector in
terms of processes to prevent fraud? I mean, is Medicaid and
Medicare getting ripped off any more than private insurance
companies?
Mr. Frogue. Yes, they are, and I think when you look at
Medicare and Medicaid specifically, I think a really important
distinction is the fact that un-managed fee-for-service,
particularly in Medicare and Medicaid, is much, much worse than
it is where there is some sort of managed care involved.
Secretary Sebelius sent a letter to Senator Cornyn just
last week where they identified that the fraud in managed care
was far, far less than it is where you have un-managed fee-for-
service. I mean, it is several times higher.
But the answer to your question is absolutely yes. Where
the right incentives are in place, fraud is a lot less.
Mr. Scott. Mr. Menke, one of the problems that--one of the
concerns that I have had addressed to me is that when you start
going after Medicaid fraud, there is a difference between fraud
and honest mistakes.
In the inner city where the doctors have an error rate just
the same as everybody else but their population is much more
likely to be Medicaid, they get targeted for audits. And if you
audit enough, you are going to find something. Many of these
are minority physicians, and it has an unfortunate pattern to
it.
Can we be satisfied that when you target looking for
Medicaid and Medicare fraud that you are not targeting--
essentially targeting minority physicians?
Mr. Menke. Well, we have a body of work with our office of
audit that takes a look at error rates across the board. And to
my knowledge, they don't focus in on any particular group or
group of physicians----
Mr. Scott. And you don't look at volume?
Mr. Menke. Yes, we look at volume.
Mr. Scott. So that would end up disproportionately
affecting people that practice in the inner cities.
Mr. Menke. That could happen, yes.
Mr. Scott. Well, that is not fair.
Mr. Menke. Congressman, we have our Office of Audit
Services, and I am--I have to admit that I am from the
investigation side, not the audit side, and we would be happy
to get you any information from our Office of Audit Services
regarding error rates.
Mr. Scott. And following through on that, we have--I have
heard from this panel that unnecessary--medically unnecessary
services being performed are performed for the purposes,
effectively, of defrauding insurance companies.
Mr. Menke. Yes.
Mr. Scott. We have been told that those unnecessary
services are there for some kind of defensive medicine or
something like that. Can you comment on that? Is most of this
just insurance fraud when people say that unnecessary services
are being provided?
Mr. Menke. Well, Mr. Chairman, I can give you an example.
One is regarding wheelchairs. A prescription will be written
for a power wheelchair for a person who has no need, medically
unnecessary. And sometimes the wheelchair is delivered.
Sometimes a substandard scooter is delivered instead.
And the bottom line is the beneficiary doesn't need it
because it is medically unnecessary, will never use it, and it
basically sits in their apartment with clothes hanging over it
until our agents show up and they basically say, ``You can take
it.''
Mr. Scott. And limiting attorneys' fees or capping damages
on liability suits wouldn't affect the frequency of that kind
of fraud.
Mr. Menke. I wouldn't have expertise in that area, sir.
Mr. Scott. Now, the cost of audits--I mean, it costs money
to audit and do these investigations. Do you think you save
more money than you spend on audits by saving money and
reducing fraud and billing problems?
Mr. Menke. Well, Mr. Chairman, I can refer to my specific
budget in the Office of Investigations. I have a $92 million
budget, and last year we recovered $4 billion in recoveries, so
our return on investment is pretty high.
Mr. Scott. Now, by recovering this, it seems that you don't
need any new laws, no new criminal statutes. You just need
new--more resources for investigations?
Mr. Menke. That is a fair characterization, sir.
Mr. Scott. We have heard practices where people go out and
try to recruit and get people identification numbers that they
can fraudulently bill. Is there any reward system for people to
snitch on people who have made those kinds of contacts?
Mr. Andres. Chairman, there is certainly instances where if
someone comes forward with respect to information that is used
for a prosecution there are different--there are certainly
different rewards within the criminal justice system for people
that come forward, whether it be judicial consideration at the
time of sentencing or it be some sort of agreement with the
prosecuting U.S. Attorney's Office for working proactively, for
wearing a wire, for helping us uncover a greater degree of
fraud or unveiling the other co-conspirators involved.
Mr. Scott. I mean, with the widespread fraud, it looks like
encouraging people to come forward would certainly have an
effect.
Let me just ask a general question to whoever wants to
answer it. What are we doing now that we weren't doing before
the ``60 Minutes'' report? Are we doing anything different now
than when the ``60 Minutes'' report was describing widespread
fraud where people are making tens of thousands of dollars a
day without much resistance? Are we doing something different?
Mr. Menke. Well, Mr. Chairman, if I could answer that, we
are doing some things, and basically we are working with the
Centers for Medicare and Medicaid Services to improve upon
real-time access for law enforcement. That has improved. We
have a long way to go in that area.
In the bottom line, the importance of the real-time data
access is to get the information pre-payment rather than post-
payment, which puts us--post-payment puts us behind the crooks.
They have already been paid. That is the pay and chase method.
What we are trying to do is get ahead of the curve. Within
48 hours after it is submitted to the Medicare administrative
contractor, they have about 15 to 30 days, by law, to pay the
claim.
And we are trying to get in 48 hours after that claim is
submitted to flag any type of questionable provider numbers or
beneficiary numbers, to throw red flags up, to hold payment
before the money goes out the door. That has improved since the
``60 Minutes'' piece.
Mr. Scott. If you have made a payment, why can't you chase
after it? You have got a money trail all the way to whoever is
getting the money.
Mr. Menke. We do that.
Mr. Scott. I mean, just because you have paid the money
doesn't mean--is there a problem--once you have paid the money,
you can't track down people who have cheated you out of some
money?
Mr. Menke. Absolutely not. And we are the best at doing
that. We are chasing them very well. But it is still a pay and
chase. And what is important, I think, is prevention on the
front side because, as Mr. Frogue had mentioned, law
enforcement catching up after the fact is a daunting task.
And if we can put preventative measures in on the front
side, pre-payment, it can really make a difference in the
amount of money going out the door.
Mr. Scott. Okay. Now, do you have enough in resources to do
what you need to do to reduce fraud? Or have you asked for
money that Congress has not provided?
Mr. Menke. This afternoon at 2 o'clock my boss, the
inspector general, will be testifying with the deputy secretary
on resource needs. There is a request for additional resources
to expand strike force locations to a total of 20 cities.
What I can tell you is last year in fiscal year 2009 we
referred over 1,400 cases elsewhere because I didn't have the
resources or the bodies to work them. And that amount of case
work could have resulted in an additional billion dollars in
recoveries.
Mr. Scott. And so it is your testimony that if we give you
more resources you will be able to save us much more money in--
through fraud reduction than we spend in the resources for your
office.
Mr. Menke. I would have to defer to my boss and chain of
command--the inspector general, the secretary and the
President's budget.
Mr. Scott. But I mean, I think you have suggested that it
is not even close. We will save a lot more money.
Mr. Menke. We have a very good return on investment, sir.
Mr. Scott. Mr. Gohmert?
Mr. Gohmert. Chairman, if I could, Judge Poe has got to go
to another hearing. With the votes, could I allow him to----
Mr. Scott. Judge Poe?
Mr. Gohmert [continuing]. Go in my place right now?
Mr. Poe. Appreciate my friend the Ranking Member for
yielding time.
Thank you for being here.
As Mr. Gohmert has mentioned, I used to be a judge in my
other life, tried felons for 22 years, saw about 25,000 outlaws
work their way to the courthouse, or the ``Palace of Perjury,''
as I refer to it.
These are just among the worst. And people who steal from
people who are sick or people who won't get medical attention
are the worst of the lot. And I don't care whether it is a
doctor, a nurse, an insurance company or another recipient of
Federal aid, either Medicare or Medicaid.
How many recipients illegally have received Medicare and
have gone to jail for that, Mr. Menke?
Mr. Menke. Well, I would actually have to defer to
Department of Justice on the prosecution stats.
Mr. Andres. I believe in my written testimony I speak about
that, but there have been more than 500 individuals that have
been convicted for these schemes. And certainly, there are a
number of schemes that involve the beneficiaries themselves.
Mr. Poe. Excuse me, because my time is limited. How many
recipients who have claimed they want--they need Medicare--a
patient, citizen--and they are lying, they are stealing from
the system--how many people went to jail, like, last year?
Give me a statistic that I can--because we got millions of
people on the system. How many are going to jail for stealing
from it?
Mr. Andres. I can get back to you with a specific number. I
know 94 percent of the defendants who are being tried are now
receiving jail terms.
Mr. Poe. Are you talking about the recipients? I am not
talking about the providers. I am talking about the person who
gets it.
Mr. Andres. Again, I can get back to you, Congressman, with
the specific numbers about that.
Mr. Poe. Okay. I would appreciate that.
Mr. Frogue, you mentioned some good ideas on how we could
make the system better. Two things. What do you think about--
rather than--that we deal with some of these violations with an
administrative process more than running them through the
criminal justice system, that we restructure Medicare,
Medicaid--that if you are going to come in the system, there
are administrative penalties that will be administered to you?
That would make it, it seems to me, a lot quicker, more
effective. You are kicked off the list. Whatever. What do you
think about that?
Mr. Frogue. Well, getting in the system is exactly--that is
the biggest problem. It is too easy to get in the system. And
that is why it is important for someone other than CMS--maybe a
credit card company, or a financial institution or insurance
company; it could be anyone--to do some demonstration projects
on authenticating some of these new suppliers, because once you
are in the system, you can bill and bill and bill, and law
enforcement will catch up with a couple of them, but the vast
majority go undetected.
But I think you are exactly making the right point. But I
think the real key--and I think everyone on this panel has
mentioned this--is it has got to be switched from a system--
Medicare and Medicaid--from reactive to proactive, where the
payments are screened before they go out the door.
Trying to capture them after they leave is--the horse is
already out of the barn. You might be able to get some of it
back, but you are not going to get all of it. The credit card
industry does this extremely well, and we all know this.
If we went to Fargo, North Dakota tomorrow and tried to buy
a plasma screen TV, they would ask you for your I.D. It is not
a real burden on you, but it--they check, and within seconds,
if this is a legitimate purchase. There is none of that in
Medicare fee-for-service.
Mr. Poe. Well, I guess my real question is assuming there
are violations in the system--somebody cheats--do you think
that we could restructure Medicare and Medicaid to make the
penalties--not all of them, but some of the penalties
administrative, where you are cut off a list, you are not
allowed to reapply for a period of time?
I mean, not neglect due process, but readapt the whole
model of Medicare and Medicaid to have administrative penalties
where possible.
Mr. Frogue. Yes, I think that is a fantastic idea, and I
think there needs to be much better data-sharing between the
agencies and the Federal, State and local in order to flag
people.
You know, it is like if a local police officer in Oregon
pulls someone over for a speeding violation, they know if they
have a criminal conviction in Virginia. There is not enough of
that in the health care space. There needs to be a lot more.
Mr. Poe. Well, I have never heard of anybody with a
criminal record of Medicare fraud coming through the courthouse
charged with something else. But there are those thieves out
there.
$60 billion is a lot of money of fraud. And I think if we
had people, whether they are a hospital administrator, or an
accountant, or a doctor or a nurse, or a citizen who applies
for Medicare or Medicaid, carted off to jail in handcuffs, that
might get the attention--because now it is just a cost of doing
business.
Last question, organized crime, how predominant is that in
this whole system?
Mr. Menke. Yes, sir. Organized crime is a problem. We are
starting to see an increase in the infiltration because of the
ease of getting into it. Why sell drugs and risk getting shot
when you can click a mouse when you are an organized criminal?
And we have seen different groups with similar schemes, but
different groups, across the country. It is becoming more and
more viral. And unfortunately, our agents are seeing--we are
coming across more and more guns at every single search and
arrest warrant. So they are bringing the tricks of the trade
with them into health care fraud.
We investigate health care fraud, and lo and behold, we
come across organized crime. We don't do it the other way
around.
Mr. Poe. Thank you very much.
Appreciate the gentleman for yielding.
Mr. Scott. Thank you. We have just a minute and a half
before the--run out of time on the floor. But the gentleman
from Michigan wanted to ask a brief question. And then we will
come back after the votes.
Mr. Conyers. And I will try to come back, too, Mr.
Chairman. Thank you.
How many of you here know about or have been in touch with
the Center for Health Transformation, between the Department of
Justice and HHS? Have you ever heard of them?
Mr. Menke. No.
Mr. Conyers. You?
Mr. Andres. No, sir.
Mr. Conyers. How come we haven't talked about corporate
crime here? We talked about individuals. Corporate crime sounds
more serious and more criminal to me than individual hustlers.
Mr. Collins. Mr. Chairman, I did mention in my remarks
the--what had happened with Pfizer as far as the illegal
marketing that they had engaged in. And that was pursued both
civilly and criminally.
Pfizer paid about a billion dollars in civil penalties and
then----
Mr. Conyers. A billion?
Mr. Collins. Billion. And then $1.3 billion was paid by
two--Pfizer----
Mr. Conyers. What did they do?
Mr. Collins [continuing]. Subsidiaries. They were engaged
in illegal--what we call off-label marketing, where they were
marketing drugs for a purpose that had not been approved by the
Food and Drug Administration. And there was a criminal
component to that case as well. Pharmacia and Upjohn, which
are----
Mr. Conyers. Okay.
Mr. Collins.--Pfizer subsidiaries----
Mr. Conyers. What other corporate crime investigations have
you checked into?
Mr. Andres. Mr. Chairman, the Pfizer case that was
referenced is one that was handled by the Department of Justice
both on the civil and criminal fronts. There are other cases as
well.
Mr. Conyers. Like what?
Mr. Andres. Well, sir, I can provide the specifics--I think
there are specifics in my written testimony, but I am happy to
get back to the Committee with----
Mr. Conyers. Well, what about the names? Name me some nice
famous pharmaceutical names.
Mr. Collins. Eli Lilly.
Mr. Conyers. Right.
Mr. Collins. Merck.
Mr. Conyers. Merck?
Mr. Collins. Yes.
Mr. Conyers. Okay.
Mr. Collins. And Ely Lilly are a couple more examples.
Mr. Conyers. All right. More.
Mr. Andres. There is a medical device manufacturer, Norian
Corp, that was prosecuted in the Eastern District of
Pennsylvania. That involved individuals who pled guilty to
misdemeanor offenses as responsible corporate officers in July,
and they are awaiting sentence.
There is also the Serono Laboratories, a subsidiary of a
Swiss drug manufacturer.
Purdue Pharma was a case that was handled in the Western
District of Virginia. And there are others.
Mr. Conyers. Mr. Collins, did that cover what you had in
mind?
Mr. Collins. It is. I think if you would look at it, Mr.
Chairman, most of the pharmaceutical companies in some way or
another have, at one point or another, run afoul either of the
criminal law or, more likely, of the Federal False Claims Act
and been prosecuted civilly for those types of violations.
Mr. Conyers. Please keep our Committee Chair and this
Committee advised of these.
Now, last, why do I keep seeing ads on television that say
you can get a power wheelchair or scooter free and it will be
paid for by the government?
Mr. Menke. I believe you are talking about The SCOOTER
Store, and we had a case and entered into a settlement with
that particular----
Mr. Conyers. They are still----
Mr. Menke [continuing]. Company.
Mr. Conyers [continuing]. Advertising.
Mr. Menke. Yes, they are, sir.
Mr. Conyers. Why?
Mr. Scott. The time on the floor has expired some time ago,
so there--I think we need to recess at this time, and we will
come back right after the votes, so it will be about 15
minutes.
[Recess.]
Mr. Pierluisi. [Presiding.] So the Subcommittee is back and
in order, and we will continue with the hearing.
Chairman Conyers was asking the panelists some questions
before we went on our recess, so now it is your turn, Judge
Gohmert.
Mr. Gohmert. Thank you so much.
And again, thanks for being here and particularly for your
patience. I know the money we pay witnesses is not that good.
People at home or whoever may not know that you don't get
paid anything, so we know it is a sacrifice to be here and
especially put up with questions from us. But we appreciate
that.
Let me start with my right, Mr. Frogue. And from a personal
standpoint, I really appreciate all the insights that you had
given me as I put together a bill and filed for health care
reform.
And I even appreciate the President last week and this week
acknowledging that we have some Republican bills out there.
But it was very clear to me from working with you in trying
to craft effective health care options that you know your
stuff, and you have seen and studied where the fraud is, what
can be done about it, how it could be corrected.
Let me go to the issue of the Center for Medicare and
Medicaid Services. It appeared or it occurs to me from things
that you have said here today and previously that that may be
the weakest link in the process for detecting and preventing
fraud. So would you elaborate on that, if that is, indeed, your
feeling?
Mr. Frogue. Sure, Congressman. Thank you for the nice
compliment and the question.
As I mentioned in one of my bullet points, I think it would
be a very valuable experiment at the very least to outsource
the authentication of new Medicare suppliers to someone other
than CMS, because the weakest point is how easy it is to become
a supplier.
And as I said, there is no constitutional right to become a
Medicare supplier, but that is how most people treat it. You
fill out the application, you get to be a supplier, and you get
to start billing away.
And if you said, you know, Miami-Dade County, or Houston or
Dallas, or Los Angeles or anywhere else--if you just said in
this particular county, we are going to say, ``All right,
someone other than CMS is both going to run a bidding process
and win the contract,'' there is no way they could do worse.
There is no way they could do worse, to see why it is that
we have, as I said in my opening, 897 home health agencies in
South Florida when there is fewer than that in the entire State
of California. I mean, that kind of stuff is just crazy, and it
happens all the time.
The number of HIV infusion therapy centers in South Florida
was just way disproportionate to the rest of the country. And
these kind of things just aren't detected very often until
well, well after the fact.
Mr. Gohmert. Well, and you bring up infusion therapy.
Mr. Menke, my understanding was that infusion therapy is
not that widely used anymore, but from the information seen
historically it has been a significant item for which Medicare
still gets billed.
Can you comment on that and how you deal with--how we
should go about dealing with treatments that possibly should
not be very frequently paid for?
Mr. Menke. Thank you, Congressman. We have seen a reduction
in the Medicare billing, in Part B billing, for HIV infusion in
Miami. But these crimes are viral. We address it in Miami, and
then all of a sudden HIV infusion starts increasing in Detroit.
One other disturbing thing that we have seen recently is
that beneficiaries that were getting HIV infusion which were
not getting any infusion at all--it was outright fraud--are
being de-enrolled from the Part B side, slid over to the Part C
side in managed care, and the same scheme is going on.
What I could suggest is the private sector has an
opportunity to work with CMS in order to put appropriate
technology so that edits can go across the board, from Part A
right through Part D, instead of targeting one particular part
of Medicare, and then only for high-volume fraud areas, because
we shouldn't punish the people in Wyoming for delayed payments
just because there is a hot spot--and I am just picking States
out here--because there is a hot spot in Houston or Los Angeles
or Miami.
Mr. Gohmert. Well, and Mr. Collins, the shifting that Mr.
Menke is talking about is something I understood you had seen.
How do we deal with entities who are caught moving from one
place to another, setting up shop? What is the best way, in
your opinion, to deal with that?
Mr. Collins. It can be kind of catch as catch can,
especially if you have----
Mr. Gohmert. But we got to get beyond that.
Mr. Collins. That is true, and especially--it can be
especially problematic in towns that straddle a State line, for
example--Omaha, Nebraska, Council Bluffs, Iowa--something like
that, where you have got a provider who might be excluded on
one side in Iowa, and we might not know of an exclusion on the
other. Now there is a national exclusion database that takes
care of those issues.
But as far as being involved in fraud on the civil side,
which is handled as a civil matter, it is difficult to track
those, except that--unless there is something put into the
provider agreement when they first enroll in the State Medicaid
program so that they can be screened and so that you can check
to see what had happened in other States where they had
operated.
But what you have to understand is, especially if these are
operating as corporations or as shells--you know, you can call
it ABC Corporation in one place, and 123 Corporation in
another, and it is run by the same folks who run the same scam,
and it can be difficult to catch that way if they have just
been pursued civilly.
So it provides--excuse me--a really difficult situation
when they move from State to State.
Now, our national association keeps track of these things.
When we see a trend where a certain company or a certain group
of individuals has been engaging in improper conduct, that is
something that we can kind of send out amongst all the Medicaid
fraud directors in 50 States.
But that is a more informal process. For example, we have
had a situation where we had a provider in Colorado who the
Colorado MFCU had basically run out of town, and it was thought
that they would be headed to Nebraska. And when that was about
to occur, the Colorado MFCU called us and said, ``Be on the
lookout.''
And so just like any State law enforcement agency or local
law enforcement agency does, you cooperate that way and try and
share information.
Mr. Gohmert. Well, it seems like that has been a
shortcoming when it comes to Medicare fraud. There hasn't been
as much sharing.
And I appreciate the indulgence of the Chair. My time has
expired. But let me just remind the witnesses that they--there
is so little time in this hearing. You have so much knowledge
and information.
And as the Chair pointed out earlier, this is really a
bipartisan effort, and we want to get to the bottom in dealing
with this widespread fraud. So any thoughts you have that you
haven't been able to get out, that is not in your written
testimony, things that you think of, ``You know what? Congress
ought to do this. They ought to do that. You know, this might
be able to stop this.'' Please get that to us.
Don't think when the hearing is over we don't want to hear
from you anymore. We need to hear from you. Thank you.
Thank you, Chair.
Mr. Pierluisi. Thank you.
I will ask some questions myself. Actually, I have to say
that the timeliness of this hearing is--it couldn't be better.
At a time when we are all trying to improve the health care
system in America, we should be looking at existing programs
and making sure that there is no abuse, there is no waste, no
fraud. And that is precisely what you all are doing. And I
commend you for that and for appearing here before us.
I want to ask a couple of questions about the statistics. I
saw that Chairman Scott gave an estimate of about $60 billion
being lost to fraud in both the public and private health
sector.
And then I believe Mr. Frogue mentioned--or used the figure
of $70 billion at some point. I might get that wrong. Could you
help me in understanding the size of this problem?
I know that we are talking about estimates. But still, what
is the size, maybe splitting it between or among Medicaid,
Medicare and the private health plans?
Mr. Frogue. Sure, Congressman. It is a great question, and
the scope of it is bigger than most people can get their head
around. Like I said in my opening, the Thompson Reuters study
said up to $175 billion is just flat-out fraud, across the
system.
``60 Minutes'' had asserted $60 billion a year just in
Medicare fraud.
And New York Medicaid--if 40 percent of all claims are
questionable, that is $20 billion a year in one State's
Medicaid program that might be going to places where it
shouldn't go.
But the biggest problem is that nobody actually knows,
because the data collection is so non-transparent. I think that
is the biggest issue.
And I will let the other witnesses speak from their points
of view, but all the data is out there but just not shared with
the right agencies. It is just not shared with the general
public.
And it is shared with academics in some regard, like the
Dartmouth Health Atlas and a bunch of others, so it can be
shared in a way that protects patient privacy, which is very,
very, very important.
But the data is siloed between Medicare Part A and Part B
and Part D, between Medicare and Medicaid. You can't get full
pictures. And the fact that--I mean, this is actually stuff
that really shouldn't cost very much, if anything at all, to
solve.
Just let CMS--force them to share data better so that you
are not paying people that bill, you know, 500 wheelchairs in
an area where there is not even 500 people who need
wheelchairs.
Mr. Pierluisi. Yes? Mr. Menke, yes.
Mr. Menke. Thank you. Looking at some of the midrange
estimates out there--and I know the $60 billion figure came
from the National Health Care Anti-Fraud Association.
If we take that midrange number and we take a look at
Hurricane Katrina, we have had three Hurricane Katrinas in
health care fraud in the past 5 years, looking at the payouts,
if that puts it into perspective.
And I know the numbers are all over the place. I think what
I have seen personally, if you want to cut to the chase here,
the biggest impact I have seen recently is cabinet-level
attention to the fraud effort that has really brought CMS
around to start focusing in on antifraud efforts and program
integrity more than they have done so in the past.
They are paid to cut checks. And if I am a legitimate
provider, I would like to be paid on time, between 15 and 30
days. What I have seen with Secretary Sebelius and Attorney
General Holder making this a cabinet-level priority, we have
seen people basically fall into line and change their attitude
about how they look at fraud.
I have seen much more cooperation from CMS in the past 9
months than in all the previous time I have dealt with CMS.
That is making a difference.
Mr. Andres. If I----
Mr. Pierluisi. That is good to hear.
Mr. Andres. If I could just follow up on that because we
are seeing that many of the fraud schemes are, in fact, viral:
they moved from an area in Miami to an area in Detroit when
enforcement in Miami was ramped up. This is one of the reasons
why it is important that we continue the strike force model and
why we have asked for additional money so that we can increase
the number of strike forces up to 20, so that when a group of
fraudsters moves from one area of the country to another and
are, in effect, perpetrating the exact same fraud scheme--
whether it is the HIV infusion, or it is the DMEs--we are ahead
of the game. We have learned that is an issue, that is an area
that is going to be exploited within the system, and we need be
prepared to move forward with prosecution.
Mr. Pierluisi. Yes. On the enforcement side of this, I am
intrigued about--how are you picking these new 20 cities in
which you will have this strike force working?
Mr. Menke. We have put together a data analysis team, and
they take a look at trends nationwide. They do mapping on--we
see spikes in some areas of the country where it is 2,000
percent above the national average. We call that a clue.
And what we start doing then is narrowing down the region,
the city and even a zip code, and we do mapping, and we work
with our partners at the Department of Justice who are also
involved in this process, as well as analysts from Centers for
Medicare and Medicaid Services.
And we can narrow down hot spots not only regionally but
also in particular billing areas. And that helps us in our
conversations in the HEAT operations subcommittee on
identifying future cities to put strike forces in.
Mr. Pierluisi. And on the prevention side, Mr. Frogue came
up with a good list of ideas, initiatives. I particularly like
the pre-screening of claims and adding the ``under penalty of
perjury'' to a lot of this paperwork that is submitted by the
suppliers.
I wonder, though, whether any of you, the other three
panelists, can add to that conversation--prevention side. What
can we do better prevention-wise?
Mr. Menke. Thank you, Congressman. Vetting on the front end
is absolutely essential for prevention to keep the crooks out
from getting in.
Even though it doesn't specifically address perjury, I have
got an enrollment claim form here that I would be happy to
provide to the Subcommittee. In section 14, it doesn't address
perjury, but it has multiple different areas where the person,
if they are committing false statements on the form, is subject
to criminal penalty.
But prevention is absolutely key, in vetting with CMS'
implementing surety bonds as well as accreditation processes on
the front end to keep the crooks out.
We have two different types of patterns here. We have the
outright 100 percent fraud. Crooks come into health care
because it is easy. And then we have legitimate providers who
cross over the line and put their hand in the cookie jar type
of a deal. Those are the two different types that we are
seeing.
We need to keep the outright crooks out from the beginning,
and that is--that is what the strike force is addressing.
Mr. Pierluisi. Well, I have exceeded my time, and I am
afraid Judge Gohmert will start overruling me. So I will let
you take over, Judge--or, I am sorry, Mr. Goodlatte, if you
would like to question the witnesses, you are welcome.
Mr. Goodlatte. Well, thank you, Mr. Chairman.
Mr. Menke, I would like to follow up with your conversation
with Chairman Scott about the wheelchairs and the scooters. Can
you tell me some more about that?
Are you actively investigating fraud? Are you taking any
measures? Have you recommended to CMS that they take any
measures to tighten up their screening process for who gets
those?
Mr. Menke. Yes, Congressman, we have. We entered into a
civil settlement with The SCOOTER Store specifically regarding
the scooters and wheelchairs.
Mr. Goodlatte. Is The SCOOTER Store a manufacturer or do
they sell a variety of products manufactured by other entities?
Mr. Menke. I am not sure. We can get back to you on that,
sir.
Mr. Goodlatte. All right.
Mr. Menke. The SCOOTER Store did enter into a corporate
integrity agreement for establishing a compliance monitoring
within as well as training, and our Office of Counsel at the
Office of Inspector General worked on that corporate integrity
agreement.
The commercials continue. And I think sophistication with
language and how they say certain things in the commercials--
sometimes you can dance around corporate integrity agreements
and still be in compliance. So we are monitoring the situation
very closely.
Mr. Goodlatte. And how do they get people who are not
eligible medically for these devices to get them? Don't they
have to have the cooperation of some physicians, or----
Mr. Menke. Yes, sir. We see a combination, either forged
prescriptions through identity theft, where someone purports to
be a physician, or they pay a physician kickbacks in order to
write prescriptions for medically unnecessary equipment such as
a power wheelchair.
A power wheelchair runs around $5,000. The scooter runs
around $1,900. But the power wheelchair is almost like a car.
You can get a stripped-down version of it, and then they add
all the extras, the balancing equipment, inflatable chair--
inflatable seat, all kinds of extra things that they can bill
on top of the basic model.
And their profit margin--if they do deliver something,
their profit margin, even if they deliver the power wheelchair,
sometimes $2,500. Some areas----
Mr. Goodlatte. Do you get involved in that aspect of it at
all, the pricing of it, or is that strictly something made by
regulators at CMS, the decisions about what is Medicare going
to pay for these devices?
Mr. Menke. Those are decisions made by CMS.
Mr. Goodlatte. All right. And what about the repairs? I had
a constituent dealing with the Hoveround Corporation who was
charged $2,114 for repairs, which were mostly related to, like,
replacing an arm and fixing the seat. It wasn't even the
mechanical aspects of it.
And the breakdown of these charges were astonishing--
several hundred dollars to replace the arm or fix the--one of
the arms on the chair, almost half the price of the device,
based upon what you just told me.
And we are getting kind of vague responses from CMS on
that. Have you looked into that area at all, what the companies
are charging? Some of these people have had these chairs for a
long time now. Obviously, they are going to wear. They are
going to need repairs.
But in this instance, $2,114 was charged. Medicare approved
$1,553 of that and paid $1,227. My constituent was billed $306
of that.
And we have written letters--Congressman Camp, who is the
Ranking Member of the Ways and Means Committee, has written
letters--and not gotten really any definitive response on
anybody looking into whether these repair items are not a scam
in themselves.
Mr. Menke. I am not familiar with the repair angle. We may
have ongoing cases in that area. We have about 5,000 open cases
a year. But once again, I would suggest to the American public,
if it doesn't pass the smell test, let us know about it.
Mr. Goodlatte. Yes.
Mr. Menke. There is common sense involved with this.
Mr. Goodlatte. We will let you know, but I think we are
writing to CMS. But I will send you this information as well.
If you could look into it, and if you would let the Committee
know not about this specific case, but about what your
experience is in general, I would appreciate it.
And then, Mr. Chairman, with a little forbearance, if I
might ask each of the other panelists if they have any
experience with this issue of fraud either in the purchase, in
the approval process, or in the repair of these devices.
Mr. Andres?
Mr. Andres. Sadly, we are more often dealing with the
people that are given wheelchairs that have no medical
necessity for them, so most of the fraud schemes either involve
cases where the beneficiaries and the doctors are themselves
complicit in the fraud and the devices are simply not medically
necessary, or the instances where there is identity fraud,
where individuals' and doctors' information is being stolen for
a different scam.
And obviously, in those cases as well, the services are
never rendered.
Mr. Goodlatte. And you are prosecuting people for that type
of fraud?
Mr. Andres. Absolutely.
Mr. Goodlatte. Is a physician getting a kickback? Is that
the----
Mr. Andres. That is correct. Those individuals, the
physicians, the nurses, are being prosecuted for those crimes.
Mr. Goodlatte. And when you answer your questions to
Congressman Poe, who asked you earlier about those who had
receive jail time, would you let us know if there are any who
have actually been imprisoned for fraud related to these power
devices?
Mr. Andres. To the repair or to the----
Mr. Goodlatte. Either one.
Mr. Andres. Okay.
Mr. Goodlatte. I am as interested in the sale as in the
repair, but I just wondered whether there was anything being
done about these repair charges.
Mr. Andres. Certainly.
Mr. Goodlatte. Mr. Collins? Mr. Frogue?
Mr. Collins. I do know that in the District of Nebraska
that one of the scooter stores was the subject of a criminal
prosecution federally in the last couple of years.
Due to, you know, the rural nature of our State, that is
the only case that I am aware of that we have had to deal with
the scooter issue.
Mr. Frogue. Congressman Goodlatte, I would just make two
broader points. One is this article that someone sent me this
morning from the South Florida Business Journal. It says,
``Like bugs scurrying out from under an overturned rock, the
perpetrators of health care fraud in South Florida are finding
new schemes to hide behind to siphon off public dollars.''
So even if you ended all fraud in wheelchairs tomorrow,
they would be off to something else before you even know it.
And I am happy to give this to anyone who wants to see it. But
it was HIV infusion therapy, which is still a problem, but home
health now is a huge, huge issue.
The other quick comment I would like to make is so much of
this flies under the radar screen. You hear about the large,
you know, pharmaceutical settlements and all that, and that is
very significant.
But as long as it is under a certain threshold, whether it
is a few hundred thousand dollars or a few million dollars, law
enforcement just doesn't have the resources and time to go
after the small guys. And so if you are--as long as you keep
your crimes to $50,000, $80,000 a year, you are probably going
to get left alone.
So the signal to criminals is just don't get too greedy and
you won't have a problem. And ``Tony'' in the ``60 Minutes''
piece made the point, ``There are thousands of people like
me.'' He just got a little too greedy and a little bit unlucky.
But if you keep it under a certain level, you can--these things
will go on forever.
And that multiplied by all the people doing it across the
country is actually much, much bigger that the marquee
settlements you hear about.
Mr. Goodlatte. What is the solution to that?
Mr. Frogue. The solution is to have the data out there--the
biggest solution of all, and I think I speak for everyone on
the panel, but please correct me if I don't. The biggest
solution is to pre-screen the payments before they go out the
door.
And that is what the credit card industry does. And the
credit card industry is bigger and arguably as complex as
Medicare and Medicaid, and they do it, because we all know it.
If you travel somewhere and make a big purchase, they ask you
for I.D. There is nothing like that in Medicare fee-for-
service. That is the biggest problem.
It is very simple. We all understand it, because it has all
happened to us, and it is not a big deal. If we would add that
to Medicare, the potential savings are easily into the
billions.
Mr. Goodlatte. I agree, and I would just add that I also
agree with Congressman Poe that we would like to see some of
these folks, large and small, serving some jail time and a lot
of other people hearing about the fact that they are in prison
for these outrageous ripoffs of the public.
Mr. Pierluisi. Okay. Chairman----
Mr. Goodlatte. Thank you, Mr. Chairman.
Mr. Pierluisi.--Chairman Scott is back with us, so he will
probably want to continue his line of questions.
Mr. Scott. [Presiding.] Let me just ask a question on
recommendations. We have had a lot--what we would like to hear
from you are specific recommendations on how to do audits,
policies and procedures, fraud detection, and whether or not we
need legislation to do that or whether it can be done
administratively, and also what--whether or not we are
providing the Administration sufficient resources for
investigations and prosecutions.
And if the ball is in our court, put the specifics in our
court so we know what we are dealing with. And I think the
testimony is clear that if we put more money into
investigations and prosecutions, we would get more back than we
are spending.
So we should not be shy--with the level of fraud and crime
going on, we should not be shy in going after it and curing the
problem.
Mr. Andres. The Department of Justice is asking for
additional resources so that we can increase the number of
strike forces in different cities.
As I explained, since some of these schemes are viral and
they move from one city to another, we need to be in a position
to anticipate that and to be in the areas where they are--where
the fraud will occur so that we can deal with those
prosecutions and have the deterrent effect of these people
going to jail and serving significant jail sentences.
That in and of itself will serve some deterrent effect
after the fraud has happened.
Mr. Scott. And if there is some procedures we can go
through, research or best practices that we can disseminate in
the private sector that could apply to the Medicaid and
Medicare, if you could help--if any of the panelists can help
us on that--and if it costs money to try to implement them that
Medicare and Medicaid presently doesn't have, perhaps we need
to authorize expenditures in those areas.
But whatever we need to do. I think after the Ranking
Member showed the clip from ``60 Minutes,'' obviously, we are
in an embarrassing situation that we want to cure.
Mr. Collins. Well, one thing, Congressman, that is an issue
on the Medicaid side of the house and provides an obstacle to
Medicaid fraud units being able to pursue some of these
providers is Federal regulation that prohibits Medicaid fraud
units from engaging in data mining.
We have been in discussion with folks from the U.S.
Department of Health and Human Services and with the Justice
Department concerning this prohibition. But the current rules
break down the process so that data mining is to be done by the
program integrity unit of each State's Medicaid program, which
is kind of the State equivalent of CMS.
But a lot of times, those program integrity units in State
Medicaid programs are understaffed and don't have the time and
the resources to do the data mining. Medicaid fraud units would
love to be involved in data mining, but the the Code of Federal
Regulations----
Mr. Scott. Who funds the----
Mr. Collins [continuing]. Prohibits us from doing that.
Mr. Scott [continuing]. State offices--fraud detection
offices? Who funds these State fraud detection--you are in
Nebraska, right?
Mr. Collins. Yes, sir.
Mr. Scott. Who funds your office?
Mr. Collins. In the MFCUs?
Mr. Scott. Yes.
Mr. Collins. Okay. Medicaid fraud units across the country
are funded 75 percent with Federal dollars and 25 percent with
State dollars throughout the duration of their operation.
Mr. Scott. And I suspect that with the budgets that States
have, there is not going to be much increase in the 25 percent.
Mr. Collins. I would be surprised, sir.
Mr. Scott. So if we want to do something, we might have to
do it with no match or a better match than that. And Medicaid
will do--would save more money than we spend in that area.
Mr. Collins. I think so, Congressman, but I don't even know
that it is necessarily an issue where resources have to be
expended.
But I think it is--if we were--if we would be allowed to
engage in data mining ourselves rather than relying upon
Medicaid agencies doing the data mining for us, I think that we
would reap the benefits of that for both the State governments
and the Federal Government.
Mr. Scott. Wait, wait a minute. The data mining that you
are talking about is being done but by doing--somebody else, so
we are not talking about new invasions of privacy. That is not
the issue?
Mr. Collins. No.
Mr. Scott. It is who does it.
Mr. Collins. It is who does it. The way the rules are
written now, the folks in the Medicaid program have a program
integrity unit that does the data mining. Medicaid Fraud
Control Units are not inside of the Medicaid program. Most of
us who have an MFCU operate within a State attorney general's
office.
The rules do not allow us to be involved in data mining, in
what they call random statistical analysis. If we were able to
do that ourselves, we would have more cases that we could
pursue.
Mr. Frogue. Mr. Chairman, if I might just emphasize his
point even more, that is exactly right. That wouldn't
necessarily cost a penny to let them do data mining.
And I talked to one State attorney general who said, ``I
would go even one better than that--is allow for contingency-
fee-based outsiders to come in at, say, 20 percent and also
look at the data,'' with full protections for patient privacy,
of course, which can absolutely be built in, and should be.
But the more eyes that are looking at this, the better. No
one program integrity unit is going to be as good as all the
other people who could look at this and find better ideas.
Mr. Pierluisi. [Presiding.] I believe Ranking Member
Gohmert has a couple of questions.
You may proceed.
Mr. Gohmert. Thank you.
And it really is just a follow up of what Chairman Scott
was talking about, what you have each been alluding to, but
this discussion about CMS sharing information--I was staggered
to find out by virtue of this hearing that CMS just has not
been good about sharing information.
And I understand, as Mr. Frogue was just saying, we have to
ensure patient confidentiality so that someone's medical
records are not just all over the place. But that can surely be
done--that information could be protected. We do that--DOJ
does--I mean, that is done in so many areas. It doesn't seem
like it would be a problem.
For Mr. Menke to find out that HHS I.G. has trouble getting
information from CMS in the past is just staggering to me. If
there is anybody that should have been able to just say, ``We
need to see this,'' have adequate protection for patient
protection and get it, my goodness, it ought to be you.
So we need to know what we need to do to help you do your
job. And of course, I think people on both sides of the aisle,
when it comes to DOJ, we recognize the balance that there is
between protecting society and not being too much--too invasive
into society, like--was thinking about--while there was talk
here about, you know, if we can anticipate.
You don't want to get to the point that that Tom Cruise
movie did, where you arrest people because you figure they are
going to commit a crime in the future, so arrest them now. We
don't want to get there.
But it seems that if CMS could share information with HHS
I.G., and then when you see these patterns, man, that stuff
ought to be going to DOJ. We don't want you out there actively
recruiting, you know, in case somebody might commit a crime.
But when there is patterns that could just be provided--and
of course, that is what we have seen from a law enforcement
standpoint when it comes to the courts having said that a pen
register, for example, is not protected and you don't
necessarily have to get a warrant for a pen register.
But for any information that goes with it, whose it is, you
know, all that kind of stuff, that is when we require a
warrant. But it seems like there ought to be a way to data mine
without getting into personal information that picks up when
you have got somebody that is, you know, billing for five
chairs out of the same house, or whatever it is.
Those things ought to be able to be picked up. So any
thoughts you may have--you will think about it after the
hearing--ways that we can effectively pass not regulation, but
just a law saying, ``This is what you got to do.''
We are going to protect personal data, but we have got to
do a better job of sharing information with the people that can
use it and do something about it. So please keep that in mind.
Forward us any information you have.
I know Chairman Scott--I know all of us would like to see
that and try to craft something to make your job not only
easier but far more effective than you--it just seems like you
got your hands tied. And we have got to unburden you so that
you can do your jobs.
So thank you very much.
Mr. Pierluisi. On behalf of Chairman Scott and all the
Members of the Committee or the Subcommittee, I would like to
thank the witnesses for their testimony today.
Members may have additional written questions which we will
forward to you and ask that you answer as promptly as you can
so that they may be made part of the hearing record.
The record will remain open for 1 week for submission of
additional material.
Without objection, the Subcommittee stands adjourned. Thank
you.
[Whereupon, at 12:24 p.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Material Submitted for the Hearing Record