More than 345 people, including 100 licensed medical professionals, were charged in what the Department of Justice called its largest healthcare fraud enforcement action to date. The massive investigation found more than $6 billion in alleged fraud from telemedicine, substance abuse treatment facilities and opioid distribution schemes.
Roughly $4.5 billion of the total was tied to kickback schemes involving telemedicine. Companies allegedly paid doctors and nurse practitioners to order unnecessary medical equipment, tests or pain medication. In exchange, they received kickbacks from medical equipment suppliers or genetic testing laboratories, according to the DOJ report.
For example, in one case investigated by prosecutors in Florida, New Jersey and Southern California, two San Diego men were charged with conspiracy for reportedly paying kickbacks for durable medical equipment claims, which they submitted to Medicare and other programs.
The claims were generated using telemarketing along with paying kickbacks to telemedicine doctors who rarely spoke with the patients. According to the U.S. Attorney’s Office for the Middle District of Florida, they had at fraudulently established at least 22 medical equipment companies across the state.
In another case, the owner of a telemedicine company pled guilty for a kickback scheme that involved paying call centers and healthcare professionals in exchange for ordering Medicare patients medically unnecessary genetic cancer screening tests. The case, brought by the U.S. Attorney’s Office for the District of New Jersey, attributed roughly $414 million of healthcare fraud to this scheme.
“Telemedicine can foster efficient, high-quality care when practiced appropriately and lawfully. Unfortunately, bad actors attempt to abuse telemedicine services and leverage aggressive marketing techniques to mislead beneficiaries about their health care needs and bill the government for illegitimate services,” HHS Deputy Inspector General Gary Cantrell said in a news release. “Unfortunately, audacious schemes such as these are prevalent and often harmful. Therefore, collaboration is critical in our fight against health care fraud.”
A Deep-dive Into Specialty Pharma
A specialty drug is a class of prescription medications used to treat complex, chronic or rare medical conditions. Although this classification was originally intended to define the treatment of rare, also termed “orphan” diseases, affecting fewer than 200,000 people in the US, more recently, specialty drugs have emerged as the cornerstone of treatment for chronic and complex diseases such as cancer, autoimmune conditions, diabetes, hepatitis C, and HIV/AIDS.
Separately, the CMS Center for Program Integrity announced it would revoke the Medicare billing privileges of 256 additional healthcare professionals for their involvement in telemedicine schemes.
The American Telemedicine Association (ATA), which has been lobbying for expanded coverage of telehealth, said it was “appalled” at these schemes and emphasized that they do not represent legitimate telemedicine practices.
“Covid-19 has driven unprecedented demand for telehealth services as patients seek more convenient care, but historic legacies of ‘pill mills,’ illegal online pharmacies, or illicit telemarketing schemes to defraud Medicare have rightly led to concern. It is important to note that these examples of illegal operations are not legitimate telemedicine services,” ATA CEO Ann Mond Johnson said in a statement. “We agree that it is critical to differentiate between telehealth providers and fraudulent outfits as the latter can threaten public confidence in new technologies and care models that benefit growing numbers of patients and providers.”
Photo credit: Feodora Chiosea, Getty Images
