The U.S. Department of Justice announced Wednesday it is charging hundreds of individuals across the country with committing health care fraud worth hundreds of millions of dollars, in what is being hailed the largest health care fraud bust in U.S. history. Here are the five fast facts you need to know.

1. 301 People Charged in Health Care Fraud Bust

The bust resulted in the takedown of 301 individuals, including 61 licensed medical professionals, 28 of whom were doctors. The charges include various health care fraud-related crimes, including conspiracy to commit health care fraud, violations of the anti-kickback statutes, money laundering, aggravated identity theft, and Medicare Part D pharmacy fraud.

Attorney General Lynch called out the alleged perpetrators in the release saying,

They target real people – many of them in need of significant medical care.  They promise effective cures and therapies, but they provide none.  Above all, they abuse basic bonds of trust – between doctor and patient; between pharmacist and doctor; between taxpayer and government – and pervert them to their own ends.

2. $900 Million in False Billings

The DOJ found the defendants to be responsible for a total of $900 million in false billings. The largest portion of fraudulent billings was traced to Florida, where a total of 100 defendants were charged for their involvement in approximately $220 million in false billings for home health care, mental health services and pharmacy fraud. According to the release,

In one case, nine defendants have been charged with operating six different Miami-area home health companies for the purpose of submitting false and fraudulent claims to Medicare, including for services that were not medically necessary and that were based on bribes and kickbacks.  In total, Medicare paid the six companies over $24 million as a result of the scheme.

Defendants in California, Texas, and Michigan are charged with committing more than $100 million worth of fraud in each state.

3. This Was a Joint Effort

Medicaid Fraud Control Units in 23 states and the Medicare Fraud Strike Force in 36 federal districts coordinated with the Justice Department and the Department of Health and Human Services in  the “unprecedented nationwide sweep.”

National Health Care Fraud Takedown Results https://t.co/LQk9OJpzKN pic.twitter.com/HMVFxvFrgd

— Justice Department (@TheJusticeDept) June 22, 2016

The Medicare Fraud Strike Force operations are part of the Health Care Fraud Prevention & Enforcement Action Team (HEAT), a joint initiative announced in May 2009 between the DOJ and HHS to help prevent waste, fraud, and abuse in the Medicare and Medicaid programs.

4. New Study Identifies 27 Home Health Care Fraud “Hotspots”

The U.S. Health & Human Services Office of Inspector General released a new study in conjunction with the DOJ’s arrests citing 27 geographical “hotspots” in 12 states where health care fraud is committed most often.

Eye on Oversight: OIG identified 27 hotspots for probable home health fraud. Watch the VIDEO. https://t.co/1KPY9RQe6D

— OIG at HHS (@OIGatHHS) June 21, 2016

The states include Arizona, California, Florida, Illinois, Louisiana, Michigan, Nevada, New York, Oklahoma, Pennsylvania, Texas, and Utah.

5. This Recent Bust Helped Pad Federal Authorities’ Record

Since its launch in March 2007, the Medicare Fraud Strike Force has charged over 2,900 defendants who collectively have falsely billed the Medicare program for over $8.9 billion. Wednesday’s announcement marks the second time that districts outside of Strike Force locations participated in a national health care fraud bust, and they accounted for 82 defendants charged in this takedown.

Alexis Evans

Alexis Evans is an Assistant Editor at Law Street and a Buckeye State native. She has a Bachelor’s Degree in Journalism and a minor in Business from Ohio University. Contact Alexis at aevans@LawStreetMedia.com.

The post 5 Fast Facts: The Largest Health Care Fraud Bust in History appeared first on Law Street.

The Affordable Care Act (ACA) never has a boring day in court, and today is no exception. Rulings were just made in two related ACA cases, and they couldn’t be more different. First, in a case called Halbig v. Burwell, the D.C. Circuit Court of Appeals ruled that people who get their insurance from the federal government exchange are not eligible for tax subsidies. More specifically, the 2-1 decision in Halbig says that subsidies are only permissible for those customers who enroll in health care exchanges run by individual states or the District of Columbia. Meanwhile, the Fourth Circuit Court of Appeals heard King v. Burwell on the same topic, this time ruling against the plaintiffs to hold the law as it stands. According to the Richmond, Virginia based Fourth Circuit Court, the federal government subsidies can stay. These rulings directly contradict each other, meaning that once again, the ACA’s status is uncertain.

As many states have opted to rely on the federal government’s exchange rather than establish their own programs, millions of Americans would lose tax credits for their health coverage if the D.C. Circuit Court’s decision stands. The ACA would lose much of its effectiveness in the 36 states that rely at least partially on the federal exchange. Before the Halbig decision was made, the Urban Institute reported that such a ruling, “would broadly undermine implementation of the ACA in [those] states, with substantial coverage and financial implications for their residents.” The report goes on to predict what monetary losses would be in 2016 for lower-income Americans who would have otherwise relied on those federal subsidies. Of the 11.8 million people projected to enroll in the federal government exchange, 7.3 million would likely receive tax subsidies. If the Halbig decision holds, those lower-income health care customers would lose $36.1 billion in 2016 alone, according to the Urban Institute report.

The Obama administration has now requested an en banc review of the case, in which all judges on the D.C. Circuit Court of Appeals would review the case. The fate of insurance subsidies in the states that rely on the federal exchange now rests in the hands of the 11 active judges on the D.C. Circuit Court.

In the Halbig case, the issue is the wording of the ACA. The law, as written, says that lower-income citizens are eligible for the subsidy if they receive insurance from “an Exchange established by the State under section 1311.” Because there is no mention of the federal government in the tax credit regulations, the D.C. Circuit Court’s interpretation limited subsidies to state exchange programs. Healthcare reporter Joe Carlson writes that such precise wording, “is widely seen as a drafting error.”

This discrepancy between the wording of the bill and the intention of the bill is what caused this debate. Jonathon Cohn of the The New Republic argues that at no point did lawmakers conceive that these tax credits should be limited to state exchanges. He wrote:

Not once in the 16 months I reported on the formal congressional debate did any of the law’s architects suggest they were thinking along these lines. It wouldn’t make sense in the context of the law, which depends upon those subsidies to accomplish its primary goal.

This was the same rationale behind the Fourth Circuit Court’s King decision. That ruling acknowledges the ACA’s linguistic ambiguity, and defers interpretation to the IRS, which did allow tax subsidies for people in the federal exchange. Further, the Fourth Circuit Court decision even included an analogy between Pizza Hut and Domino’s–comparing the similarities between the pizza chains to health coverage from a state and health care from the federal government. All argument aside, we all have to recognize that analogy is quite creative and apt–the two exchanges, like the pizza giants, are meant to provide the same service.

The conflicting arguments by the two appellate courts highlight the importance of the rift between semantics and intention. If the intention of a piece of legislation is so well understood that its literal wording is overlooked, are those who enforce that interpretation breaking the law? Or are they operating in accordance with the law? Furthermore, while the way that D.C. Circuit Court interpreted the law may seem overly strict, shouldn’t the legislature anticipate such questions and write laws exactly as they would like them to be enacted?

The cases are indicative of a philosophical disagreement between law as a means–the ACA was created to help insure those who can’t access health care–and the law as an end–the strict language of the ACA must be adhered to, regardless of why it was created. We aren’t just witnessing a dispute about tax credits; this may become a battle about the nature of law itself. The outcome has yet to be seen, but this proves that the battle over the ACA is far from over.

—

Jake Ephros (@JakeEphros)

Featured image courtesy of [Joe Mabel via WikiMedia Commons, Progress Ohio via Flickr, modified by Jake Ephros]

Jake Ephros

Jake Ephros is a native of Montclair, New Jersey where he volunteered for political campaigns from a young age. He studies Political Science, Economics, and Philosophy at American University and looks forward to a career built around political activism, through journalism, organizing, or the government. Contact Jake at staff@LawStreetMedia.com.

The post Conflicting Courts: Affordable Care Act Up in the Air Again appeared first on Law Street.

On October 22, 2013, the New York Times ran an article describing the various problems that have accompanied the roll out of a central tenet of the Affordable Care Act (Obamacare), www.HealthCare.gov.   The gist of the article focuses on the technical issues that the public has encountered when trying to shop the online marketplace for health insurance.  Essentially, the volume of interested potential buyers has diminished the ease with which the site was to be navigated.

Because of the apparently gargantuan inconvenience of a website loading slowly, there is a large demand for apologies from all levels of the government, starting with President Obama and trickling down to Department of Health and Human Services Secretary Kathleen Sebelius.

Indeed, after our government’s united front in reopening the government (after a shutdown that was their fault) and subsequent dangerous proximity to reaching the debt ceiling, it was shocking that Speaker of the House John Boehner called for the Obama Administration to answer questions related to the flaws in the website’s launch.

That was sarcasm, friends.

Because a glitch in a website visited by thousands of people a day is totally a reason to delay or repeal the availability of health insurance.  That’s also sarcasm.

These problems are called growing pains! Are they annoying? Absolutely.  But they happen- there is no need to make a mountain out of a molehill.  Especially when you consider what Americans stand to gain from the Affordable Care Act.  With health insurance, more people can visit their primary care physicians for routine physicals and for small aches and pains.  It’s often small aches that turn into large medical problems.  Large medical problems lead to large medical bills.  Similarly, there are catastrophic events.  Nobody plans to get hit by a bus on their way to work.  Nobody plans to be in a car accident.  These catastrophes happen, and health insurance provides a buffer of security the necessity of which is not always readily apparent.  When you’re in the thick of medical debt, though, you wind up kicking yourself for not taking advantage of small monthly insurance payments.  The utility of medical insurance, and the costs of that insurance, can be exponentially less than the cost of catastrophic care.  Emergency room visits by the uninsured, for example, have frequently been cited as one of the primary reasons for high costs of healthcare.

This all seems unnecessary considering the fact that we’re in the world’s super power, and that there are concrete examples of how a government-mandated expansion of healthcare can thrive (take France or Sweden, for example).

Do you guys know what this is called?  It’s called a stall tactic.  It’s also called a diversion.  This “controversial” roll out of the website is meant to distract you from what’s really going on.

“Well, what’s really going on?”

Oh nothing, just thousands of people being presented with an opportunity to have a primary care physician for the first time.

Just decisions about your health being ripped from the sole decision of a private insurance company that is more concerned with their bottom line than a rash on your arm.

At the end of the day, the website problems are frustrating, but they are not insurmountable.  The failure of a website to run as efficiently as we would prefer is certainly not a reason to engage in protracted political debates, especially after being so closely linked to a sixteen day protracted political debate that left hundreds of thousands of people out of work.  Health care, for now is debatable (it shouldn’t be, but it is).  Two things that are not debatable are the necessity for protections against the unpredictable occurrences in life and the inconvenience of a website that will eventually help thousands of people.

[New York Times]

—

Featured image courtesy of [Daniel Borman via Flickr]

Peter Davidson II

Peter Davidson is a recent law school graduate who rants about news & politics and raves over the ups & downs of FUNemployment in the current legal economy. Contact Peter at staff@LawStreetMedia.com.

The post Everyone, Let’s Lay Off the Obamacare Online Marketplace? appeared first on Law Street.