Invitation – Solutions: Curb Medicare Fraud

Six members of the Senate Finance Committee are appealing to the health care community – providers, payers, health plans, contractors, non-profit entities, consumers, data analytics entities, governmental partners, and patients – to provide suggestions for combating Waste, Fraud and Abuse in Medicare/Medicaid programs.

“Drawing on the collective wisdom and accumulated insights of thousands of professionals and individual experiences could offer a fresh perspective and potentially identify solutions that may have been overlooked or underutilized.”

The Government Accountability Office (GAO) indicates that few programs are as much at risk for fraud, waste and abuse as the Medicare and Medicaid programs. Estimates of the amount of fraud and misspending in these programs vary widely, from $20 billion to as much as $100 billion, according to the Senators’ Open Letter.

U.S. Health and Human Services’ (HHS) Centers for Medicare and Medicaid Services (CMS), working in conjunction with the HHS-Office of Inspector General (OIG), is taking steps to increase accountability and decrease the presence of fraudulent providers.

From February to April of 2012, reported fraud includes a former drug dealer in Miami who, as reported by the Miami Herald, changed to Medicare fraud because he viewed it as easy money. His 20-year sentence was cut in half after he helped to resolve “seven Medicare fraud cases involving a dozen defendants who plotted to steal $120 million from the taxpayer-funded program”. His attorney told the judge that “Miami prosecutors have convicted more than 1,000 Medicare fraud offenders since 2006 and that the vast majority are Cubans who came to this country in the past 15 years”. The perpetrator indicated that “only Cubans were involved. We try to keep it among us.” 

In March, as reported by the FBI-Detroit Division, three Detroit area clinic owners, Karina Hernandez; Marieva Briceno; and Henry Briceno, all of Miami, pled guilty for their roles in a $5.4 million Medicare fraud scheme. “At each clinic, Hernandez and Marieva Briceno hired recruiters who paid cash bribes to Medicare beneficiaries to attend the clinics and provide their Medicare numbers and other information. Hernandez and Marieva Briceno admitted that they used the beneficiary information to bill for medically unnecessary diagnostic tests and treatments. Henry Briceno admitted that he incorporated Manuel Medical Clinic and opened a bank account to conceal the actual ownership of the clinic.” According to court documents, the Clinics fraudulently billed Medicare for $5.4 million during the course of the scheme.

KHOU of Houston, TX, reported that three Houston-area psychiatric clinics picked up homeless people, brought them to their clinics, and let them watch TV while collecting information. They would then bill Medicare or Medicaid for the visits.They were raided
by FBI agents in April.

According to the FBI-Detroit Division, “since their inception in March 2007, the Medicare Fraud Strike Force operations in nine districts have charged more than 1,190 individuals, who collectively have falsely billed the Medicare program for more than $3.6 billion”.

At a Chicago summit highlighting new high-tech tools to be used against healthcare fraud, U.S. Health and Human Services Secretary Kathleen Sebelius and U.S. Attorney General Eric Holder said”, according to UPI, ” the Health Care Fraud Prevention and Enforcement Action Team — known as HEAT — helped recover more than $4 billion in fiscal year 2011 — an all-time high”. 

According to US Officials, “criminals face sentences 20 percent to 50 percent longer for Medicare fraud involving more than $1 million, under the Affordable Care Act”, reported UPI.

The six members of the Committeee extending invitations to the healthcare community for suggestions in curbing fraud, abuse, and waste are: Senators Tom Coburn (R-Okla.), Ron Wyden (D-Ore.), Chuck Grassley (R-Iowa), and Tom Carper (D-Del.), led by Orrin Hatch (R-Utah) and Chairman Max Baucus (D-Mont.)

We invite you to submit white papers offering your best ideas, built on years of experience and insight. We want to know what areas you see for improvement in current program integrity efforts, as well as additional solutions that we should consider,” says Committee members.

The general categories in which we the Committee seeks input are listed below. They expect that some recommendations may include multiple categories:

Program Integrity Reforms to Protect Beneficiaries and Prevent Fraud and Abuse
• Payment Integrity Reforms to Ensure Accuracy, Efficiency and Value
• Fraud and Abuse Enforcement Reforms to Ensure Tougher Penalties Against Those Who Commit Fraud

Those interested in “submitting white papers should email a PDF or Microsoft Word document to by June 29, 2012. Submissions should include summary information about the entity or individual submitting a white paper, as well as phone and email contact information. White papers should be as succinct and concrete as possible. When possible, please include cost-benefit or potential savings information.” They indicate that the staff will review submissions and compile a summary document highlighting key proposals later this year.

One may contact Julia Lawless or Antonia Ferrier and the Communications Office at 202.224.4515

News Release – Senate Finance Committee
Miami Herald
FBI-Detroit Division


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