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Pinnacle Speaker: Many Healthcare Fraud Cases Come Via Disgruntled Employees

healthcare fraud

"If you're doing something wrong, you might want to have a strong relationship with your wife," said FBI Special Agent Shaun O'Neill during his presentation, "Chasing the Medicare Dragon: An FBI Investigator's Perspective," Wednesday afternoon Aug. 9 at the Pinnacle conference in Boca Raton, Fla.

One-third of healthcare fraud and abuse cases come to the Bureau via disgruntled employees and ex-spouses, said O'Neill, who has more than 19 years of experience working high-profile criminal matters for the FBI. Other sources of fraud cases in the healthcare realm include qui tam (whistleblower/False Claims Act) suits, billing inconsistencies and referrals from other law enforcement agencies.

Common ambulance fraud schemes include billing for medically unnecessary services, transport "upcoding," billing for services not rendered during transport, the anti-kickback statute and participating in unlawful agreements with healthcare facilities, said O'Neill, who currently supervises a squad of agents and analysts that investigates healthcare fraud, public corruption, civil rights and human trafficking.

With added scrutiny on healthcare billing in light of skyrocketing spending in this sector, O'Neill offered advice for EMS administrators.

"How do you stay off the radar screen?" asked O'Neill. The basics: Whether a company is small or national, you have to do the basic things right. Know your coverage requirements. "Ignorance is not a defense," O'Neill said. That defense won't hold up against the government or the federal jurors.

Constantly be up to date on training and knowledge, O'Neill advised. Other tips:

  • Written policies & procedures;
  • An experienced compliance officer;
  • An anonymous ethics hotline;
  • Continuing employee education;
  • A robust internal audit program;
  • Knowledgeable legal counsel; and
  • Proper documentation

Finally, document everything. At some point, you'll be facing a compliance officer and a potential audit, and you'll have to present and defend your policies. "It's not 'if,' it's 'when,'" O'Neill said. And agency administrators in need of advice in these matters should approach federal regulators proactively, rather than waiting until a case is brought forth. "I'd rather talk to you in a suit than in a blue rain jacket," O'Neill said.

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