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  4.  | How Does The DOJ’s Health Care Fraud Unit Identify Fraud?

How Does The DOJ’s Health Care Fraud Unit Identify Fraud?

On Behalf of | Oct 18, 2023 | Health Care Fraud

Allegations of healthcare fraud typically result in federal prosecution. The use of banking systems and state insurance programs funded by taxpayers all but ensures that federal authorities have jurisdiction in cases involving substantial healthcare fraud. Professionals implicated in healthcare fraud causes can face incarceration and financial penalties, as well as licensing penalties that can affect the future of their careers.

The Department of Justice (DOJ) has established a Health Care Fraud Unit that employs more than 80 specialized prosecutors. This unit first identifies cases that seem likely to involve fraud and will then investigate and eventually prosecute them when appropriate.

How does the Health Care Fraud Unit determine what professionals or healthcare organizations have likely committed acts of fraud?

The use of cutting-edge software

Data analysis and certain proprietary algorithms allow the Health Care Fraud Unit to screen insurance claims and business practices rapidly for warning signs of likely fraud. The claims submitted for reimbursement, including claims made against military health insurance, Tricare, and state-run insurance programs like Medicare and Medicaid, can trigger closer review if there seem to be concerning trends in how a business operates.

This software can potentially spot signs of unbundling, which involves billing for services separately instead of at a combined, discounted rate. The software can also identify trends in treatments provided to patients or the billing practices at individual medical offices.

The use of multiple agencies

The Health Care Fraud Unit looks into both insurance fraud and dangerous prescription practices. The organization will collaborate with a variety of other agencies to gather evidence. The Federal Bureau of Investigation (FBI), the Department of Health and Human Services (HHS), the Drug Enforcement Administration (DEA) and even the United States Postal Service (USPS) can cooperate with the Health Care Fraud Unit to gather or analyze data about possible health care fraud.

There are nine independent Strike Force teams, many of which are regional. There is also a specific Strike Force focusing on prescription fraud and another prioritizing rapid response. Professionals implicated in a healthcare fraud case will often require a thorough review of federal evidence to establish a workable defense strategy.

Learning more about how federal authorities develop health care fraud cases may facilitate a better response to a pending investigation or recent indictment. Seeking informed legal guidance can help individuals to obtain this kind of clarity and support.