Attorney General Jeff Sessions is poised to announce a major law enforcement action this week targeting health care fraud, focusing on opioid treatment programs exploiting Obamacare insurance plans, according to two people familiar with the matter.
In what is described as a nationwide sweep with hundreds of arrests being carried out across the U.S., the Justice Department is cracking down on fraudulent claims made to some of the nation’s biggest insurers, said one of the people.
People who run drug addiction treatment centers that have filed bogus claims and those who have filed reimbursement claims for drugs they then sell illegally are among those to be charged, the person said.
Arrests will be carried out in cities including Miami, Chicago, Detroit and Los Angeles, the person said. Scores of arrests are expected in southern Florida, which is home to hundreds of residential drug addiction treatment centers, said the person.
Federal prosecutors, some of whom have been working on cases for a year or more, were directed to accelerate their efforts in time for this month’s operation, the person said. The Government Accountability Office did an investigation and found last year that the sign-up process for the Affordable Care Act exchanges was "vulnerable to fraud."
In a related action, a report on opioid use is expected to be released Thursday by the Office of Inspector General for the Department of Health and Human Services. The OIG investigates waste, fraud and abuse in government health programs, including Medicare and Medicaid.
Under the continuing crackdown on opioid abuse, Mallinckrodt Plc, a maker of pain medications, on Tuesday agreed to pay $35 million to resolve allegations that it failed to notify the Drug Enforcement Administration about suspicious orders from pharmacies and pain clinics.
The company denied it had behaved improperly.
This comes as a fight brews in Congress over how much money to allot for opioid treatment and as Republicans spar over how to repeal or replace the Affordable Care Act.
Some Republicans want more funding to help states combat the opioid addiction epidemic, which is estimated to have killed 60,000 Americans last year. Changes to a Senate bill expected to be released later this week may include more money in addition to other changes, but it’s unclear if it will secure the 50 votes needed to pass.
While the government has been doing health care fraud roundups every year, past actions have focused on people who were defrauding government programs, including Medicare and Medicaid.
While those types of cases are still part of the roll-up, this year the emphasis will be on fraud against private insurers by treatment programs that have taken advantage of Obamacare’s more generous coverage, the person said. Both of the people who discussed the initiative asked not to be named because they weren’t authorized to speak publicly about it.
A Justice Department spokesman declined to comment.
Obamacare requires that health insurers cover a set of benefits, including mental health and substance use disorder services. The health law expanded insurance coverage to about 20 million people.
At its root, health-care fraud has more to do with the lack of control of the state Medicaid program than anything that comes out of Washington, according to Len Nichols, director of George Mason University’s Center for Health Policy Research and Ethics and a proponent of Obamacare. Medicaid’s day-to-day operations are administered by the states and funded through a joint partnership between the federal and state governments.
“They’re pretty desperate to switch the narrative away from 20 million uncovered,” said Nichols, referring to the number of people estimated to lose insurance under the Republicans’ proposed Obamacare replacement.
In a sign of shifting priorities under Sessions, many of the planned arrests target people who’ve made fraudulent claims against major private health insurers, including Anthem Inc., Cigna Corp. and companies that sell insurance under the Blue Cross Blue Shield brand, the person said. Sessions himself plans to announce the arrests in Washington as soon as Thursday.
Anthem, which sells insurance plans under the Blue Cross and Blue Shield brand in 14 states, said it’s "actively working with federal and state law enforcement in several states on these types of cases.” An Anthem spokeswoman declined to comment on any specific investigation, but noted that the company has a special unit that investigates cases involving opioid fraud, waste and abuse.
Cigna said in a statement that the crackdown is “a positive step forward in the country’s efforts to drive greater accountability.”
Aetna Inc. declined to comment, and UnitedHealth Group Inc. and Humana Inc. didn’t respond to requests for comment. Florida Blue, the state’s Blue Cross and Blue Shield insurer, said it works with authorities to fight fraud in substance abuse treatment.
In one case unsealed Monday, Eric Snyder, the owner of an addiction treatment center and recovery home in Delray Beach, Florida, and an associate, were accused of filing $58 million of allegedly fraudulent claims to Blue Cross Blue Shield, Cigna, UnitedHealth, Aetna and Humana from 2011 to 2015, according to a criminal complaint filed in federal court in West Palm Beach. The insurers reimbursed the men $18.6 million for the fraudulent claims, according to an affidavit by an agent of the Federal Bureau of Investigation that’s attached to the complaint.
Snyder is accused of bilking insurers for years for services that weren’t needed or weren’t provided to treat drug addicts he recruited as patients, according to the FBI affidavit. Snyder delivered treatment by unqualified and unlicensed providers and paid illegal commissions for patient recruiters and kickbacks to patients themselves, the complaint says. The claims were all filed for coverage required under the Affordable Care Act, the affidavit states.
Snyder’s lawyer, Bruce Zimet, said the case hasn’t been presented to a grand jury yet and that there are "significant facts" that point against indicting his client.
"He has literally saved the lives of many, many people who had gone through his facility in the past and were suffering from addiction issues," Zimet said. "We are hopeful that the government will keep an open mind and realize that while there’s a lot of abuse in the industry, Snyder is not one of those people who is an abuser."
Southern Florida has the biggest concentration of residential treatment centers in the country -- hundreds are based mainly in single-family homes in and around Delray Beach, a small town in Palm Beach County, north of Miami. A December 2016 grand jury report commissioned by the State Attorney for Palm Beach County found addiction treatment centers to be rife with operators who use deceptive marketing, illegal patient brokering and fraudulent insurance claims to profit from addicts.
The report found treatment centers and half-way houses, known as sober homes, operate out of strip malls and house addicts recruited from around the country, charging their private insurers thousands of dollars a day for questionable treatment. Many residential facilities are “unsafe and overcrowded ‘flophouses’ where crimes like rape, theft, human trafficking, prostitution and illegal drug use are commonplace,” the report found.
“Over the past decade, bad actors have been using these laws to hide exploitation of the very people these laws were meant to protect,” the report concluded. This year, the Florida legislature passed a law that seeks to regulate and prohibit deceptive marketing practices in opiate addiction treatment services.
‘Preying’ on people
The centers are "preying on some of the most vulnerable people," said Deb Herzog, a retired Anthem investigator and former prosecutor who examined such centers in California. "They’re not providing treatment and they’re collecting a lot of money."
Fraudulent claims became so rampant that Cigna, the fourth-biggest U.S. health insurer, quit Florida’s Obamacare market in the fall of 2015, ahead of the sign-up period for 2016 plans. At the time, the company blamed fraudulent and abusive practices by drug-treatment centers for driving up its costs.
"You do not have to be a rocket scientist to defraud the insurance companies, they make it so easy," said Herzog. "The insurance company has no idea what services if any are being provided, there’s no itemization. In my humble opinion, that’s the insurance industry’s fault."
While Sessions plans to highlight the opioid treatment fraud, federal prosecutors have already brought cases in this space. In May, Kenneth Chatman, the owner of a Florida sober home, was sentenced to more than 27 years after pleading guilty to health care fraud, money laundering and human trafficking. That case exposed a scheme where Chatman used drug addicts as sex slaves while receiving insurance money meant for treatment programs.
As of Tuesday, several cases in Miami, Los Angeles, New York and Detroit had already been made public. Many of those cases involved alleged fraud of Medicare and Medicaid.
In Detroit, a Macomb County resident was indicted on July 6 in a case alleging more than $1.4 million in false Medicare claims for psychotherapy services through her company, according to court documents. In Brooklyn, prosecutors brought a fraud and tax case on July 5 against five people accused of fraudulently billing Medicare for therapy services, reaping $43 million over six years.
Copyright 2017 Bloomberg. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.