Transcript: This is Real
Welcome to This is Real, a podcast series produced by the Department of Health and Human Services, Office of Inspector General. I'm Todd Silver with the Communications Office.
In this season, I'll take you behind the scenes of criminal cases, as told by the special agents who worked the investigations.
The focus is on health care fraud: from medical ID theft, to multimillion dollar scams.
The stories are real…
[Agent Lewis: "I've never seen this in any of my other cases..."]
The agents are real…
[Agent Thompson: "I may be the only person that's going to save my life before my cover team can get there."
And the results are real…
[Agent Curtis: "You name it, they did it. At HHS, we do health care fraud, that's what we honed in on."]
What you are about to hear may be shocking to you. It may even strike a nerve, but This is Real.
[Music intro]
Episode 1: "Rabbit Holes"
In February of 2014, more than 30 people were arrested in the Nation's Capital on charges related to health care fraud.
Those arrested included owners and operators of home health care agencies, office workers, personal care assistants, and patient recruiters.
Millions of dollars in bank accounts and property were seized, and the bust remains the biggest health care fraud takedown in D.C. history.
You may have heard about the case in the news, but what you didn't get were the stories behind the takedown. You didn't hear about the agents who worked the cases for years, or about the greed of the individuals who stole thousands, and in some cases, millions, from Medicaid, which supports our nation's most vulnerable citizens.
These criminals would never be mistaken for Robin Hood - it's not like they're stealing from the rich to give to the poor. They're stealing from the poor to get rich.
But these agents work tirelessly to track down these fraudsters.
They are law enforcement officials who are on the front lines of our country's battle against fraud, waste, and abuse in federal health care programs such as Medicaid and Medicare.
They work for the Department of Health and Human Services, Office of Inspector General, or "HHS-OIG" for short. But, in this podcast I'm just going to call it "the agency."
In this episode, you'll hear the story of Florence Bikundi and how she ripped off Medicaid for millions.
[Agent Curtis: "What caught my attention the most is that we had a provider - Florence Bikundi - she should have never been involved in the health care system."]
That's Agent Curtis, which by the way isn't his real name. We'll be using pseudonyms for all the agents throughout the series to ensure their identities are protected.
Agent Curtis worked on the case: United States V Florence Bikundi.
Florence Bikundi was the owner of Global Health, which was a large home health care company in Washington, D.C. It employed hundreds of personal care attendants, and they were responsible for the care of thousands of patients, many of whom were Medicaid recipients.
Medicaid provides health coverage if you have a very low income. Medicare, on the other hand, provides health coverage for the elderly or disabled, no matter your income.
Nearly 70 million people are enrolled in Medicaid, which makes it the largest federal health care program. While Medicare is run by the federal government, Medicaid is jointly administered at both the federal and state levels. In 2016 alone, federal and state spending for Medicaid was roughly half-a-trillion dollars.
The agency investigates fraud schemes in both programs, but in this case with Global Health, they were primarily billing Medicaid.
On the outside, Global appeared to be a legitimate company, writing plans of care, obtaining doctor's signatures, and they were billing Medicaid for personal care services.
But on the inside, Global was nothing more than a massive fraud scheme. And it was all orchestrated by a woman who was banned from billing Medicaid.
[Music break]
The agency first learned about the case from the D.C. Department of Healthcare Finance - they run the Medicaid program in the nation's capital.
The tip included three allegations:
First, that Florence Bikundi's company was submitting false documents to Medicaid.
Second, they were billing for services that never occurred.
And third, that Global Healthcare was hiring patient-recruiters. Now, these recruiters were targeting Medicaid beneficiaries to sign up for home health care, even if there was no medical reason for it.
[Curtis: "That's against the rules, you just can't go and knock on people's doors and ask them if they need services. People should go to their doctors first, and then their doctors recommend the services, and that's the appropriate way a home health care relationship should start."]
The beneficiaries were allegedly getting paid by the very same people who were supposed to be providing health services for them: the personal care aides.
[Curtis: "So for not coming to my house, not doing any of the work, the aide gives the patient $100 a week, and you have money then being paid, which is a kickback, from home health care employees to Medicaid recipients for not doing services."]
Agent Curtis was intrigued and dove right into the Bikundi case. But before he could get started he had to find out who this person really was. So he pulled her billing data, he looked at her applications, her paperwork, and any and all documents he could get his hands on to find out more.
[Curtis: "She was very crafty at what she would do in her filling out of documents."]
And what he found was that Bikundi was licensed in different states. Now, that's not uncommon - providers will often service multiple states in the same region.
This is done to ensure they can serve their patients, no matter where they live.
The problem was that Bikundi was using multiple names in her licensing paperwork.
And one of those names, was Florence Igwacho.
Igwacho was Florence Bikundi's maiden name, and in order to make the connection, Agent Curtis did something that you and I do every day.
[Curtis: "I Googled her. You know? Just like everybody else does. And when you Google Florence Bikundi, it comes up with her maiden name, Florence Igwacho, so once I really had her full name I was able to run it on the Exclusion Database and Igwacho did pop up. Florence Igwacho had been previously excluded by HHS-OIG, and Florence Bikundi was that individual - they were one and the same."]
Quick timeout to explain Exclusions. An Exclusion is a legal authority by which the agency can ban an individual or entity from billing Medicare, Medicaid, or any other federal health care program.
Okay, that's a lot of jargon, but this is how it works.
Let's say a doctor's caught diverting drugs for her own use.
The state medical board where she practices can either suspend, or revoke her medical license, which means she can no longer practice medicine in that state.
However, this doesn't necessarily prevent her from practicing medicine in another state, especially if she is already licensed in multiple states.
The agency can exclude her nationwide, meaning she won't receive payments for the care of a Medicare, or Medicaid patient in any state.
In the late 90s, Florence Igwacho was a practicing nurse in Virginia, who was caught abandoning a patient in her care who required around-the-clock attention.
The Virginia Board of Nursing revoked her license in 1999, and the agency excluded her in 2000.
[Music fade out]
[Curtis: "She should have never been involved in the health care system at all, so it intrigued me from that point on - how did this individual get into the system and re-enter the program."]
Ok, let's go through the scheme:
In June 2009, Florence Igwacho registered Global Healthcare with Medicaid using her married name: Florence Bikundi.
Bikundi and her husband then hired office staff, personal care attendants, and patient recruiters to carry out the scheme.
She directed her office staff to create fraudulent patient files and billing information.
The personal care attendants filled out phony time sheets for services that were not fully provided, or were not provided at all.
Lastly, she had patient recruiters target Medicaid beneficiaries and offer cash for their personal health information. That information was then used to bill Medicaid.
The more patients they recruited, the more they could bill.
Over time, Global increased its billing of Medicaid from 1.3 million dollars in 2009 to over $27 million in 2013.
[Todd INT: "…so this was a huge, smooth-running criminal operation going on."
Curtis: "It flows almost like clockwork. Where, you know, they just submit the claims to the District of Columbia for Medicaid. The District of Columbia Medicaid pays them, the money goes into the Global bank accounts, Global cuts checks to all their home health care aides, and then the aides go cash their checks, go to the house, and the aides are paying $150 to the patient. It's great - everybody in the community's happy."]
Not everyone was happy. Hard working D.C. residents, Medicaid recipients who really need care, and of course you and me - the taxpayers - could not be happy about being ripped off by this scheme.
[Music in]
So how'd they steal our money?
Let's do some quick math.
In many cases Global was charging D.C. Medicaid about $16 an hour, 8hrs a day, 7 days a week, for an aide to care for a patient.
That's almost 50,000 dollars a year, per patient. Global had hundreds of aides, many of whom had multiple patients.
[Curtis: "They were able to pay $150 to $200 every two weeks, to a recipient, to a patient out of their paycheck for doing absolutely nothing. That is a kickback, that's against the law, and that is something that our agency goes after, you know, very vigorously."]
[Music break]
If there was so much money flowing out of Medicaid for this one company, how'd they go years before getting caught?
The Centers for Medicare and Medicaid Services, or CMS, they receive billions of claims every day from providers.
Yes - billions of claims.
[Agent Thompson: "You got to understand, they're looking at the claims for every provider. We're talking…millions of providers and billions of claims data that is being processed every single day. So, realistically, it's hard to expect them to find everything.]
That's Agent Thompson. She's an assistant special agent in charge at the agency. You'll be hearing from her a lot during this series.
She's worked extensively with CMS to flag, and prevent fraud that exploits these kinds of gaps in the system.
For example, if the agency identifies a potentially false billing by a provider, it can ask CMS to suspend payments until a more thorough review can be done.
But the challenge with catching a company like Global, is that they know how to bill without raising any red flags.
In fact, for the most part, their claims to Medicaid, which included plans of care, proper codes, and doctors' signatures - they all appeared legitimate.
And remember, those claims aren't just a drop in the bucket. It's more like they're a drop in the ocean of billings that CMS processes every single day - that's the kind of volume we're talking about.
[Agent Thompson: "The data, again, is just the starting point, and even if they were to catch it on that end, that can be just one flag that they're catching…but what else is this doctor doing? You know, what else could they be potentially doing? Just because you stopped that one particular claim from going through. It's definitely better, but, you know, there's still a need for us to be boots on the ground."]
Agent Curtis interviewed dozens of Medicaid beneficiaries and reviewed hundreds of patient files.
He looked at the billing records and diagnosis codes, and what he found was that the number one ailment that Global was billing for, was hypertension.
Now, generally speaking, Medicaid covers different ailments for home health care.
But these services are usually for non-ambulatory Medicaid beneficiaries. So if you break your hip, and you're having trouble moving around, or even getting out of bed, you would likely qualify.
On the other hand, hypertension, or high blood pressure, that was not a qualifying diagnosis for receiving home health care, and yet the claims still slipped through.
Global Healthcare had found a loophole in the system - one that's since been closed up by the way - but nevertheless, they found a way to exploit the system for millions of dollars.
And the fraudulent billing? That wasn't the only scam going on...
[Curtis: "Everybody involved in this scheme, from the lower level home health care aide, all the way up to the top of Florence Bikundi. Everybody in the scheme had a little scam all by themselves."]
Agent Curtis discovered people working as taxi drivers at the same time they were billing as home health care aides.
Other aides were studying to be nurses when they were supposed to be providing care, or they just wouldn't show up at all for their appointments. But they were still billing for care they never provided.
He found that registered nurses were forging documents at the office for a hundred dollars a pop.
[Music fade in]
But one of the most egregious acts of fraud was committed by Florence Bikundi herself.
Say you're a legitimate provider, and you applied for a job at Global.
She wouldn't hire you, but she would keep your application on file.
Then she'd either sell your personal information, or have a relative assume your identity to expand the scheme.
This is Aggravated Identity Theft 1-0-1.
[Music fade out]
As the investigation continued, Agent Curtis uncovered more and more fraud. It seemed like around every corner was another scheme to swindle Medicaid.
[Music fade in]
[Curtis: "It was big. Every door you opened, we call them rabbit holes, every rabbit, every time you find something, it was never-ending with this case. And it was just hole, after hole, after hole."]
Join us in our next episode as Agent Curtis breaks the case wide open and prepares to arrest Bikundi. But with so much money at stake, would she go quietly?
[Curtis: "A search warrant is one of the most dangerous things that we do. If Florence Bikundi or whoever else we're doing a search warrant on, is committing other crimes that we have no idea about? Well, they don't know that we don't know that. They just know the police are knocking at the door - that, that drives people to do things they normally wouldn't do."]
Tune in next time to find out.
Until then I'm Todd Silver. Thanks for listening.
[Music fade]
This is Real is produced by the Department of Health and Human Services, Office of Inspector General.
The agency reminds you that if you suspect fraud, waste, or abuse in any HHS programs… including Medicaid or Medicare, report it to our Hotline at 800-447-8477, or 800-HHS-TIPS.
Visit oig.hhs.gov for more information. Follow us on Twitter, like us on Facebook, and watch us on YouTube.
Episode 2: Opulence
Welcome to This is Real, a podcast series produced by the Department of Health and Human Services Office of Inspector General.
I'm Todd Silver, and in our last episode, we dove into the investigation of Florence Bikundi and her home health care company, Global Healthcare.
[Curtis: "She should've never been involved in the health care system at all because HHS-OIG, 10 years previous to this, had excluded her. So, it just, it intrigued me from that point on - how did this individual get into the system and re-enter the program?"]
In this episode, we're going to go into how far Florence Bikundi went to conceal her scheme, and the extent to which she spent the money she stole from you and me.
[Music intro]
Florence Igwacho, which is Florence Bikundi's maiden name, had her nursing license revoked in 1999. The next year the agency excluded her from participating in all federal health care programs.
However, she was able to conceal her past and get back into the system using her married name.
Once she was in, she carried out a massive health care fraud scheme, billing millions to Medicaid for personal home health services that were not fully provided to Medicaid beneficiaries.
The case against Florence Bikundi took years to develop, but the investigation started to take shape when Agent began interviewing the "so-called" patients.
[Curtis: "Where you start to get mad, where you start to see things that bother you is when you start to go and interview patients. And you go and you knock on the door and somebody answers the door that looks healthier than you do. And you start to ask them about why they have home health care, and they start to tell you about high blood pressure."]
Agent Curtis even describes an instance where he went to visit a patient who was supposedly receiving home health care, and the patient wasn't even home!
Later, Agent Curtis received a call from this "home-bound" patient while he was at work - at a home improvement store.
[Curtis: "It's mind-boggling to think."]
The more patients Agent Curtis interviewed, the more he realized that the bulk of Global's patients did not need home health care.
Global didn't want patients who needed home health care, because they'd have to take care of them. The company only wanted patients who had an active Medicaid card through whom they could bill Medicaid.
This is a big problem, because you have a company billing Medicaid for services that were not provided, and now these services may not be available to people who really need this care.
Although Agent Curtis could never prove that Global denied patients who needed home health care, he has seen cases where this kind of behavior has real consequences.
[Curtis: "I have investigated abuse and neglect in the District of Columbia of an individual that was shot - it was a young kid - who was shot and was a quadriplegic. When you're quadriplegic you have to have somebody assist you in moving so you don't get ulcers or sores on your, on normally your buttocks and your back. This kid couldn't get a legitimate company to take care of him because he's too much work, and it's too dangerous. This kid actually died from having open sores on his back get infected and, and that actually took his life because of this type of care."]
[Music]
Let's take a step back and identify the players in this scheme.
Bikundi's the mastermind, the beneficiaries are in cahoots with the patient recruiters and the personal care attendants.
Agent Curtis believes that Bikundi's family is also involved, namely her husband, her son, and two of her sisters.
But the one outstanding question is, what about the doctors?
According to Agent Curtis, the doctors' signatures are crucial in a scheme like this because, whether they're complicit or not, that signature verifies that the patient needs this care.
If Global didn't get that doctor's signature? They wouldn't get a dime from Medicaid.
[Music fade in]
The problem was that the doctors refused to sign a prescription for unnecessary home health care for their patients.
But that didn't stop Bikundi. She turned this problem into a party. A signing party to be exact…
[Curtis: "They would have signing parties and Florence would send one particular employee out to buy, in her words, 'special pens,' to do this. And then, buy them pizza. And they would sit all night long, forging District of Columbia medical professionals' - mainly doctors' - signatures."]
During these signing parties, Bikundi also directed her staff to forge legitimate plans of care.
So this is what they'd do: they'd take real plans of care, they'd cut out the doctor's signature, then they'd glue it to a new fraudulent plan of care, and then they'd photocopy it to make it look legitimate…
[Curtis: "…and then that was what they would turn in to Medicaid. So, they were quite masterful at document forgery at Global Healthcare."
[Music fade out]
Todd: "You said that they had these parties late at night when some of the other staff were gone, so there were actually other staff who thought this was a legitimate business?"
Curtis: "Yes. So there was the inside group, and then there was all the other, all the other people. They weren't necessarily aware of the in-depth crimes which were going on. Now, those people provided great information when we interviewed them on what their job was and what they were told they were supposed to be doing. So we could prove Florence Bikundi knew the Right from the Wrong through interviewing these people."]
One employee in particular was the key to the investigation.
[Music fade in]
The Director of Quality Assurance at Global provided intricate details - the dates, the times, the receipts, the "special pens," and it all pointed to Florence Bikundi.
[Curtis: "He sunk the ship for them. He was the linchpin to Florence. He knew everything, and it all lined up with the evidence. So it put it right in Florence Bikundi's lap."]
[Music break]
You may recall that Agent Curtis described this case as going down one rabbit hole after another, and each one added more evidence, more suspects, and more money.
The case could have gone on for many more years, but he says at some point you have to finish the investigation and take it to the prosecutor.
That isn't easy.
Special Agents LOVE working these complex cases, where every day they uncover something new.
The more evidence they uncover, the stronger their case. And that's exactly what the prosecutors are looking for.
That's why they work closely with prosecutors when developing the case.
The prosecutors help the agents determine - among other things - when to go to Medicaid officials with the evidence and tell them to stop reimbursing this fraudulent company.
I mean, you have cut off the money at some point and go after the bad guys, right?
[Curtis: "You want to be very judicious in how you use that administrative authority. That is a very tough decision, because, what if they were a legitimate operating place, and we just shut them down? So you really try to go through your investigation to make sure you have a credible allegation of fraud before you shut someone's payments down."]
This is where the danger of health care fraud comes into play.
In the Bikundi case, a suspect was making millions of dollars from a fraudulent scheme.
But she may also be involved in other criminal activities - things that the investigators may not even know about - drug diversion, identity theft, organized crime. You name it.
[Curtis: We don't just do administrative stuff. We come in, we put criminal cases together, and we come with an arrest warrant and we take you to jail."]
But aren't we talking about medical providers like doctors, nurses, and pharmacists? Isn't this just white collar crime?
[Agent Thompson: "It's white collar crime but, you know the back of our raid jackets say police."]
That's Agent Thompson, an assistant special agent in charge with the agency. She has more than two decades of experience in law enforcement and has investigated just about every type of health care fraud.
She's also an instructor at the agency's special agent training academy. One thing she stresses to the agents is how careful they have to be when they knock on a suspect's door, and say they're the police.
[Thompson: "I can't tell you how many search warrants I've done where we've come away with drugs and guns…yea, I think every single search warrant I've been on we've found at least one weapon."
Curtis: "You never know. A search warrant is one of the most dangerous things that we do. You don't know what's going to happen when you knock on someone's door. Whether you're there for the health care crime - those people don't know that. If Florence Bikundi or whoever else we're doing a search warrant on is committing other crimes that we have no idea about? Well, they don't know that we don't know that, they just know the police are knocking at the door and they might - that drives people to do things they normally wouldn't do."
[Music fade in]
Thompson: "You know, just because it's white collar crime, you know, we're going into their million-dollar mansions, and it's a potential that they could lose their livelihood, so no, they're not just going to be…you know…umm…"
Todd: "They're not just going to roll over."
Thompson: "Exactly. Or just go quietly. You know what I mean? There's a lot of risk involved."]
[Music break]
After careful planning, Agent Curtis and his team arrived at Bikundi's doorstep to arrest her in February 2014.
[Todd: "How did that go? What was her face like when she opened the door?"
Curtis: "So, she was completely shocked. She was completely shocked at the search warrant. It was one of those things where I don't think she ever believed it would get to this point, like we would figure this out."]
[Music in]
Fortunately, the arrest of Florence Bikundi was non-confrontational. Once they had her in custody, Agent Curtis could see firsthand where all that Medicaid money was going.
[Curtis: They had a huge house. It's a mansion. They had fake palm trees planted in the yard. A pool. A deckhouse out back. Numerous luxury vehicles."]
The vehicles alone were valued at over $400,000.
She took Medicaid fraud to a whole other level, to the point that Thanksgiving Day was every day at her house.
[Curtis: "Inside the house, they had a complete dining room table that was not being used, that was permanently set up to look like a Thanksgiving feast, with wax turkey, like a complete spread meal just decked out for looks. So, if you name it, they had it in their house. They spent the money that they got on, on opulence. They spent it, they wanted to look good. They had lavish parties at their house. They, they really put on a show."]
[Music fade out]
That's Thanksgiving Day. 365 days a year.
Investigators were able to prove in court that Global Healthcare cheated D.C.'s Medicaid program out of more than 80 million dollars.
That's $80 million that could've helped low income families, children, and individuals with disabilities.
[Thompson: "I don't think you'll find one agent who isn't passionate about, you know, their cases. And we don't want to let them go until someone has either paid restitution or what I like to tell folks is that we're selling jail time. You know - they're locked up. When you get that end result of a doctor getting sentenced to, you know, 40 months in prison, you know for, for Medicaid fraud and you know you're stripping them of that big mansion that Medicaid paid for - it's a good feeling. It's a good feeling. I think it's what keeps a lot of us going."]
After the arrest, the government was able to secure over eleven million dollars' worth of assets - seizing the cars, freezing more than 70 bank accounts, and putting a lien on the mansion.
The judge also ordered restitution to be paid back to Medicaid, but we'll discuss the aftermath of the trial and what happened to Florence Bikundi later on in the series.
[Music fade in]
Coming up in our next episode, we take a look at another extraordinary case that was part of the 2014 D.C. Takedown.
This time, the fraudsters went after an especially vulnerable population for their Medicaid scam: the homeless.
[Agent Lewis: "I've never seen this in any of my other cases. And I was actually, I actually couldn't believe what I was seeing. And it was so rampant all across the District."]
See you next time on This is Real.
I'm Todd Silver, thanks for listening.
[Music fade]
This is Real is produced by the Department of Health and Human Services, Office of Inspector General. The agency reminds you that if you suspect fraud, waste, or abuse in any HHS programs including Medicaid or Medicare, report it to our Hotline at 800-447-8477, or 800-HHS-TIPS. Visit oig.hhs.gov for more information. Follow us on Twitter, like us on Facebook, and watch us on YouTube.
Episode 3: The Puzzle
Welcome to This is Real, a podcast series produced by the Department of Health and Human Services Office of Inspector General.
I'm Todd Silver, and in our last episode, we dove into the investigation of Florence Bikundi and her home health care company, Global Healthcare.
[Curtis: "We're talking, you know, close to $80 million in services had been paid to an individual who should have never received any of that money because she's excluded."]
The 2014 takedown in our nation's capital resulted in over 30 arrests, including the arrest - and eventual conviction - of Florence Bikundi.
In this episode of This is Real, you're going to hear about another complex, wide-ranging Medicaid fraud scheme from this takedown.
This scheme involved patient recruiters meeting up with beneficiaries in homeless shelters, and then paying them to act like they needed home health care services.
[Music intro]
Yes, you heard that right - beneficiaries in homeless shelters were getting cash to pretend that they needed specialized services in their home.
Let's go over the details of the case.
The agency first learned of this case from the D.C. Department of Healthcare Finance, along with anonymous complaints from Medicaid recipients.
Agent Lewis was the lead investigator on this case. After receiving multiple tips and conducting dozens of interviews, she suspected widespread fraud in D.C.'s home health care program.
[Agent Lewis: "I've never seen this in any of my other cases. And I was actually, I still couldn't believe what I was seeing, and it was so rampant all across the District."]
The Medicaid fraud seemed to go beyond a single scheme. As Agent Lewis said, it was everywhere.
In the D.C. area, it wasn't just one company. It seemed to involve all aspects of the home health care industry.
Here's the rundown:
-You had companies allegedly paying patient recruiters to bring in Medicaid beneficiaries.
-Once they were recruited, the beneficiaries were getting paid cash to act like they needed home health care.
-Then you had doctors allegedly getting paid to sign off on the home health care plans that weren't medically necessary.
-And you had personal care attendants getting paid, but they weren't performing home health care services.
And this was happening all over the city. Like Agent Curtis would say, it ran like clockwork.
Since there are so many moving parts, we're going to break this down piece by piece.
Let's start with the beneficiaries and the patient recruiters.
[Lewis: "For example if they went down near the homeless shelter, they'd just hang out on the street and if people would come by, they would say 'Hi, do you have Medicaid?' And the person would say yes. If they say yes, they'd say 'Is it straight Medicaid?' And they, you know, there's a 1-800 number that you can call to verify that the person actually has Medicaid. And so they would do that just to verify that the person really has Medicaid and, you know, can get the services. But once they tell one person, that person tells a friend, and it just grows."]
Hold up. Did you catch that? I want to play that again…
[Rewind SFX ]
[Lewis: "There's a 1-800 number that you can call to verify that the person actually has Medicaid… and, you know, can get the services."]
Once a recruiter obtained a person's Medicaid information, they called the 800-number to verify the Medicaid ID was active.
This is something normal providers do every day, to ensure that their patients' medical information is accurate - it's like when they ask you for your insurance card at the doctor's office.
But unlike normal doctors, these patient recruiters were using the hotline to ensure they could bill Medicaid and leverage their schemes.
In other words, they were treating the Medicaid cards like an ATM.
An ATM at the bank of the taxpayer. Remember whose money we're talking about. These people are stealing from the Medicaid program, and who pays for Medicaid?
That's right, you and me.
It comes out of our paychecks, each and every pay period. And some of our hard-earned pay is going right into the pockets of these criminals.
To make matters worse, without this money, Medicaid beneficiaries who really need care, may not be getting it.
[Lewis: "And that's one thing that we stressed to the Medicaid recipients when we went out to interview them. They're, you know, by participating in the fraud, they're helping to diminish the Medicaid funds. You know this money is needed and at any point it can be reduced and the services, you know, you might not be able to receive the services when you actually need them."]
[Music]
There's something about this story that doesn't make sense. Why were patient recruiters visiting homeless shelters and signing up homeless beneficiaries for home health care? Why would they need home health care if they didn't have a home?
I asked Agent Lewis if this was legal…
Lewis: "It's not illegal, but it's quite obvious. I mean, it's a homeless shelter - they just pretty much stay there for the night. And we actually went to the homeless shelter and interviewed the staff there. And they did tell us that at one time they were allowing the personal care aides to come in and assist, and they found them sitting in the TV room with their feet up watching television and not doing anything. So, they said they put a stop to it because there were more and more coming in every day, so they actually ended the you know, the whole process of the personal care aides coming in to allegedly provide care."]
The beneficiaries were receiving two to three hundred dollars a month to participate in this scheme.
Pretty much all they had to do was share their Medicaid card, go see a doctor, and fill out some paperwork.
That's as close to free money as it gets. But what the beneficiaries weren't seeing were the ultimate consequences of their actions.
[Lewis: "That money could be used for other Medicaid recipients who really need personal care services. And you see people waiting to receive personal care - they really need it. It's disheartening. And I think that the service is more important than them receiving cash in exchange for a signature."]
[Music break]
While the beneficiaries were treated as cogs, the patient recruiters were the engine of the scheme.
And the more beneficiaries they could recruit, the more money they could make.
In some cases, the patient recruiters were also the personal care aides.
Agent Lewis found that the personal care aides were often working for multiple home health care companies at the same time, and they were billing for excessive hours for a job that was never fully done - if it was done at all.
Agent Lewis was building a strong case against the personal care aides, but what about the home health care companies?
Was there an illegal partnership between them? Were the home health care companies paying the personal care aides to recruit Medicaid beneficiaries?
[Lewis: "I'm pretty sure the companies knew about it because some of the recruiters that we identified would sit in the doctor's office - like at the front desk. So they had a relationship with some of the physicians, so we knew that at least the physicians knew what was going on. So there's no way to me the companies didn't know what was going on.
We never could prove that there was a coordinated hierarchy. So the only thing we really could prove is that the personal care aides were recruiting, or they had recruiters, and that they were paying the recipients for their signature."]
Logically, the flow of money made sense. Similar to the Bikundi case, Medicaid reimbursed the home health care companies, and the home health care companies paid the personal care aides for services that were allegedly rendered.
If the personal care aides were paying off the beneficiaries, how could you prove that the companies were A) aware, and B) in on the scheme?
Imagine yourself in Agent Lewis's shoes. You've spent years laboring over boxes of patient information and financial records, but there was no smoking gun.
You've interviewed dozens of personal care aides, but none of them would flip on the home health care companies.
I mean we hear all the time to just follow the money, but tracing the money back to the home health care companies proved to be…difficult.
[Lewis: "I know when we first started the home health cases - one of my first cases - there was a personal care aide who was stealing from the Medicaid recipients. And when we went in to interview the owner of the company, they were very cooperative. They provided us all the documents we needed, and everything. They actually fired the employee who was committing the fraud, or stealing. So they were very cooperative - anything we asked for they provided to us."
Todd: "So you're saying the companies may not have known that this fraud was going on, that maybe they were legitimate agencies but they had some bad actors?"
Lewis: "Yes, we could say that, yea. Because I mean it's hard to keep up with, I mean, you think about it. They have 500 personal care aides. It's hard to keep up with 500 personal care aides."]
[Music fade in]
This was turning out to be more than just a run-of-the-mill Medicaid fraud scheme, like a simple false-billing case. It was a complex puzzle with multiple pieces that didn't seem to fit where they should.
At this point, she knew the personal care aides and the Medicaid beneficiaries were in cahoots, but the home health care companies being part of the fraud? That was still just a theory.
The other piece of the puzzle was the doctors. Were they involved in the scheme, or were they just innocent victims?
This uncertainty made the doctors a focal point of Agent Lewis's investigation.
On one hand, Agent Lewis said she received complaints from doctors that personal care aides were pressuring them to sign fraudulent plans of care.
On the other hand, what she saw at the doctors' offices? That led her to believe they were in on the scheme.
[Music fade out]
[Lewis: "Their offices would be overflowing with patients. There would be lines of patients, down the, down the sidewalk just waiting to get in so they can get their paperwork signed."]
[Music fade in]
Seems like all this evidence would be enough to show the doctors were complicit in the scheme, but would it hold up in court?
The simple answer was no. Agent Lewis knew she needed more concrete evidence, like money changing hands or someone willing to testify against a doctor.
Her interviews with witnesses were valuable to the investigation overall, but no one would flip on the doctors, and there was no evidence of doctors getting kickbacks.
[Lewis: "I think there had to be some level of cooperation between the doctor and, you know, the home health agencies and the personal care aides and recruiters. But the thing for us is we have to prove that."]
Agent Lewis didn't have enough solid evidence to go after the doctors or the companies.
She was running out of leads, and. needed a different approach.
She needed…someone to go…undercover.
Enter: Special Agent Rogers.
[Music fade in]
Next time on This is Real:
[Agent Rogers: "I just remember one other time just sitting in the car with these guys and they, they questioned whether or not I was a police officer…that, uh, you know, had the heart beating, kept me on my toes there, when he asked me that just out of the blue, you know. 'Man, you sure you're not a police officer? Are you police?'"]
Until then, I'm Todd Silver, thanks for listening.
[Music fade out]
This is Real is produced by the Department of Health and Human Services, Office of Inspector General. The agency reminds you that if you suspect fraud, waste, or abuse in any HHS programs including Medicaid or Medicare, report it to our Hotline at 800-447-8477, or 800-HHS-TIPS. Visit oig.hhs.gov for more information. Follow us on Twitter, like us on Facebook, and watch us on YouTube.
Episode 4: Undercover
[Music in]
Previously on This is Real:
[Agent Lewis: "I've never seen this in any of my other cases. And I was actually, I actually couldn't believe what I was seeing. And it was, it was so rampant all across the District."]
The home health care investigation worked by Agent Lewis was growing more and more complex.
Beneficiaries, patient recruiters, doctors, multiple home health care companies - it seemed as if everyone was involved in some aspect, and like a sturdy oak, the roots of the scheme kept spreading.
But connecting all the dots proved to be a major challenge.
Agent Lewis needed someone on the inside, to verify the fraud she was seeing on the outside and finally bust this scheme. But she couldn't get anyone to flip.
So she decided to bring in Agent Rogers to go...undercover.
[Rogers: "I got a call from my colleague who was working a home health agency case and it stemmed from allegations that there was some billing for beneficiaries in homeless shelters. I thought this was a great opportunity for me to go out there and I looked at it as a challenge. I, I was very excited. I was ready to get in, and dig in and just do something, totally different."]
The plan was to infiltrate the criminal network as a homeless person and collect evidence against the alleged fraudsters.
With any luck? He could find a way to obtain the information Agent Lewis needed for her case.
[Music intro and fade out]
Now, Agent Rogers was a seasoned veteran, with over 20 years' experience in law enforcement, but this was his first time going undercover as a homeless person, so I wanted to find out how he prepared for his covert operation.
[Todd: "When you went undercover, and you were preparing for it, did you watch TV shows or movies of undercover people and, if so, who did you try and emulate or who were you trying to look at to get some tips?"
Agent Rogers: "Well, you know it's interesting you asked that, but I just wanted to kind of be myself though. And I think, you know, there's no better person to be than yourself while you're out there."]
Agent Rogers said he was intrigued by the case, namely the involvement of the homeless in a home health scam.
[Rogers: "And that kind of stood out. I mean, homeless shelters with no home but they're billing for home health."]
He knew that going undercover as a homeless person presented many challenges.
He was about to go into a completely unfamiliar and unpredictable environment, so mental preparation was key.
[Rogers: "How can I even bring up a conversation with any of the individuals in the shelter? There was, you know, people were talking to themselves, and you know various actions, so that was the challenging part right there initially."]
Agent Rogers prepared himself for every situation that he could think of, rehearsing every element of his new identity.
He had to know his story, and his purpose for being at the homeless shelter.
He studied his name, his date of birth, the information on his Medicaid card.
How would he act once he got into the homeless shelter? Who would he approach? What would he say? And what if someone called him out?
[Rogers: "It was all about how can I fit in, and how could I break the ice once I got in the shelter."]
His first time out undercover, Agent Rogers prepared for a long day at the shelter, because he really didn't know what was going to happen.
I asked him what it was like inside. What were people doing? Was it crowded? What were the conditions?
Thing is, he said everything happened so fast, he doesn't even remember much about the shelter itself.
Only that it took a few minutes to find what he was looking for.
[Music fade in]
[Rogers: "I went into the shelter, I was able to, it didn't take me long, to talk to I believe a couple individuals and I pretty much you know said, 'Hey, I'm here I understand I can make some money. I have a Medicaid card and I was told I could make some money if I have I Medicaid card. Do you know anything about that?' And I would say about ten minutes later I was approached. I was approached by a recruiter."]
[Music interlude]
[Todd: "Give me, give me the real, like how did you really approach them? What'd you really say?"
Rogers: "Hehe. Hey what's going on, hey man what's happening man? You know I'm, I'm here, I got a Medicaid card. I'm looking to make some money. You know how I can make some money?"
Todd: "And just like that you had people coming at you?"
Rogers: "Hehe. Just like that. And I had a person to approach me once I said that. It was very interesting. It didn't take long at all for someone approached me just based on what I said there. And I was like 'Wow. Man I hit the jackpot.'"]
[Music fade in]
[Todd: "Now the person who approached you, was that a homeless person, too, or…?
Rogers: "No actually - he was a recruiter. He was a recruiter who worked at a home health agency. So he was actually in the building at the time that I came there. It just worked out that way."
Todd: "You're at a homeless shelter, and a guy is recruiting you for home health services?"
Rogers: "Can you imagine that? With no home and I'm at a homeless shelter. That's how bold, that's how bold they are."
Todd: "Why do you think they chose a homeless shelter? I guess that's where the Medicaid recipients are, you know?"
Rogers: "Ah, yes without a doubt. Most of the Medicaid, most of the people there at the homeless shelter are Medicaid recipients."]
The patient recruiter asked Agent Rogers a series of questions, mostly relating to his Medicaid status. He took Agent Rogers's Medicaid card and gave it to an accomplice, who verified that the card was valid, and active.
He then informed Agent Rogers that - yes indeed - he "could make some money with his Medicaid card."
[Music break]
The whole scenario was moving fast. The recruiters, it turned out, they were efficient businessmen.
These guys were on top of their game, and the operation was such a well-oiled machine that Agent Rogers was in and out of that homeless shelter in less than an hour.
Before he knew it, he was on his way to a doctor's office with the recruiter. What happened next? Well, that even surprised the veteran agent.
[Music fade out]
[Rogers: "It was unbelievable. When I walked into the waiting room, it appeared to be about 20 to 30 people just sitting around. There were other people coaching these individuals as to what to do, what to say once you go into the doctor's office."
Todd: "In the waiting room."
Rogers: "In the waiting room. So you can tell they were recruiters as well. So we're talking about a number of recruiters bringing patients in to this particular doctor's office, so they can get the necessary paperwork certified and signed to get home health."]
The patient recruiter coached Agent Rogers on what to say, and how to act once he went into the examination room.
He gave Agent Rogers a back brace and a cane as props for his fake illness.
He never even asked Agent Rogers if he actually had a real illness or injury. In fact, they never even talked about why Agent Rogers was homeless in the first place.
All that mattered, was that Agent Rogers had an active Medicaid card.
[Rogers: "He said, 'Hey, when you walk in, definitely walk in with some ailment. Let them know that you have issues with your knee or your back.' Something to tell the doctor to, I guess to qualify me to be able to get home health. As I walked into the doctor's office, you know I had to say 'Hey, my back, my knee,' whatever the case may be, and you know 'I need home health, I need a home health aide to come to my home.'
Todd: "The home that you don't have."
Rogers: "The home that I don't have. The recruiter realized that. I mean, because as the - he filled out the paperwork. And of course on the paperwork it asks for an address. So I was like, 'Hey, I'm homeless, man! You know? Ha, I don't have a home!' And he said, 'Well, aw man, do you have a girlfriend? Do you have someone's address? I just need to put an address down here.' You know, I had to be quick and think of an address! So I basically thought of an address right then and there to come up with as where my girlfriend lives."]
[Music break]
In the doctor's office, Agent Rogers complained of back pain and he played his part.
The doctor did a limited physical exam and then he wrote a prescription for Agent Rogers:
Home health care.
Eight hours a day.
Seven days a week.
All that from a doctor's visit that took less than five minutes.
[Music fade out]
[Todd: "He wrote a script for eight hours a day, seven days a week?
Rogers: "Yes."
Todd: "And you walked in to, well even with a cane, you walked into his office - so you were mobile - and he gave you basically…I mean, what kind of person would need that much care? I figure they could hardly do anything themselves."
Rogers: "Right, right. And that's, that's, that's the part we couldn't understand. I mean why would this physician even sign off or order, or qualify me for home health, when he knew I pretty much walked in? Walked in, whether I had a cane or a back brace, but he gave me the maximum that I could get. You know because, I'm not sure but I believe that the recruiters were paying the physicians to give me the max."]
Once he got the forms signed and left the doctor's office, Agent Rogers met up with the patient recruiter outside.
[Rogers: "He said, 'Man, great job. Good job.' At that point I knew I got my foot in the door, I was on my way. And he paid me 60 dollars, just for the office visit."
And that was just the money the Medicaid recipient made. We may never know how much money other players made in this scheme.
What we do know is that this one doctor's visit for Agent Rogers's quote-unquote "back pain," spurned tens of thousands of dollars in Medicaid spending for unnecessary home health services.
As we learned in Episode 1, the annual cost to provide that amount of personal care prescribed to Agent Rogers, was almost 50,000 dollars.
On top of that, Agent Rogers was approached by at least eight different patient recruiters, and he met them everywhere - liquor stores, parking lots, grocery stores, motels, even outside churches.
He was promised up to $200 every few weeks for his role in the scheme. Of course, every cent he earned was placed into evidence.
I was curious how much money Agent Rogers made while he was undercover, so I decided to give him a call back to find out. You're not going to believe his answer.
[Music fade in]
[Rogers: "Well I was actually paid $59, but I was promised, they promised to pay me between $200 and $250 every two weeks - that's what they promised me.
Todd: "The recruiters were not only ripping off Medicaid, they're ripping you off too?
Rogers: "Yea, I was ripped off. I was totally ripped off. They kept the money that they were receiving on my behalf by using my Medicaid card."
[Music fade out]
Some of the patient recruiters also encouraged Agent Rogers to do some recruiting of his own, to earn more money for himself. And his recruiters.
But Agent Rogers wasn't in it for the money. His goal was to find a connection between the patient recruiters and the doctors.
The thing is - it's like walking a tight rope trying to collect evidence without exposing your cover.
[Rogers, "I think we kind of knew that these recruiters were actually paying the doctors, but how do you get up to the top? Um, very difficult for me, because they wouldn't give me that type of information.
"Um, I just wanted to first just on my level - on the recruiter's level - be able to go in and then get the doctors to sign off on the forms. And I was thinking more so, once we arrest the recruiters, bring them in, we were able to maybe flip the recruiters to give us that information to get up to the doctors. But I didn't want to pose too many questions to the recruiters, because I didn't just didn't want to give myself up."
Todd: "Because I'm sure that kind of puts you a little out of character."
Rogers: "Yes, that would definitely put me out of character, and I think that would have them thinking like, 'Hey, this guy might be law enforcement."
Todd: "You know, one of the things that Agent Lewis mentioned was that, there was almost a feeling from the beneficiary point of view that what they were doing wasn't really illegal. The patient recruiters made it sound almost like, like, well this is just part of the process. You go and get this stuff done, and then we, you know, we give you cash. Did the patient recruiters, like when they were trying to sell you on this, did they say anything like that, or tell you what the scenario would be like?
Rogers: "I recall that when I met one of the recruiters at the motel, he was trying to justify why they were doing this. It was almost like I was entitled to be paid and there was no, there was nothing wrong with it. He brought up the, he even said that, you know, you should be able to get a piece of the pie. So, that's the approach that they were using. They didn't really, after a while they didn't think they were doing anything wrong."]
Agent Rogers was undercover for almost a year.
He was constantly rehearsing his role, and reminding himself what he'd told the patient recruiters.
Agent Rogers was on-call, 24 hours a day, 7 days a week, because the patient recruiters would call at all times - day or night.
He never wanted to get tripped up, which might've put himself in a dangerous position. As prepared as he was, there were still some close calls…
[Music fade in]
[Rogers: "I recall going to a liquor store actually. Meeting a guy at the front of the liquor store. And he would get my information and my Medicaid card but he would take it over to another guy who would also run my Medicaid number. And this guy kept looking at me and looking at me and he was asking a lot of questions. At that same time, I heard one of the guys say, 'Wow, man, look at that car over there. It look like that could be a police car. And of course you know, heart kind of, you know, heh, turned around like 'Whoa, you know that ain't no police car, you know.' But I think at that point they might've spotted one of our, my cover team's vehicle. And, so that was, you know. That was interesting."]
[Music fade out]
He was able to talk his way out of the situation, but it put his senses on high alert.
[Rogers: "I'm quite sure if they found out that I was an undercover agent the circumstances wouldn't have been good. The situation wouldn't have been good because I could've, I kind of seen a mean streak in these guys. I mean, they were nice and all, but if they knew I was indeed the police or an agent, I don't think the situation would have turned out well."]
But it did turn out well.
Agent Lewis got what she needed from Agent Rogers, and she could finally take the case to the prosecutor and begin the next phase: indict, and arrest.
[Rogers: "It's just very unfortunate that we have these type of individuals taking advantage of the system. I just have a passion working these cases, and bringing money back and saving money for the government, and for, especially for our most vulnerable individuals and our seniors, it's just a great feeling. Very rewarding."]
[Music in]
Next time on This is Real, we wrap up the 2014 D.C. Takedown.
Who was arrested and who plead guilty? Who was convicted and who went to jail?
And what happened to Florence Bikundi and those involved in her million-dollar scheme?
Stay tuned for the final episode in this series.
I'm Todd Silver, thanks for listening.
[Music out]
This is Real is produced by the Department of Health and Human Services, Office of Inspector General. The agency reminds you that if you suspect fraud, waste, or abuse in any HHS programs including Medicaid or Medicare, report it to our Hotline at 800-447-8477, or 800-HHS-TIPS. Visit oig.hhs.gov for more information. Follow us on Twitter, like us on Facebook, and watch us on YouTube.
Episode 5: Consequences
[Music in]
Previously on This is Real:
[Lewis: "I've never seen this in any of my other cases."
Thompson: "I may be the only person that's going to save my life before my cover team can get there."
Rogers: "What's going on? Hey man. What's happening, man? You know I'm here, I got a Medicaid card, I'm looking to make some money."
Curtis: "You name it, they did it. At HHS, we do health care fraud. That's what we honed in on."]
[Music fade out]
The 2014 D.C. Takedown resulted in the arrests of over 30 individuals on charges related to health care fraud. Those arrested included operators of home health care agencies, office workers, patient recruiters, and personal care aides.
Most of the defendants pled guilty, and combined, they were sentenced to over 22 years in jail with 14 months of home detention. The defendants were also ordered to pay over $120 million in fines, restitution, and forfeiture.
In the case of Florence Bikundi, who was the owner of Global Healthcare and fraudulently billed Medicaid over 80 million dollars, she was sentenced to 10 years in prison.
Her husband, Michael Bikundi, who was co-owner and also part of the scheme, was sentenced to seven years in prison.
Seven other defendants who worked at Global - including Bikundi's family members - were sentenced to a combined 24 months in prison.
Two defendants fled the country, and as of this recording are fugitives from justice and still on the run.
The judge in the case ordered the Bikundis to forfeit over $11 million from 76 different bank accounts.
The mansion was also seized, which was worth about a million dollars, along with $73,000 in cash that was found inside the house, and a handful of luxury vehicles worth over $400,000.
The judge imposed a forfeiture order of nearly $39 million in assets on both defendants.
And finally, the judge ordered the defendants to pay more than $80 million in restitution to D.C. Medicaid.
Agent Curtis felt he had closure when the final sentences were handed down.
The investigation took years to develop, and it involved hundreds of hours working the case, conducting surveillance, interviewing witnesses, and pouring through an endless amount of files.
But it was worth it - the investigation had strong results, with significant jail time for the Bikundis, as well as full restitution for the money stolen.
But there was a personal satisfaction for Agent Curtis, because his family made sacrifices during this lengthy investigation, too.
[Music fade in]
You see, Agent Curtis wasn't the original case agent for this investigation…
He agreed to pick up the case from an agent who went on maternity leave, even though he knew his wife would be…let's just say, less than thrilled. I'll let him explain.
[Curtis: "My wife wasn't the happiest camper in the world, because my wife was 7 months pregnant at the time. So I caught the case right at a critical point, and it was tough."
Todd: "Has your wife forgiven you yet?"
Curtis: "Uh, no, we still talk about it and when I told her that I would be doing a podcast about this particular case, she was like, 'Are you going to talk about how it wasn't your case to begin with?' So, yes."]
[Music fade out]
Such is the life of a special agent. They are dedicated and love the work they do.
They know they are making a difference: fighting health care fraud, putting criminals in jail, and most importantly, protecting our most vulnerable Americans - our seniors, people with disabilities, and under-privileged families.
As Agent Thompson would say:
[Thompson: "I don't think you'll find one agent who isn't passionate about, you know, their cases. And we don't want to let them go until someone has either paid restitution or what I like to tell folks is that we're selling jail time. You know? Or they're locked up."]
As for Agent Lewis's investigation, with help from Agent Rogers and his undercover work, her case resulted in 19 defendants pleading guilty, which included patient recruiters and personal care aides.
They were sentenced to a combined 18 months in jail, six months of home detention, and over 100 hours of community service. They were also ordered to pay over $300,000 in restitution, and fines.
[Lewis: I was relieved that the case ended. It was very complex, there were a lot of moving parts - but I was glad it brought awareness to the problem so that hopefully things will change and it will just improve the program."]
Because the defendants pled guilty, there was no trial, so Agent Rogers didn't have to testify about his undercover work.
That can be a mixed bag for an agent.
I mean it's good that the defendants pled and that Agent Rogers didn't have to reveal his true identity. But for the undercover agents? The big reveal can be a special moment.
When you walk into the courtroom, you make eye contact with the defendant, and he realizes for the first time who you really are.
[Music fade in]
Agent Thompson has seen those moments first-hand, and to her, the looks on their faces are priceless.
[Music beat]
[Thompson: "Yea, you could just see the life is just sucked right out of the person, and they're just deflated and they slump, and you can tell the jury is kind of like, 'What's going on here? I've seen where they've gotten angry, or looking at them like 'You S.O.B.!!' You know what I mean? 'I asked you if you were a cop and you told me no!' You know that's usually the biggest one. 'How dare you lie to me?!' That kind of thing. And then the fact that they were just played all this time. You know what I mean? 'I asked you over and over again were you a cop and you told me no!' Well, my bad."]
[Music fade out]
The sentencings represent the culmination of years of hard work. The 2014 D.C. Takedown was truly a team effort: with HHS OIG, the U.S. Attorneys' Office, the FBI, the D.C. Office of Inspector General, the Centers for Medicare and Medicaid Services, the D.C. Department of Health Care Finance, and many other agencies that played a vital part in the takedown.
The two Medicaid fraud cases described in this series occurred several years ago, but make no mistake about it, these schemes still exist, and they are evolving. They're becoming more elaborate, and more numerous.
Health care fraud has become a financial epidemic.
The National Healthcare Anti-Fraud Association estimates that these crimes cost the nation about 68 billion dollars annually.
How is the agency combatting all this fraud?
This is a big bear to wrestle with.
[Thompson: "You have like, you know home health agencies popping up. We'd shut two down, three would pop up. So it's like, "How are they figuring this out?" And they're getting a lot savvier. But we stay on top of it by just communicating and staying in network with each other."]
For starters, agents closely track how these fraud schemes are evolving, and they work with other law enforcement agencies to discover new trends, and new methods used by criminals.
One way to do that? Data. Lots of data.
[Music fade in]
[Thompson: "You can do all kind of algorithms and different analysis to break down the data because data is very intricate and essential in a lot of our cases now."]
Identifying - and solving - potential billing problems requires a sophisticated understanding of how CMS processes the enormous number of claims it receives every day.
The agency works closely with CMS, as well as the state Medicaid agencies, to help them improve their systems, and weed out dishonest billers.
For example, after the 2014 D.C. takedown, the agency analyzed D.C. Medicaid's billing system for home health care services - an industry that was eating a multimillion dollar hole in the Medicaid fund because of rampant fraud.
One change they made? Limiting the number of hours that could be billed for personal care services in a given week.
Now that may seem minor, but when you're operating on a national scale, these changes can result in millions of dollars saved just by taking away one vulnerability that criminals can exploit.
[Music interlude]
The agency uses many different kinds of law enforcement tools to identify, track, catch, and prevent criminal behaviors.
The agency also has the legal authority to indict, arrest, and exclude wrong-doers from billing all federal health care programs.
The proof is in the pudding, as they say, and these agents are busy bakers.
During the past three years, their investigations have resulted in over $10 billion in expected recoveries - that's money expected to be returned back to Medicare and Medicaid.
In that time, more than 7,000 people have been excluded from participating in federal health care programs, and there have been nearly 5,000 criminal and civil actions.
The agency makes a lot of headway, but they don't do it alone.
You - the consumer, the honest health care worker, the patient - you have a big role in finding and preventing this fraud, too!
If someone approaches you and asks for your Medicare or Medicaid number, remember to Guard Your Card!
If the beneficiaries in these cases hadn't given out their information, this fraud may have never happened.
Health care fraud is a serious crime. One that Florence Bikundi and others involved in the D.C. Takedown paid the price on.
HHS-OIG special agents are here to protect the most vulnerable Americans and fight fraud in federal health care programs.
[Thompson: "We know we're serving a purpose. We know we're making a difference. Every time a bad guy gets sentenced for some type of Medicare/Medicaid fraud…it sends a message that's saying, 'Hey, if you try it we will come after you as well."]
[Banner music fade in]
I hope you enjoyed the first season of This is Real, and be on the lookout for more, compelling stories in future podcasts.
Until then, I'm Todd Silver, and thanks for listening.
[Music out]
This is Real is produced by the Department of Health and Human Services, Office of Inspector General. The agency reminds you that if you suspect fraud, waste, or abuse in any HHS programs including Medicaid or Medicare, report it to our Hotline at 800-447-8477, or 800-HHS-TIPS. Visit oig.hhs.gov for more information. Follow us on Twitter, like us on Facebook, and watch us on YouTube.
[End This is Real, Season 1]
Let's start by choosing a topic
