iLoveBenefits: Industry News Blog

US DOJ – Health Care Fraud cases rising

U.S. Department of Justice (DOJ) Intervened vs. Declined Cases Settlements and Judgments In Healthcare Fraud


Intervened Cases

Declined Cases


$1.03 Billion

$12.68 Million


$1.96 Billion

$33.78 Million


$2.32 Billion

$100.99 Million


$2.64 Billion

$173.11 Million


$3.33 Billion

$29.39 Million

Source: Bass, Berry & Sims PLC

April 10, 2013 | Categories: Cost,Fraud and Abuse,healthcare | Tags: , , | Comments (0)

Berwick: To Reduct Health Care Costs Try Everything!

The attached videos are divided into sections of a speech given by Dr. Don Berwick. They are at the same time inspirational, depressing and challenging. Take the time to listen to them.

Dr. Don Berwick: “To Reduce Healthcare Costs, Try Everything!”

In his 16 months as administrator of the federal Centers for Medicare and Medicaid Services, Dr. Don Berwick was at the center of the storm that surrounded the historic Patient Protection and Affordable Care Act (ACA) after it was passed on March 23, 2010. Though he was a self-admitted  newcomer to “the world of national policy and politics at the most tumultuous time for . . . modern American healthcare,” he had already developed and demonstrated firm convictions about the need for affordable healthcare for all Americans and the ways to make it happen. These beliefs were sharpened and focused during his tenure at CMS, and a few days after he resigned his post in early December 2011, he discussed his experiences ingovernment in an address he gave after receiving the 2011 Picker Award for Excellence in Advancing Patient-Centered Care. In this excerpt from that talk, Dr. Berwick discusses the social imperative for reducing healthcare costs, identifies the six most egregious areas of waste and propounds five principles to guide any cost-cutting efforts.

Click  here for the video.

Medical Identity theft and fraud cost Americans

Medical ID Theft Statistics

  The amount victims pay each to resolve cases. More than half say they had to pay for medical care they didn’t receive in order to restore health coverage. Nearly half of victims also lost health coverage due to the fraud, and nearly one-third siad their health premiums rose after they were victimized – $20,000
  The percentage of medical fraud victims who say their incidents were completely resolved. – <10%
  Americans who have been victimized by medical identity theft – 250,000-500,000
  Percent of americans age 18-49 carry their Social Security card in their wallet, putting them at risk for medical identity theft – 36%
  Percent of Americans age 50 and over do the same – 43%

Source: Employee Benefit News, December 2011
Data Source:

Medicare’s Most Wanted List

Health Care Fraud: Not A Faceless Crime Any Longer
The government wants the public’s help in trying to catch more than 170 fugitives wanted for fraud, so it’s developed a new health care most-wanted list, with its own website. [ Associated Press | Feb 7

GlaxoSmithKline, the British drug giant, has agreed to pay $750 million to settle criminal and civil complaints that the company for years knowingly sold contaminated baby ointment and an ineffective antidepressant — the latest in a growing number of whistle-blower lawsuits that drug makers have settled with multimillion-dollar fines.

Read more here:

Fraud and Abuse – Why Can’t We Action This

10% of Health Care Expenditures Can be Fraud; AHIP’s Institute 2010 to the Rescue
As the health care system strives to improve quality, cut costs and prevent waste, fraud continues to counter these efforts–costing taxpayers more than $60 billion a year. [ Mari Edlin | May 18

International Health Care Fraud

*Europe* EU panel votes to crack down on illegal medicines that are worth C10.5 billion a year
CBC News reports that the battle against counterfeit medicines took a big step forward Tuesday when the European Parliament public health panel approved a bill to crack down on a fast growing industry worth C10.5 billion ($14 billion) a year in Europe alone. If it becomes law, drug makers must produce medicines that can be tracked from the factory to the patient to make sure no one tampers with the content.
CBC News, April 27, 2010

A Closer Look at Hospital Compliance

The HITECH Act, meant to protect the security of patients’ personal information, took effect in February 2010.  According to a recent survey:
  • 84.3% of hospitals are not in compliance with the HITECH Act.
  • 41.5% of hospitals have 10 or more Data breaches each year – a 120.7% increase over last year’s survey.
  • Currently, over 20% percent of hospitals have 20 or more breaches annually.
  • 34% of hospitals keep inadequate photo ID records
  • 71.4% of hospitals investigate less than 1 case per week of potential patient ID fraud and misuse

Source: “Spring 2010 National Survey of Hospital Compliance Executives: Slow Hospital Compliance with New Regulations Causing Increased Data Breaches & Medical Identity Theft,” Identity Force, April 20, 2010,

What’s Ahead for CMS and Don Berwick

10 key issues await the next CMS administrator
The new CMS administrator will face a variety of challenging issues, including rebuilding the agency’s reputation, establishing the CMS Innovation Center, increasing efforts to root out fraud and waste, and handling the influx of new Medicaid recipients. HealthLeaders Media

What Requires Legal Change and What Doesn't?

Editor’s note: What requires new laws? What requires regulatory intervention? And what will not yield regardless?


Estimated range of healthcare system waste is $600-$850 billion annually

At President Obama’s Healthcare Summit, SEN. Tom Coburn cited Thomson Reuters’ white paper “Where Can $700 Billion In Waste Be Cut Annually From the U.S. Healthcare System?” The report identifies the most significant drivers of wasteful healthcare spending as follows:

1. Administrative System Inefficiencies: $100-$150 billion

2. Provider Inefficiency and Errors: $75-$100 billion

3. Lack of Care Coordination: $25-$50 billion

4. Unwarranted Use: $250-$325 billion

5. Preventable Conditions and Avoidable Care: $25-$50 billion

6. Fraud and Abuse: $125-$175 billion

Source: Thomson Reuters. “Where Can $700 Billion in Waste Be Cut Annually From the U.S. Healthcare System?” October 2009.

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