The Koyal Training Group, Health care fraud a growing criminal enterprise

Since March 2007, federal investigators have uncovered more than $5 billion in Medicare fraud, but they suspect that might just be the tip of the iceberg.

As the prolific bank robber Willie Sutton reportedly said of robbing banks – because that’s where the money is – health care fraud has become a huge problem throughout the country.

According to the U.S. De­part­ment of Justice, Geor­gia ranks 12th in investigations, seventh in the number of fraud cases and sixth in total recovered – almost $98.95 million in 2012.

In the Southern District of Georgia, more than $27 million in restitution was collected last year in one of the country’s largest Medicare fraud prosecutions in 2005 – The Bio-Med Plus in Savannah.

In Augus­ta, optometrist Jeffrey Spon­sel­ler was sentenced Jan. 9 to 33 months in prison and ordered to pay $441,000 in restitution for bilking Medicare.

Federal investigations into Medicare fraud have exploded in response to the problem, said David Stewart, who recently left the U.S. attorney’s office where one of his duties was health care fraud coordinator.

Medicare fraud affects everyone because Medicare has become the primary health care coverage for most Amer­i­cans when they turn 65, said Ken­neth Crowder, who recently left the U.S. attorney’s office and joined Stewart in private practice.

When Medicare coverage started in 1966, 19.1 million were enrolled. In 2013, that number was 43.5 million, according to the Centers for Medicare and Medicaid Services.

With the last of the baby boomer generation turning 50 this year and increased health insurance coverage through the Affordable Care Act, Stew­art and Crowder said fraud is expected to expand.

Going after health care fraud holds the promise of getting money back for the government, Stewart said, which is another reason the Jus­tice Department has set that as a top goal.

The attack on those defrauding Medicare and military health care provider TriCare occurs in criminal and civil courts. The difference between prosecution and a civil lawsuit is intent, Stewart said. And intent can be difficult to prove.

In the Sponseller case, the defense attorney tried to portray the optometrist’s act as more billing errors than intentional fraud because of the complexity of the Medicare billing process.

But in cases such as Spon­seller’s – who billed for 177, 45-minute comprehensive exams performed in a single day – the intent to defraud becomes clear. The more outrageous cases are the ones that are criminally prosecuted, Stewart said.

In another case from the Sou­thern District, two nutritionists bilked Medicaid of $4 million by billing for services to Head Start programs throughout the state. The intent to defraud became clear when investigators uncovered bank records that proved they were on Florida vacations at the same time they were allegedly visiting Head Start sites, Stewart said.

Crowder, who was the chief of the civil division for the U.S. attorney’s office in the Southern District of Georgia, said that in 10 years the investigation of health care fraud became the largest part of their work.

Special strike forces have been sent to areas deemed as hot beds of Medicare fraud. In May, teams working in eight cities made 89 arrests while uncovering $223 million in fraudulent billing.

The fraud can take the form of medical professionals billing for services they do not perform, or when thieves obtain Medicare billing and patient numbers and create scam operations, Stewart said.