WASHINGTON – If there ever was any question that Miami is the champ when it comes to health care fraud, a peek inside Medicare's list of banned providers should settle it.
Of all the people and businesses in the federal government's "exclusions database," Miami tops the list – and does so by a long shot, according to a McClatchy analysis.
Of the medical providers in the database, 1,491 list Miami addresses. Second place: Los Angeles, with a relatively meager 522 names. They're followed by Phoenix; Brooklyn, N.Y.; and Houston in the top five.
"Despite our measurable successes in combating fraud, South Florida continues to be a hot spot of health care fraud and Miami is considered 'ground zero,' " Brian Martens, a federal health care fraud investigator responsible for combating Medicare crimes in Florida, recently told a Senate panel.
To help root out further fraud and abuse, the federal government maintains a "list of excluded individuals/entities," aiming to provide information to the health care industry, patients and the public about people or businesses currently excluded from participating in Medicare, Medicaid and all other federal health care programs.
As of April, there were more than 57,000 entries on the list.
And more join each year. In fiscal 2013, a total of 3,214 names were added to the database, according to the annual report from the Department of Health and Human Services inspector general. Of those, 1,132 were added because they'd been convicted of crimes related to Medicare or Medicaid, a higher level than at any time in the past 17 years for which records were available.
"A lot of this has to do with greater enforcement, but part also could be an increase in fraud itself," said Louis Saccoccio, the chief executive officer of the National Health Care Anti-Fraud Association. "In some places, you've seen an explosion in health care fraud: in Miami, Houston, Detroit, Southern California. And there is more aggressive law enforcement there. They're getting convictions, and they're getting exclusions."
In Florida, for example, one of the fraud exclusions took place on Feb. 20, 2013, representing one of the final steps in prosecuting a South Florida man who helped run a series of clinics that trafficked in oxycodone and oxymorphone, the powerful pain medications.
Juan De Dios Gomez owned and operated clinics in Hialeah, Miami and Plantation. Federal prosecutors say Gomez and his co-conspirators began their operation as early as November 2007. Physicians who worked at the clinics would prescribe the painkillers for people who didn't need the drugs but did qualify for Medicare or other health insurance plans.
These so-called patients would present the prescriptions to complicit pharmacies; once the prescriptions were filled, the insurance plans would be billed and the pills would be sold elsewhere.
According to the HHS inspector general, Gomez would offer kickbacks, bribes and other inducements to recruit patients to his clinic. He pleaded guilty in 2012 and was sentenced to more than 16 years in prison; in 2013, he was kicked out of the Medicare program for a minimum of 50 years.
He shows up in the exclusions database with the last address Medicare had for him: a Miami post office box associated with a federal prison.
In fact, the ZIP code with the federal prison in Miami tops any other ZIP code in the nation. The presence of the prison does a little to inflate Miami's numbers, but those addresses make up less than a quarter of the Miami entries in the database – and even without them, Miami leads other cities by a long shot. In addition, some people busted for Medicare fraud in Miami are in federal prisons in other states and don't show up in Miami's total, records indicate.
Of all the businesses and individuals nationwide in the exclusions database, the biggest share of them – 44 percent – are there because their medical licenses had been revoked.
The second biggest share – 27 percent – is due to convictions for crimes related to Medicare or Medicaid.
In Florida, those shares have been flipped: The top reason for Florida exclusions is for Medicare- or Medicaid-related crime, at 38 percent. Second, at 34 percent, is having a license yanked.
Why there's so much Medicare and Medicaid fraud in Florida is tough to determine. But the people who monitor the issue say it's always been so.
U.S. Sen. Bill Nelson, a Democrat from Florida, pointed to the large number of retirees in the state – "and so lots of Medicare."
He also mentioned the ability of long-criminal elements there, as for those anywhere, to change tactics.
"A lot of these criminals used to deal in drugs, and they were facing long jail terms," Nelson said. "Now they can use a variety of easier tools. Instead of sticking people up or breaking into their homes, they can use laptops. And because it's not violent crime, if they're caught they face shorter sentences."
One reason there may be so much documented Medicare fraud in Florida is that there's so much investigative muscle on the ground. Miami was the first city, in 2007, to get what are known as Medicare fraud strike forces. There are now eight others: across the state in Tampa, as well as in Baton Rouge, La.; Brooklyn, N.Y.; Chicago; Dallas; Houston; Detroit; and Los Angeles.
In Miami, investigator Martens helps oversee the strike force. In the beginning, it had four teams, each with three to five agents drawn from HHS and the FBI along with a dedicated prosecutor.
Initially, one of their missions was to change the mindset on Medicare and Medicaid fraud, bumping it up from being seen as traditional health care fraud to "theft of government funds," Martens said.
"It was to try to change the mindset in order to move these cases quicker," he said.
Now there are 11 teams in Miami. And over the years, the fraudsters have used their own quickness to evade detection – or to try to.
"As we identify an issue and step on it, they're going to look at something else that won't get as much scrutiny," Martens said.
He said the teams' enforcement efforts continued to identify more ways Medicare could make administrative changes to protect the program – and the American taxpayer.
In addition to there being so much Medicare fraud in Florida, it's more aggressive, Martens said.
In other states, a doctor might treat somebody and tack on a little something extra to the Medicare claim.
"Here, they're having your mom sign some forms and she's never gotten anything at all," he said. "It's a little more egregious in nature."
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