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The Health Care Fraud Prevention and Enforcement Action Team (HEAT) is a group of investigators from various agencies at the state, federal and local levels. HEAT was created by the Department of Justice (DOJ) and the Department of Health and Human Services (HHS) in May 2009 to help address the issue of healthcare fraud.

Acting at the federal level through the HEAT Medicare Fraud Strike Force, HEAT examines information from Medicare claims to target and investigate any sudden or suspicious concentrations of Medicare claims within a region.

HEAT also works with state MFCUs (Medicaid Fraud Control Units). These units target patient neglect and abuse in healthcare settings. They also act as a healthcare fraud prevention and enforcement action team at the state level.

HEAT and the FCA

HEAT makes use of the False Claims Act (FCA) to investigate and prosecute healthcare fraud, including fraud brought to the attention of the government by whistleblowers.  The False Claims Act prohibits the submission of false Medicare claims, and efforts to defraud government healthcare programs. The qui tam provisions of the FCA enable whistleblowers to initiate and prosecute lawsuits on behalf of the government to stop fraud, recover money for the government, and receive a portion of the recovery.

HEAT and the FCA have been very successful in addressing healthcare fraud. Over $17.5 billion has been recovered under the False Claims Act since January 2009 in cases involving claims of fraud against federal health care programs. In 2013 alone, the Department of Justice recovered from FCA claims involving healthcare fraud.

Healthcare Fraud

Healthcare fraud has continued to be a concern in our country. Improper billing, falsified bills and kickbacks are just some of the types of cases pursued under the False Claims Act.

One common trend in healthcare fraud involves the unnecessary admission of patients to hospitals through the emergency room. One such case in May 2016 involved a lawsuit against Prime Healthcare Services Inc., 14 hospitals belonging to that organization, and the CEO of the group. According to the lawsuit, which the Department of Justice joined, Emergency Departments at hospitals belonging to Prime Healthcare Services were pressured by the CEO through various corporate practices to unnecessarily admit patients to the hospitals, resulting in false Medicare claims. Doctors at the Emergency Departments were encouraged to increase admission inpatient numbers, even when admitting patients was not medically necessary. The alleged fraud was uncovered when an employee at one of the affected hospitals filed a claim under the provisions of the False Claims Act.

Do You Have A Claim?

Goldberg Kohn has been involved in a number of high-profile healthcare fraud cases and successfully represented two whistleblowers who alleged that Community Health Systems, Inc. (CHS), one of the country's largest hospital chains, unnecessarily admitted patients to its hospitals through the emergency department. These whistleblowers alleged that CHS billed for inpatient treatments even in cases where outpatient treatment or observation would have been medically advisable. CHS agreed to pay $98.15 million in the settlement.

Even with the Medicare fraud task force, and the False Claims Act in place, many whistleblowers have questions about job protections and the process of filing a claim. Goldberg Kohn offers support to whistleblowers, and has an extensive track record of successfully representing healthcare fraud cases. If you have observed healthcare fraud in your workplace, contact Goldberg Kohn for a free and confidential consultation.