FBI Investigation of Health Care Fraud Explained

Who is the primary agency investigating Health Care Fraud?

The FBI is the primary agency for investigating health care fraud for both federal and private insurance programs.

What Agencies Does the FBI Work With to Investigate Health Care Fraud?

The FBI investigates these crimes in partnership with:

Federal, state, and local agencies
Healthcare Fraud Prevention Partnership
Insurance groups such as the National Health Care Anti-Fraud Association, the National Insurance Crime Bureau, and insurance investigative units

Who are the Primary Targets of FBI Health Care Fraud Investigations?

The FBI’s primary health care fraud investigation targets are medical providers, patients, and third parties that provide devices such as durable medical equipment or materials, testing or drugs via telemedicine.

What is the Helen Zervas Fraud Prosecution About?

Recently optometrist Helen Zervas plead guilty in Bridgeport, Connecticut to health care fraud and public corruption. Her company was “Family Eye Care” and it billed both Medicaid and Medicare. The charges to which she pled involved claims to Medicaid and Medicare falsely representing that she had provided, or determined it was medically necessary to provide, certain treatment. The prosecution stated that she made more than 300 false claims to Medicaid and more than 30 false claims to Medicare for insertion of an amniotic membrane to the eye surface of a patient when that treatment was either not provided or was not medically necessary.

The case started with an audit. There were then charges that Zervas interfered with the audit by conspiring with both a senior official in the State’s Office of Policy and Management and a Connecticut State Representative. The ultimate guilty plea was much lighter than the original charges but the potential penalties were still huge. Zervas pleaded guilty to one count of health care fraud, an offense that carries a maximum term of imprisonment of 10 years, and one count of conspiracy to commit extortion under color of official right, an offense that carries a maximum term of imprisonment of 20 years.

This case illustrates the type of fraud that the FBI focuses on.  Billing was for a population of those who were obtaining government assistance or Medicare benefits.  The billing was not regularly reviewed by this population because they had little or no co-payment (which would trigger a review).  Attempts to avoid criminal charges compounded the problem.