The Heroes Who Took on Medicare Fraud – and Won!
Policy + Politics

The Heroes Who Took on Medicare Fraud – and Won!

Meet Omar Perez Aybar and Reginald France, two veteran investigators for the Department of Health and Human Services’ Inspector General, who are the worst nightmare for Medicare cheats. After teaming up several years ago on an elite taskforce designed to root out Medicare fraud in southern Florida, the two men have led the way in cracking down on rip-off artists who have drained the Medicare Trust Fund of tens of billions of dollars annually.

Medicare, the federal health insurance program for 54 million people over age 65, paid out about $583 billion in benefits last year.

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The FBI at one time hazarded a guess that between three percent and ten percent of all claims were fraudulent, which translates to between $17 billion and $58 billion of bad payments every year. The Miami area, with its high concentration of seniors, is considered “ground zero” for much of the fraud.

Whatever the precise amount, France describes the magnitude of fraudulent activity as “staggering” and said his personal outrage over the widespread fraudulent activities fuels his drive to identify and prosecute unscrupulous operators and beneficiaries.

“We have Medicare patients who are willing to sell their information for whatever reasons so that someone can bill the Medicare program for services they never received,” Aybar recalled in an interview with Partnership for Public Service, an advocacy group for an improved government service. “You have nurses who will alter documentation to give the appearance that they provided a service when in fact they haven’t.”

While the federal workforce is frequently pummeled by lawmakers, the media and the public for gross inefficiency, waste and wrongdoing, many like Aybar and France are smart, hard-working and innovative federal workers who aspire to excellence. They were among nearly a dozen civil servants honored Monday evening at the 13th annual Samuel J. Heyman Service to America Medals gala, a black-tie affair organized by the Partnership for Public Service that attracted Attorney General Eric Holder and other top officials.

Related: Medicare by the Numbers

The awards recipients ranged from a Centers for Disease Control and Prevention official who organized a 60-country global vaccination campaign for children to two Veterans Affairs researchers who developed “innovative medical advances and novel drug therapies” to assist paralyzed veterans.

The mounting challenge of Medicare fraud first caught Aybar’s eye in 2007. That was when he joined forces with Department of Justice agents to form a pilot program, the Healthcare Fraud Enforcement Action Team (HEAT). Through extensive data mining, audits, undercover investigations and surveillance, the team began putting a serious dent in Medicare fraud. Then in 2011, France, another HHS special agent, joined the Miami HEAT operation.

France and Aybar together became involved in virtually every facet of the squad’s work – supervising agents and signing off on strategies, including the timing for obtaining search warrants and getting their hands on bank records. They’ve worked in tandem with the U.S. Attorney’s Office and the FBI as well as HHS officials in Washington.

Moreover, they advised officials in eight other federal judicial districts – Baton Rouge, La., Brooklyn, N.Y., Chicago, Dallas, Detroit, Houston, Los Angeles and Tampa -- to form their own HEAT Teams.

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Between 2008 and June 2014, these teams obtained 857 indictments and 685 convictions, and returned nearly $1 billion to the Medicare Trust Fund, the Partnership for Public Service reported.

The Miami team also reined in Medicare claims related to durable medical equipment. Billings plummeted from $6.1 billion when the investigations were first launched to just $2 billion in early 2014. “They also took down many fraudulent community mental health scams, reducing billings in that area from $70 million to about $10 million per quarter since the crackdown started,” according to the same report.

One example came in 2013, when the owner of a Miami mental health clinic and three other conspirators were sent to prison for filing $50 million in false and fraudulent Medicare claims. France and Aybar’s team developed the evidence that the defendants paid “patient recruiters” to refer ineligible Medicare beneficiaries to the clinic for services that were never provided or not legally reimbursable under Medicare rules.

Joan Silverstein, chief of the Economic and Environmental Crimes Section in the U.S. Attorney’s Office in Miami, told the Partnership for Public Service that “the number of cases and people affected [by Aybar’s and France’s work] is nothing less than amazing.” Joseph Beemsterboer, of the fraud section of the Justice Department’s Criminal Division, said that “Reggie and Omar work tirelessly every day to make sure our prosecutors have what they need. They foster a professional environment that allows us to get a return on taxpayer dollars.”

Now that’s refreshing.

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