Yes, the quote is the opening of A Tale of Two Cities.  On the one hand, the healthcare fraud Subject Matter Experts are enjoying the small wins; while on the other hand, the new to healthcare fraud interns  are struggling to understand the yoke of healthcare fraud.

We have been doing healthcare fraud so long that we are happy about the small wins rather than appalled that more is not happening.  It takes a fresh set of eyes.  We had two individuals on our team, a 30+ year retired HHS-OIG agent and a highschool intern, read the same report. 

Last week in OIG Files, our retired agents looked at The Pennsylvania Insurance Fraud Prevention Association (IFPA) recently published their 2020 annual report and they shared “we were really excited to see some of the great work that the SIU investigators at Highmark did on a case involving a physical therapist.

Our healthcare intern read the same report and was not excited at all.  In fact she said, “the biggest thing that keeps popping out to me is that when people are committing these white-collar crimes, they just get a slap on the wrist. They receive a very short prison sentence with probation (which is hardly punishment) BUT the bills they must pay are through the roof. Some are as high as $325k, that’s the price of a house. My question is, where does that money go? Do they pay the government? These crimes are very serious, and it seems to me like people don’t treat them that way due to the punishments.” 

Our intern (who just learned how to drive) went on to disgustedly state “The stats on page 20 are insane, the increase in fraud referrals has risen. Which I’m presuming are the reported cases, however, that’s both good and bad. It’s great that these people are getting caught, but it also means that there are even more people breaking the law and abusing their corporate power. The arrests for frauds have gone down quite a bit, which is not good news in the slightest.” 

She finally closed with “I think legal teams need to step up their game against these crimes and help slow the increase in healthcare fraud.”  Well I agree that we need to all step up our game and the small wins are simply small nothings.  We need to do more to dramatically change what is being done.  I have been with this business for almost a decade and I wake up as disgusted as our intern daily.  My friends work hard to fight the good fight but we are losing as a country and until we move the entire healthcare fraud needle in a significant direction, we are hamsters on our wheel.