El 15M como escenario de ruptura con la Transición

In FY 2012, the United States Attorney’s Offices (USAOs) were allocated approximately $35.4 million in HCFAC funding to support civil and criminal health care fraud and abuse litigation, as exemplified in the Program Accomplishments section. The USAOs dedicated substantial district resources to combating health care fraud and abuse in 2012, and HCFAC allocations have

supplemented those resources by providing funding for attorneys, paralegals, auditors and investigators, as well as funds for litigation of resource-intensive health care fraud cases. The 93 United States Attorneys and their assistants, or AUSAs, are the nation’s principal prosecutors of Federal crimes, including health care fraud. Each district has a designated Criminal Health Care Fraud Coordinator and a Civil Health Care Fraud Coordinator. Civil and criminal health care fraud referrals are often made to USAOs through the law enforcement network described herein, and these cases are usually handled primarily by the USAOs, although the civil referrals are sometimes handled jointly with the Civil Division’s Commercial Litigation Branch (Fraud Section). The other principal source of referrals of civil cases for USAOs is through the filing of qui tam (or whistleblower) complaints. These cases are often handled jointly with trial attorneys in the Frauds Section. USAOs also handle most criminal and civil appeals at the Federal appellate level.

USAOs play a major role in health care fraud enforcement by bringing criminal and affirmative civil cases to recover funds wrongfully taken from the Medicare Trust Funds and other taxpayer- funded health care systems as a result of fraud, waste, and abuse. Civil and criminal AUSAs litigate a wide variety of health care fraud matters, including false billings by physicians and other providers of medical services, overcharges by hospitals, Medicaid fraud, kickbacks to induce referrals of Medicare or Medicaid patients, fraud by pharmaceutical and medical device

companies, home health and hospice fraud, and failure of care allegations against nursing home owners. Working closely with their partners in the Civil Division, several civil health care fraud AUSAs have focused their efforts on pharmaceutical fraud, resulting in significant recoveries including: $3.0 billion from GlaxoSmithKline, and $950 million from Merck, Sharp and Dohme. Most of the civil settlements, including these settlements were part of a global resolution, which also addressed the criminal liabilities, resulting in criminal pleas, as well as significant fines and forfeitures. The criminal portion of these investigations and resolutions was handled by criminal health care fraud AUSAs, often working with their counterparts at the Consumer Protection Branch of the Civil Division. These global settlements resolved allegations including, reporting of false and inflated drug prices, manufacturing and distributing adulterated drugs, off-label marketing and kick-backs. These cases are detailed earlier in this report.

Several of the USAOs have dedicated significant resources to investigate fraud perpetrated on our most vulnerable citizens. To this end, the USAOs have partnered with Civil Frauds in the Elder Justice and Nursing Home Initiative to address elder abuse and neglect. As a result of USAO efforts, the owner and operator of three nursing homes was sentenced to serve 20 years in Federal

prison on charges of conspiring with his wife to defraud the Medicare and Georgia Medicaid programs by billing them for “worthless services” in the operation of three nursing homes. This is the first time that a defendant has been convicted after a trial in Federal court for submitting claims for payment for worthless services. The defendant was also ordered to pay $6.7 million in restitution to Medicaid and Medicare

The USAOs partner with the Criminal Division in the Strike Forces, which are currently operating in nine USAOs across the country. Each USAO has dedicated several AUSAs and support

personnel to work with Criminal Division attorneys in this important initiative. The MFSFs use data analysis to identify high-billing levels in health care hot spots so that emerging or migrating schemes can be targeted. The significant successes of the MFSFs have been detailed earlier in this report.

Special Focus Teams, consisting of criminal and civil AUSAs, paralegals, and auditors, are operational in three districts and focus on pharmaceutical, biologics, and medical device fraud. The teams have contributed significantly to the success of the pharmaceutical investigations and recoveries this year. To increase the capacity of other districts to successfully litigate these complex health care fraud cases, the Special Focus Teams have organized monthly training Webinars and serve as advisors for the USAO community in the various complex areas of health care fraud.

In addition to the positions funded by HCFAC, the Executive Office for United States Attorneys’ Office of Legal Education (OLE) uses HCFAC funds to train AUSAs and other DOJ attorneys, as well as paralegals, investigators, and auditors in the investigation and prosecution of health care fraud. In 2012, OLE offered a Health Care Fraud Seminar, which was attended by over 100 AUSAs and DOJ trial attorneys. In addition, an ACE Conference, with a heavy concentration on health care fraud issues, was offered for paralegals, auditors, and investigators. Many USAO attorneys, investigators, auditors, and paralegals serve as faculty at these OLE trainings, and also participate in other Federal, state, and private health care fraud seminars.

Criminal Prosecutions

In FY 2012, the USAOs received 1,131 new criminal matters involving 2,148 defendants, and had 2,032 health care fraud criminal matters pending,15 involving 3,410 defendants. The USAOs filed criminal charges in 452 cases involving 892 defendants, and obtained 826 Federal health care fraud related convictions.

Civil Matters and Cases

In FY 2012, the USAOs had opened 885 new civil health care fraud investigations. At the end of FY 2012, the USAOs had 1,023 civil health care fraud investigations pending.

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When a USAO accepts a criminal referral for consideration, the office opens it as a matter pending in the district. A referral remains a pending matter until an indictment or information is filed or it is declined for prosecution.