U.S. Office of Personnel Management www.opm.gov - Recruiting, Retaining and Honoring a World-Class Workforce to Serve the American People

Investigative Activities

EHBP 
Receives
$252,200 in
Settlement Agreement

We continued to pursue aggressively criminal and civil prosecutions against all persons and businesses we identified as having engaged in some form of trust fund  fraud. Our efforts resulted in 17 arrests and 12 convictions, along with $1,483,547 in judicial and administrative monetary recoveries. 

We opened 39 investigations, closed 17, and 91 were still in progress at the end of the period. For additional information on investigative activity during this reporting period, refer to Table 1 on page 36 of this section as well as the OIG's productivity information at the beginning of this report. We received a total of 483 hotline calls and complaints during this reporting period. These calls and complaints included such areas as health care fraud, retirement fraud, employee misconduct or other suspected wrongdoing by individuals. Information we obtain through these hotline calls, as well as written complaints received in the office, continue to be extremely helpful to us in our investigative efforts to protect the programs under the jurisdiction of our agency. Please consult page 37 in this section for additional statistical data relating to our OIG hotline and complaint activity. 

In keeping with the emphasis that Congress and various departments and agencies in the executive branch place on combating health care fraud, we  coordinate our investigations with the Department of Justice (DOJ), the FBI, and other federal, state and local law enforcement agencies. 

At the national level, we are participating members of DOJ.s health-care fraud  working groups. We work actively with the  various U.S. Attorney's offices in their efforts to further consolidate and increase the focus of investigative resources in those regions that have been particularly vulnerable to fraudulent schemes and practices engaged in by unscrupulous health care providers.

Additionally, our office maintains a close liaison with other federal law enforcement agencies participating in health care fraud investigations throughout the country. As a consequence, we participate in many health-care fraud working groups that simultaneously represent governmental interests at the federal, state and local levels. Our OIG special agents also work closely with the various health insurance carriers participating in the Federal Employees Health Benefits Program (FEHBP). This cooperative effort provides an effective means for reporting instances of possible fraud by FEHBP health care providers and subscribers. Our investigators, of course, continue to have a close working relationship with our OIG auditors on fraud issues that may arise during the course of FEHBP health carrier audits. 

The following case summaries represent three typical, but significant, health care fraud activities carried out against the FEHBP, culminating in federal prosecution, guilty pleas or settlements during this reporting period. 

Physician Commits Major Medical Fraud

On June 22, 2001, in U.S. District Court in Jacksonville, Florida, Dr. Sammir Najjar of Orange Park, Florida, pleaded guilty to making false claims for payment of medical services. These claims were paid by insurance carriers participating in the Federal Health Employees Benefit Program and the federal Medicare program and which also provided health insurance coverage to private citizens, businesses, and state employees in the state of Florida where Dr. Najjar practiced medicine. 

Dr. Najjar's plea and sentencing were the culmination of a three-year investigation conducted by the Florida Division of Insurance Fraud, the FBI, our office and that of the Office of Inspector General at the Department of Health and Human Services (HHS). HHS is responsible for overseeing and administering the Medicare program on behalf of the federal government. 

The investigation disclosed that Dr. Najjar submitted over $5 million in false claims for services he never performed. These services all related to women purportedly having silicone breast implant-related problems. While there was no evidence that Dr. Najjar gave a false diagnosis to any of his patients, the claims for treatment were all fraudulent. 

Following his plea, Dr. Najjar was sentenced to a three-year prison term and ordered to pay $5 million in restitution, $85,790 of which was to be returned to the FEHBP.

Diagnostic Services Firm Agrees to Settlement

The Department of Justice and UroCor, Inc. (UroCor), an Oklahoma City-based corporation providing medical diagnostic services, signed a settlement agreement on June 11 of this year in which UroCor agreed to pay the federal government $9 million for billing fraud involving federal health insurance programs, including the FEHBP. 

The fraud included billing for laboratory tests and pathology services that:

• Were medically unnecessary.

• Were never performed.

• Had never been ordered.

• Contained falsified billing codes that led to a higher rate of reimbursement. 

This settlement followed a four-year investigation initiated as a result of a referral to the Department of Justice by the affected federal parties whose health care programs had  been defrauded.

Specifically, this included the Department of Defense, the Department of Health and Human Services and OPM. Consequently, our respective OIGs conducted this investigation.