Case Study: Stewardship of Public Trust

Case Study: Stewardship of Public Trust

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Case Study: Stewardship of Public Trust

The stewards of Medicare: How four public servants helped protect one of America’s signature health programs

Each year, phony Medicare claims cost the American taxpayer billions of dollars and deprive those eligible for coverage—senior citizens, and people with disabilities and serious illnesses—of proper health care. These fraudulent schemes turn Medicare, a historic federal program that insures more than 60 million Americans, into a personal piggy bank for private interests who prey on the vulnerable and exploit the public good. 

One group, however, has protected this vital national asset with unprecedented success.

Since 2007, the Medicare Fraud Strike Force has employed teams of investigators from the departments of Justice and Health and Human Services to prosecute Medicare’s worst abusers at every turn.

Operated jointly within the HHS and DOJ’s Health Care Fraud Prevention and Enforcement Action Team (HEAT) program, the strike force began as a four-team pilot project run out of Miami, the epicenter of Medicare fraud in America.

Today, it is a nationwide initiative operating in 12 cities across 24 federal districts that has charged more than 4,000 individuals with Medicare fraud and saved about $10 billion in Medicare costs.

More than that, it is a clear symbol of the results that federal employees can deliver when they uphold the oath of office, protect vital public resources and embrace the highest standards of professional integrity.

Below are 6 examples you can explore with questions to reflect on and consider:

Passion for public service

Four federal investigators helped transform the strike force in its early years and represent the power of public service.

Omar Pérez Aybar of the Department of Health and Human Services, Joe Beemsterboer of the Justice Department, Daniel Bernstein of the U.S. Attorney’s Office, and Randy Culp of the FBI had different specialties, worked in different agencies and took different paths to government work.

Inspired by his father’s career in the Navy and interested in criminal justice, Aybar participated in ride-alongs with the Virginia Beach Police Department before enrolling in the John Jay College of Criminal Justice and working as a paid intern at HHS; Beemsterboer fell in love with government work during a law school internship with the U.S Attorney’s Office in Washington, D.C.; Bernstein started as a paralegal in the private sector before shifting to the Miami-Dade State Attorney’s Office; and Culp initially worked as a certified public accountant before a continuing education seminar on white collar crime organized by the FBI led him to apply for a job with the agency.

Despite these differences, however, these investigators were bonded by a commitment to protect taxpayer dollars and hold accountable those who cheat the government and line their pockets at the public’s expense.

“I don’t like cons, I don’t like cheats and I don’t like fraudsters,” Culp, a former supervisory special agent with the FBI, noted. “And I enjoy putting some of them behind bars and out of business.”

“These were educated doctors,” Beemsterboer, then assistant chief of the DOJ Fraud Section, said. “They could have done anything they wanted, but they decided to rip off the system. Those are my tax dollars, your tax dollars. That’s a big part of protecting the public trust.”

“Medicare,” said Bernstein, an assistant attorney with the South Florida U.S. Attorney’s Office, “is one of the best things the government has ever done for the people of this country.”

Taking down those who exploited the program, he added, made the work worthwhile. “It’s the greed,” he said when asked what angered him most about Medicare fraud. “Privileged folks do this.”  

The impact of Aybar, Beemsterboer, Bernstein and Culp is undeniable. From 2008-2014, they forged a new model for interagency collaboration that enabled decisive legal action against Medicare fraud and helped return nearly $1 billion to the Medicare Trust Fund. Few have done more to protect one of America’s signature health programs.

Omar Pérez Aybar, supervisory special agent, Office of the Inspector General, Department of Health and Human Services
Omar Pérez Aybar, supervisory special agent, Office of the Inspector General, Department of Health and Human Services
Stewardship of public trust

Given the vast and unmatched influence, power and resources of our government, affecting the United States and the world, trust in federal leaders and their integrity is paramount. Federal leaders represent the American people and must be held to the highest standard. They are stewards of the Constitution, taxpayer dollars and the workforces they lead.

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I do solemnly swear (or affirm) that I will support and defend the Constitution of the United States against all enemies, foreign and domestic; that I will bear true faith and allegiance to the same; that I take this obligation freely, without any mental reservation or purpose of evasion; and that I will well and faithfully discharge the duties of the office on which I am about to enter: So help me God.

From the story: How is stewardship illustrated in these individuals’ careers and motivations?

For reflection: Think back to when you took the oath of office. What did it mean to you then?

For action: How might you share stories of the important and impactful work of public servants?

Obstacles to collaboration

Launching the strike force was no easy task.  

Each of its federal entities—the FBI, HHS, DOJ and U.S. Attorney’s Office—recognized Medicare fraud as a major problem in South Florida but worked along parallel tracks and ran up against limited resources.

“There were four separate entities all reporting to their respective management, even though we were all tackling the same issues,” Culp noted. 

“And you don’t have unlimited resources to address every problem,” he said. “You’ve got to figure out how to staff each area—whether it’s drugs, human trafficking or violent gangs.”

With multiple agencies working together, strategic differences were also inevitable.

“Some agencies would say, ‘Listen, we need to produce a lot of cases quickly,’” Beemsterboer said. “Others would say, ‘Listen, we should do a few big impact cases.’ We needed to manage those tensions.”

At times, the agencies also worked unilaterally. When the FBI and DOJ excluded HHS from important decision-making processes and field operations, Aybar reminded his colleagues of the value his department brought to the team.

“I could appreciate that the FBI were the big dogs on the block and the DOJ had the prosecutors that were ultimately going to take the cases [we researched and investigated],” Aybar said. “But we were subject matter experts on health care fraud.”

From the story: How might these leaders have gone about creating a coalition? What advice would you give the strike force in this position?

For reflection: How does cross-agency collaboration enhance stewardship? 

For action: In your own work, how might you build strategic coalitions to achieve better results?

Launching the strike force

To overcome these pitfalls, the agencies on the strike force had to work together to find common ground.

“We had to check our egos at the door,” Culp said.

Fortunately, the strike force’s structure enabled collaboration and teamwork.

To kickstart the new initiative, the DOJ provided the South Florida U.S. Attorney’s Office with additional trial lawyers to join new strike force teams. In return, the office lent its own major crimes attorneys to these teams as well. Both sets of lawyers then partnered with local HHS and FBI agents already investigating Medicare fraud in the area.

The arrangement benefited each agency on the strike force. The South Florida U.S. Attorney’s Office received new personnel, DOJ experimented with a new way to tackle Medicare fraud, and HHS and FBI agents gained easy access to prosecutors who would take cases to court.

As a result, strike force investigations were highly effective and efficient. Working together, agents and prosecutors investigated and filed cases quickly, avoiding the delays that typically occur when investigators have to pitch a case to an unknown district or U.S. attorney from afar.

On his first day on the job in 2010, Beemsterboer saw HHS and FBI agents, assistant U.S. attorneys and DOJ fraud section trial attorneys working together side by side in a large off-site facility.

It was an unusual arrangement, but Beemsterboer immediately saw the benefits.  

“It made a lot of sense. We worked hand in hand, moved cases really quickly and had the ability to review evidence with each other. We were able to do so much more being in the same location.”

For Culp, the horseshoe seating arrangement at strike force headquarters enabled open discussion and information sharing.  

“We didn’t have to hunt down prosecutors and try to sell them an investigation one at a time,” Culp said. “We all worked from the ground-up as a team.”

Working together also enabled the strike force to cultivate a culture of continuous learning.

Beemsterboer was new to health care fraud when he joined the strike force, but the group helped him get up to speed quickly.

“They were there to collaborate and help,” he said of his colleagues. “I didn’t know much about health care, but they helped bring me along right away.”  

From the story: Based on what you know, what were the keys to these teams successfully working together?

For reflection: Why is it often difficult for agencies to work together?

For action: What challenges have you had working on interagency projects? How were you able to work through those challenges?

Early success

This collaborative environment produced fast results. Initially, the strike force investigated fraudulent Medicare schemes involving durable medical equipment and HIV infusion treatments.

In January 2008, the group charged six individuals with filing more than $50 million in phony Medicare claims for items such as nebulizers, wheelchairs, oxygen concentrators and hospital beds.

Later, the strike force took down a $100 million scheme involving 11 Miami clinics that filed false HIV medical infusion claims. In some cases, patients received a mix of vitamins and saline solution rather than any actual HIV medication.  

Throughout, the investigators examined billing patterns, bank accounts and medical records to detect Medicare quickly and prevent further corruption. In one early case, this type of data analysis helped the strike force discover that the owner of a durable medical equipment company had stolen doctor and patient ID numbers to submit more than 4,000 Medicare claims for over $2 million in just three months.

The positive results enabled the strike force to expand.

“It seemed like the more success we got,” Culp noted, “the more agents we got and the more prosecutors we got.”

Aybar helped drive this change by advertising the strike force to other HHS agents and getting more agencywide buy-in.

“Part of my job was trying to get the rest of the agents who weren’t a part of the pilot project to rethink and reimagine how we go about investigations. We knew this was going to become a staple program, but we needed to make sure that all the partners saw it and really bought in,” he said.

From the story: How else might the team have shared their successes and gained additional buy in?

For reflection: How do successes like these strengthen the public’s trust in government?

For action: How might you build quick wins into your work? How do you share best practices and successes from your work?

Driving impact

For Aybar, driving this kind of change was nothing new. 

Throughout his career, the twenty-two-year HHS veteran routinely made an impact by taking the initiative, building networks and committing himself to uphold the oath of office.     

Aybar’s first assignment as an agent within the HHS’ Office of the Inspector General was to open up an HHS office in Puerto Rico, a difficult assignment for a 22-year old new hire living far from families and friends.

Aybar recalled the initial challenges of working amid difficult conditions in a country that lacked a robust health care system. The final straw was a large power outage that turned off his refrigerator and left him without food after a grueling day at work. Soon after, he called his supervisor and requested a transfer to work closer to home.

But the oath of office compelled Aybar to stay.

“I swore an oath,” he told himself. “They trusted me to do this and I need to make it happen. I’d be remiss if I didn’t leave my footprint on a place and try to leave it better than I found it.”

Eventually, Aybar turned the Puerto Rico outpost into the most productive HHS field office in the New York region. Laying out the office’s potential workload and impact to his supervisors, he hired a close-knit team of DOJ prosecutors and FBI agents that mirrored the Medicare strike force he would later join in Miami. The new professional network, built from scratch, offered camaraderie, community and shared sense of mission in a new work environment.  

After 5 1/2 years, Aybar transferred to the New York field office. But he missed the unique chemistry he had developed with his team in Puerto Rico and found it more difficult to get his cases before a judge without a dedicated prosecutor.

“New York is the financial capital of the world,” he said. “There’s a whole host of crimes that, from a jury’s perspective, are much sexier – drug cases, violent crime cases, public corruption cases, insider trading cases. And here I am trying to present a health care fraud case. It was an uphill battle.”     

So Aybar got creative, leading an undercover operation—then uncommon at HHS—to take down a pharmaceutical employee illegally supplying pills to several local pharmacies.

Operating in another new work environment, Aybar relied on the oath he took as a federal employee to stay motivated and achieve success.

“The work was still fulfilling,” he said, “because I kept thinking, ‘You took this oath to protect people. You need to do all you can to live up to that.’” 

A year later, while preparing for a recruiting event at John Jay, Aybar came across a USAJOBS posting for a full-time position with the Medicare Fraud Strike Force in Miami. After inquiring about job specifics, and debating whether to uproot his family again and leave New York City, he accepted an offer to join the group in South Florida.

From the story: What values are embedded in Aybar’s remarks?

For reflection: What is unique about public service?

For action: What keeps you in public service?

New directions

Once there, Aybar employed the same mindset and strategies—taking the initiative and tapping into his professional networks—to make an impact as he did in his previous positions in Puerto Rico and New York City.

After two years, Aybar realized that the strike force, despite its early success, needed to tackle new and emerging types of fraud.

“We were getting results,” Aybar said. “But I said, ‘At some point, this is going to dry up.’”

He got his chance to lead the strike force in a new direction in 2010, when an analyst working for the Centers for Medicare and Medicaid Services advised Aybar to investigate possible Medicare fraud at community mental health facilities.

Aybar invited the analyst to present the evidence to his supervisors, but they remained unconvinced by what they heard and balked at building a case.

But Aybar persisted, driven once again by his responsibility to serve and protect the public.

“These are folks with Alzheimer’s and dementia—people who are struggling and supposed to be receiving some type of mental health support so they can carry on their lives. We couldn’t leave the vulnerable population that way.”

He then seized an opportunity to turn a civil case on a related issue involving community health centers into a criminal case. To do so, Aybar made a smart personnel move, pairing two new eager strike force hires—a new HHS agent and a new DOJ prosecutor—together to investigate the issue.   

“We were trying to capitalize on opportunities when they presented themselves,” Aybar said.

The aggressive approach paid off.

Within five months, the strike force had charged the American Therapeutics Corporation with operating an eight-year, $205 million scheme that involved bribing assisted living facilities to refer patients with Alzheimer’s and dementia to the company for unnecessary—and in some cases nonexistent—services.

In 2011, a judge ordered the company’s owner to pay more than $87 million and sentenced him to 50 years in prison, the longest sentence handed down on a Medicare fraud case at the time.

From the story: What would you do in Aybar’s situation? What points would you make to the skeptical bosses and how would you weave principles of stewardship into them?

For reflection: How does stewardship play a vital role in driving change in government?

For action: How might you take risks to maximize your impact?

Creating lasting change

By the early 2010s, the strike force hit its stride. With new cases came more press coverage and a greater public recognition that Medicare fraud was a serious problem.

“Eventually cases we’re doing ended up on the front of the Wall Street Journal and the New York Times,” Beemsterboer said.  

“We’d arrest a ton of people and the press would write about it,” Bernstein added.

The public spotlight made a difference.

In the early 2010s, Beemsterboer and Bernstein began to investigate fraud in Miami’s home health care agencies. The strike force eventually charged several owners with defrauding Medicare of $170 million. A judge sentenced the owners to between three and 10 years in prison.

In response, the Centers for Medicare and Medicaid Services suspended new home health agency enrollments in the Medicare program in Miami for nearly six years, a move that drastically reduced home health fraud in Miami.

More recently, federal agencies replicated the strike force model to tackle the nation’s opioid epidemic. Within the four months, the Appalachian Regional Prescription Opioid Strike Force had spearheaded the largest opioid takedown in U.S. history to date, charging 60 individuals across 11 federal districts with illegally distributing more than 32 million opioid pills

Looking back, Aybar believes these successes demonstrated how federal employees who uphold their oath and protect the public interest can rebuild public faith in government.

“Conceptually, the strike force is embodiment of public service,” he said.

“The foundation of our work is the oath that we took. The impact is that we’ve shaped what John Q. Public thinks about when he imagines someone in government service. We were able to say, ‘We’re here to safeguard you, and all of the freedoms and benefits you expect this country to provide.’”

From the story: How are Aybar and his team upholding the values found in the Constitution? What factors led to the broader adoption of their model?

For reflection: How does public trust grow?

For action: Go back and read the oath of office again. What does it mean to you now?

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