Recent Court Actions Provide Insight into Future of Fraud & Abuse Laws

Posted on November 3, 2024 by Dr. David Edward Marcinko MBA MEd CMP™

By Health Capital Consultants, LLC

Two recent court actions may serve as harbingers for the future of healthcare fraud and abuse laws. In September 2024, a federal judge in the Southern District of West Virginia ordered parties in a qui tam False Claims Act and Stark Law case to brief the court on the implications of Loper Bright Enterprises v. Raimondo on the interpretation of the Stark Law to the case at hand.

That same month, a federal judge in the Middle District of Florida dismissed a qui tam lawsuit on a novel theory that the False Claims Act’s whistleblower provisions are unconstitutional.

This Health Capital Topics article discusses these cases and the potential impact on federal fraud and abuse laws. (Read more…)

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HEALTH FRAUD: Abuse Control Program Annual Report

Posted on November 18, 2023 by Dr. David Edward Marcinko MBA MEd CMP™

By Staff Reporters

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Healthcare Fraud and Abuse Control Program Annual Report Released

In Fiscal Year (FY) 2022, the Department of Justice (DOJ) opened more than 809 new criminal healthcare fraud investigations. Federal prosecutors filed criminal charges in over 419 cases involving at least 680 defendants. More than 477 defendants were convicted of healthcare fraud related crimes during the year. Also, in FY 2022, DOJ opened more than 774 new civil healthcare fraud investigations and had over 1,288 civil healthcare fraud matters pending at the end of the fiscal year. 

Federal Bureau of Investigation (FBI) investigative efforts resulted in over 499 operational disruptions of criminal fraud organizations and the dismantlement of the criminal hierarchy of more than 132 healthcare fraud criminal enterprises. In FY 2022, investigations conducted by HHS’s Office of Inspector General (HHS-OIG) resulted in 661 criminal actions against individuals or entities that engaged in crimes related to Medicare and Medicaid, and 726 civil actions, which include false claims, unjust-enrichment lawsuits filed in Federal district court, and civil monetary penalty (CMP) settlements. HHS-OIG excluded 2,332 individuals and entities from participation in Medicare, Medicaid, and other Federal healthcare programs.

Source: U.S. Department of Health and Human Services and U.S. Department of Justice

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PODCAST: Six [6] Commission Relationships in Healthcare

Posted on September 2, 2021 by Dr. David Edward Marcinko MBA MEd CMP™

The Healthcare Industry is Filled with Commission Relationships Where Money Is Paid, But It Is Not Always Obvious.

BY RIC BRICKER MD

Your comments and thoughts are appreciated.

CITE: https://www.r2library.com/Resource/Title/0826102549

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What Health Care Fraud Costs Us

Posted on August 2, 2012 by Dr. David Edward Marcinko MBA MEd CMP™

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Scrutiny Needed from the Patient Citizenry – Too?

As health care takes the center stage at the forefront of contemporary politics it is under scrutiny from several angles.

The Fraud Rate

One aspect of the health care system that has been garnering growing levels of interest is the rate at which medical fraud occurs. As the developed world steeps itself further and further into the digital age, things like medical history and billing records become more easily susceptible to fraud since they’re accessible from virtually anywhere.

Expensive Care

And, the fact of the matter is that trying to stay healthy is an expensive business. Each year, 300 million Americans spend about $2 trillion on health care, but the amount of that money that is lost to fraud seems to have grown a great deal in recent years.

Types

The government continues to crack down and identify fraudsters in all their forms—and they do come in many forms. Perhaps the most common type of health care fraud concerns how medical care providers bill. This type of fraud relies heavily on the fact that many patients don’t take the proper amount of time to really scrutinize their medical bills and invoices.

Source: InsuranceQuotes.org

Assessment

Fraud can cost a huge amount of money for victim, insurance companies and society. The best defense against fraud remains understanding EOBs forms and what’s on your medical bills.

Conclusion

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Off Road Touring in Boston with Dr. Marcinko

Posted on December 31, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

How Doctors Get Paid

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

Just before the Christmas Holidays, I flew up to Boston at the invitation of a pharmaceutical company to lead a managerial workshop entitled: “How Doctors Get Paid” [Treatment is only the beginning in the Changing Billing and Medical Reimbursement Climate].

Our goal was to inform drug representatives, and their regional managers, what value added information physician offices might expect from the pharmaceutical industry of the future.  

Topics of Discussion

The two hour interactive workshop included team projects, flip chart exercises, a mock role-playing session and the customary [hopefully energetic] ppt presentation. Other topics of discussion included:  

  • Health insurance payment evolution
  • Collapse of Medicare
  • Rise of managed care
  • Medical records documentation
  • ICD-9 and 10, HCPCS, DRGs and CPT® coding
  • ABNs, super-bills and HCFA 150 forms
  • Billing methodologies
  • Healthcare fraud, abuse and related policies
  • Capitation, HSAs, concierge medicine and RACs
  • Futuristic health 2.0 payment mechanisms, and more.

Assessment

Rest assured; these folks were a very knowledgeable and aggressive group; not like your father’s “detail men” of yore! They seek to … talk the talk, and walk the walk, of the Health 2.0 era.

Many thanks again to Helen, and Jon D, for the invite.

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