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

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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DAILY UPDATE: ChristianaCare Settles FCA Lawsuit as Stock Markets Celebrate 2023 but Start Off Rocky in 2024

By Staff Reporters

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SPONSOR: http://www.MarcinkoAssociates.com

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ChristianaCare agreed to pay $47.1 million to resolve illegal kickback allegations flagged by its former chief compliance officer.

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Markets: The stock market was closed yesterday to give investors time to celebrate New Year’s Day 2024. As the just passed old year, 2023, provided plenty of reasons to pop bottles and celebrate:

For example, global stock markets had their best year since 2019, and all three major US indexes finished the year higher than they started it, with tech company gains pushing the NASDAQ up the most. Even among tech giants, Nvidia was a standout, boosted by A.I. suddenly being everywhere.

But, all major markets are down as of this posting time, today.

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HEALTH FRAUD: Abuse Control Program Annual Report

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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DOJ Recoveries for False Claims Act Cases Doubled in 2021

BY HEALTH CAPITAL CONSULTANTS, LLC.

DEFINITION: The False Claims Act, also called the “Lincoln Law”, is an American federal law that imposes liability on persons and companies who defraud governmental programs. It is the federal Government’s primary litigation tool in combating fraud against the Government. The law includes a provision that allows people who are not affiliated with the government, called “relators” under the law, to file actions on behalf of the government. Persons filing under the Act stand to receive a portion of any recovered damages.

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

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DOJ Recoveries for False Claims Act Cases Doubled in 2021

On February 1, 2022, the U.S. Department of Justice (DOJ) announced their recovery of $5.6 billion in settlements and judgments from civil cases involving fraud and false claims for fiscal year (FY) 2021. Over $5 billion was recouped from the healthcare industry for federal losses alone, and included recoveries from drug and medical device manufacturers, managed care providers, hospitals, pharmacies, hospice organizations, laboratories, and physicians.

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This figure is more than double the amount of healthcare-related recoveries secured in FY 2020, which totaled $1.8 billion. (Read more…)

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PODCAST: Six [6] Commission Relationships in Healthcare

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

BY RIC BRICKER MD

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The REAL Costs of Health Fraud

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Carol S. Miller

By Carol Miller RN MBA

The Cost of Health Fraud

There is no question that real fraud, waste and abuse exists in healthcare today. The Office of Inspector General of the Department of Health and Human Services (HHS) saved American taxpayers a record $21 billion a dozen years ago, according to Inspector General Janet Rehnquist. Savings were achieved through an intensive and continuing crackdown on waste, fraud and abuse in Medicare and over 300 other HHS programs for which the Office of Inspector General (OIG) has oversight responsibility.

More recently, according to the Centers for Medicare and Medicaid Services [CMS] and under the tenure of Eric Himpton Holder, Jr., 82nd Attorney General of the United States and more recently Loretta Lynch, Recovery Asset Contractors [RACs] collected almost $1-B in improper payments during their beta testing period in 2009-10.

Of these payments; 96% were over-payments, 4% were under-payments; and 77% of providers failed to appeal, 7% appealed successfully and 15% appealed unsuccessfully.

And, by Fiscal Year 2016, recovery auditors collectively identified and corrected more than 1,532,249 claims for improper payments, which resulted in more than $3.75 billion dollars in improper payments being corrected. The total corrections identified include more than $3.65 billion in overpayments collected and $102.4 million in underpayments repaid to providers and suppliers.

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After taking into consideration all fees, costs, and first level appeals, the Medicare FFS Recovery Audit Program returned over $3.0 billion to the Medicare Trust Funds.

More Costs

These savings did not take into account program costs and administrative expenses incurred at the third and fourth levels of appeal (Office of Medicare Hearings and Appeals (OMHA) and Medicare Appeals Council within the Departmental Appeals Board (DAB), respectively), as these components do not receive Recovery Audit Program funding for those appeals.

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Transparency Program Obscures Pharma Payments to RNs and PAs

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New data largely excludes nurse practitioners and physician assistants

By Charles Ornstein | @charlesornstein  |  Pro Publica

New data on drug and device company payments to doctors largely excludes nurse practitioners and physician assistants, though they play an ever-larger role in health care.

One advanced-practice nurse pleaded guilty last month to taking drug company kickbacks.

NOTE: This story was co-published with NPR’s Shots blog.

pill mill

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Although this book targets physicians, I was pleased to see that it also addressed the risk management, financial planning and employment benefit needs of nurses; physical, respiratory, and occupational therapists; CRNAs, hospitalists, and other members of the health care team….highly readable, practical, and understandable.

Nurse Cecelia T. Perez RN [Hospital Operating Room Manager, Ellicott City, Maryland

BENEFITS OF A HEALTHCARE COMPLIANCE PROGRAM

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Reality versus Perception

By Carol Miller RN MHA

Carol S. MillerThere are many associated benefits of a healthcare or medical practice compliance program, some of which are only perceived whereas others are very definitive.  Most providers try to comply with the rules and regulations and what is or is not covered by different insurance programs.

Risk Management and Quality Initiatives

Regardless of their ethical and quality processes in their office practice, the decision to develop and implement a compliance program still is an important and needed business decision.  The processes involved in a compliance program can help improve the organization’s performance by providing basic principles in quality improvement which can help improve the provider’s bottom line.

The Benefits

Several benefits of a compliance program are:

  • Improving the quality of patient care
  • Servicing as a resource for information about compliance-related issues
  • Saving time, money, and associated apprehensions during audits or reviews
  • Preventing or identifying improper conduct with systems for evaluation and correction
  • Providing training for employees and contracted services to recognize fraud and abuse
  • Providing a way for employees to report potential problems
  • Demonstrating to staff and community that the practice is committed to honesty and appropriate conduct
  • Minimizing loss associated with false claims through early recognition and reporting, and decreasing the provider’s exposure to civil penalties, sanctions and other administrative actions, such as exclusion

The OIG

The OIG has developed a series of voluntary compliance program guidance documents directed at various segments of the healthcare industry, such as hospitals, nursing homes, third-party billers, durable medical equipment suppliers, clinical laboratories, home health agencies, hospices, nursing facilities, ambulance suppliers, pharmaceutical manufacturers, physician practices, and others, to encourage the development and use of internal controls to monitor adherence to statutes, regulations and program requirements.

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Fraud and Abuse, Too!

The OIG documents also identify fraud and abuse risks to watch out for when creating a programs

ABOUT

Ms. Carol S. Miller has an extensive healthcare background in operations, business development and capture in both the public and private sector. Over the last 10 years she has provided management support to projects in the Department of Health and Human Services, Veterans Affairs, and Department of Defense medical programs. In most recent years, Carol has served as Vice President and Senior Account Executive for NCI Information Systems, Inc., Assistant Vice President at SAIC, and Program Manager at MITRE. She has led the successful capture of large IDIQ/GWAC programs, managed the operations of multiple government contracts, interacted with many government key executives, and increased the new account portfolios for each firm she supported. She earned her MBA from Marymount University; BS in Business from Saint Joseph’s College, and BS in Nursing from the University of Pittsburgh. She is a Certified PMI Project Management Professional (PMP) (PMI PMP) and a Certified HIPAA Professional (CHP), with Top Secret Security clearance issued by the DoD in 2006. Ms. Miller is also a HIMSS Fellow.

CASE MODEL: Compliance

Assessment

The documents provide principles to follow when developing a compliance program that best suits the organization’s needs.

Conclusion

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On Health Care Fraud Detection Analytics

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On the Intersection of Data and Linking Analytics

By http://www.MCOL.com

fraud

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Conclusion

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What Health Care Fraud Costs Us

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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

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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More about Healthcare Organizations [Financial Management Strategies]

Our Print-Journal Preface

By Hope Rachel Hetico; RN, MHA, CMP™hetico1

As Managing Editor of a two volume – 1,200 pages – premium quarterly print journal, I am often asked about our Preface.

A Two-Volume Guide

As so, our hope is that Healthcare Organizations: [Financial Management Strategies] will shape the hospital management landscape by following three important principles.

What it is – How it works

1. First, we have assembled a world-class editorial advisory board and independent team of contributors and asked them to draw on their experience in economic thought leadership and managerial decision making in the healthcare industrial complex. Like many readers, each struggles mightily with the decreasing revenues, increasing costs, and high consumer expectations in today’s competitive healthcare marketplace. Yet, their practical experience and applied operating vision is a source of objective information, informed opinion, and crucial information for this manual and its quarterly updates.

2. Second, our writing style allows us to condense a great deal of information into each quarterly issue.  We integrate prose, applications and regulatory perspectives with real-world case models, as well as charts, tables, diagrams, sample contracts, and checklists.  The result is a comprehensive oeuvre of financial management and operation strategies, vital to all healthcare facility administrators, comptrollers, physician-executives, and consulting business advisors.

3. Third, as editors, we prefer engaged readers who demand compelling content. According to conventional wisdom, printed manuals like this one should be a relic of the past, from an era before instant messaging and high-speed connectivity. Our experience shows just the opposite.  Applied healthcare economics and management literature has grown exponentially in the past decade and the plethora of Internet information makes updates that sort through the clutter and provide strategic analysis all the more valuable. Oh, it should provide some personality and wit, too! Don’t forget, beneath the spreadsheets, profit and loss statements, and financial models are patients, colleagues and investors who depend on you.ho-journal9

www.HealthcareFinancials.com

Assessment

Rest assured, Healthcare Organizations: [Financial Management Strategies] will become an important peer-reviewed vehicle for the advancement of working knowledge and the dissemination of research information and best practices in our field. In the years ahead, we trust these principles will enhance utility and add value to your subscription. Most importantly, we hope to increase your return on investment [ROI] in some small increment.

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TOC: http://www.stpub.com/pdfs/toc_ho.pdf

Conclusion

And so, your thoughts and comments on this Medical Executive-Post, complimentary e-companion are appreciated. If you would like to contribute material or suggest topics for a future update, please contact me. Subscribers, have we attained our goals and objectives, as a work-in-progress in this preface statement?

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Economics of Medical Fraud

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Healthcare Leads the Pack

[By Staff Reporters]mardi-gra-skulls

All Medical Executive-Post readers and subscribers are aware of the Federal False Claims Act. Since 1986, False Claims Act [FCA] judgments and settlements totaled over $20 billion dollars. 

Of Miscreants and Feasors

According to outside unverified resources, below are the top 20 alleged FCA recoveries to date. Notice that all twenty, of the top 20, are healthcare and big Pharma related.

The Top 20

  1. Tenet Heath Care – $900,000,000
  2. HCA – $731,400,000
  3. Merck – $650,000
  4. HCA – $631,000,000
  5. Serono – $567,000,000
  6. Taketa Abbott Pharmaceutical Products Inc – $559,483,560
  7. Schering Plough – $255,000,000
  8. Abbott Labs – $400,000,000
  9. Fresenius Medical Care (National Medical Care) – $385,000,000
  10. Cephalon – $375,000,000
  11. Bristol Myers Squib – $328,000,000
  12. SmithKline Beecham [DBA] GlaxoSmith Kline – $325,000,000
  13. HealthSouth – $325,000,000
  14. National Medical Enterprises – $324,200,000
  15. Gambro Healthcare – $310,000,000
  16. Schering-Plough – $292,969,482
  17. AstraZeneca Pharmaceuticals – $266,127,844
  18. St. Barnabas Hospitals – $265,000,000
  19. Bayer Corporation – $257,200,000
  20. Schering Plough – $255,000,000

More: You can read all the details regarding these fraud judgments & settlements here 

Assessment

The above are the very companies that doctors, patients and many stakeholders rely upon. They bombard us every hour with TV advertisements and information on the latest drugs and newest procedures. They often promote cures for the exaggerated illnesses and nebulous ailments they seek to treat. Is this expense model just business-as-usual; or the cost-of-doing business?

Link: http://www.taf.org 

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The Healthcare Whistleblowers

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A New DOJ Report

[By Staff Reporters]

According to the Deportment of Justice [DOJ], $9.3 billion was recovered from health care providers accused of defrauding the states and federal government the past decade.

The Study

The department ramped up efforts in the 1990s to combat healthcare fraud by using private citizens with insider knowledge of wrongdoing. They now initiate more than 90 percent of the department’s lawsuits focusing on fraud in health care, and receive between15 percent and 25 percent of the amounts recovered.

The Results

According to an Associated Press report on September 2, of the $9.3 billion recovered between 1996 and 2005, whistle blowers got more than $1 billion. And, while the number of claims dropped in recent years, recovery amounts have soared – jumping from about $10 million a case in 2002 to $50 million by 2005.

Assessment

The reason for this up-tick was the late addition of pharmaceutical manufacturers to the list of defendants.

Conclusion

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RAC Contractors to be Identified

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CMS Aims to Reduce Fraud

[By Staff Writers]

This month, the Centers for Medicare and Medicaid Services [CMS] will name the auditing firms that will review hospitals’ books for payment mistakes, while hospital officials say results in other states suggest the auditors will give priority to recovering overpayments.

The RAC Program

Under the so-called Recovery Asset Contractor [RAC] program, CMS pays auditors a fee based on the amount of improper payments discovered.

Hospital officials worry this “bounty hunter” approach – the second for CMS after medical practice audits – will create a bias in auditors to focus only on collecting government overpayments, reported the Pittsburgh Business Times on June 16, 2008.

Pilot Program Results

Some hospitals point to a pilot audit program in New York, Florida and California, which found $357.2 million in overpayments and just $14.3 million in underpayments. Medicare estimates its error rate at 3.9 percent in 2007, down from 9.8 percent in 2003, but still totaling $10.8 billion in improper payments

Assessment

Is this another instance of brute intimidation or just honest review?

Conclusion

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