Seven predictions for the future of healthcare fraud enforcement
Civil claims and corporate compliance will drive recoveries.
This one is too easy not to include. Based on the government's guidance documents, hiring trends and False Claims Act (FCA) statistics, it's pretty easy to see that corporate compliance is going to be a sticking point, and civil cases will be a new pathway for fraud enforcement.
In June, the OIG announced it would be assembling a new 10-person litigation team to focus solely on civil monetary penalties and exclusion cases, which adds a third leg to the government's "enforcement stool," according to Tony Maida, a partner with McDermott Will & Emory LLP who formally served as a senior official in the Office of Counsel to the Inspector General. In October, an OIG official said the government had resolved 110 civil monetary penalties and program exclusions in 2015, and expected even more cases in the coming year, presumably because of this new team.
Last month, the OIG reported that it's receiving nearly half as much in investigative receivables tied to fraud compared to last year, but civil actions have more than doubled over the past four years. In a recent interview with FierceHealthPayer: Antifraud, former U.S. Attorney for the Eastern District of Tennessee, Bill Killian, said civil fraud claims increased five-fold during the five years he was in office.
On the compliance front, the DOJ issued corporate compliance guidelines that can help organizations identify and prevent fraud, waste and abuse. Then, in November, the agency doubled down by hiring Hui Chen, who has held senior compliance positions in the banking and pharmaceutical industries, as the new compliance counsel aimed at providing a "reality check" for programs throughout the country.
Cardiology fraud prosecutions will outpace all other specialties.
We're already starting to see the beginnings of what could be a long-running string of settlements tied to unnecessary cardiac procedures. In October, 450 hospitals settled with the DOJ for $250 million over allegations that cardiac devices were implanted in violation of Medicare coverage requirements. The settlement came just days after a New York Times story blamed Medicare's fee-for-service payment system for leading three Indiana surgeons to perform hundreds of unnecessary cardiac procedures while the hospital turned a blind eye and pulled in the profits.
Cardiology procedures are a well-worn scab that the government has just started to pick at, thanks to its renewed focus on medical necessity and a small dose of self-policing. With large settlements rolling in against both systems and physicians, we're seeing that scab start to peel and bleed. And with the government intent on reducing the highest improper payments, cardiology is likely to remain ahead of just about every other specialty when it comes to FCA settlements. - Evan (@HealthPayer)