Two reports dive into expected healthcare fraud trends for 2015
Two recent reports indicate that healthcare fraud will continue to be a high priority in 2015, specifically regarding continued implementation of the Affordable Care Act, False Claims Act cases, the Stark law and anti-kickback statutes, insurance exchanges and Open Payments data.
EY Fraud Investigation & Dispute Services released its "Top Fraud and Corruption Trends for 2015," which identified life sciences and healthcare as two industries that will continue to garner attention from the fraud prevention community.
Specifically, the Foreign Corrupt Practices Act enforcement is slated to be an area of concern for life sciences companies that operate overseas. Meanwhile, the continued implementation of the ACA means federally funded insurance exchanges will provide multifaceted fraud risks "because of the increased complexity between the systems and monitoring efforts."
A second report by Bloomberg BNA's Healthcare Fraud Report's advisory board revealed the top 10 healthcare fraud issues to keep an eye on in the coming year. These include an uptick in False Claims Act cases, particularly those involving the Stark law, Medicare Advantage and managed care and pharmaceuticals.
The report pointed specifically to Kellogg Brown & Root Servs., Inc. v. United States ex rel. Carter, which is scheduled to go before the Supreme Court this year. Although the case involves defense contracting, the ruling could have implications for the healthcare industry. Additionally, experts expect to see more "worthless services" cases, despite the fact that a $9 million verdict related to worthless services was thrown out by 7th U.S. Circuit Court of Appeals in August, FierceHealthPayer: AntiFraud previously reported.
The report adds that providers are likely to continue facing pressure to self-disclose Stark and anti-kickback violations to the Centers for Medicare & Medicaid Services and the Office of Inspector General, though a backlog in the CMS self-referral disclosure protocol could cause problems.
Additionally, legal experts believe the Open Payments data released in September may drive up False Claims Act qui tam lawsuits, since whistleblowers and attorneys could mine the data for potential claims. In November, the federal government reported that whistleblower awards for false claims cases have totaled more than $2.47 billion from 2009 to 2014.
Also listed among the top fraud concerns were additional fraud enforcement in Medicare Part C and D, increased use of CMS enforcement tools, an increase in data breach and cybersecurity investigations and more cases alleging fraud within insurance exchanges.
For more:
- read the EY report
- see the Bloomberg BNA report (.pdf)
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