Fierce Exclusive: After explosion of compounded drug fraud, legal experts say party's over

In April 2015, Tricare spent $545 million on compounded pharmaceuticals, more than 58 times its monthly spending just three years prior. The spike in spending marked the peak of a gradual increase in spending on compound drugs that accelerated during the first several months of 2015 as Tricare was initiating changes to its pharmaceutical formulary. Now, federal investigators are digging into pharmacies that may have relied on marketers to generate referrals, while shielding the true effectiveness and cost of compounded medications.  

Federal fraud recoveries reach $2.4B in 2015

The federal government collected $2.4 billion through the Healthcare Fraud and Abuse Control (HCFAC) program during fiscal year (FY) 2015, nearly one-third less than the previous year.


Olympus pays $646M to settle kickback allegations

The nation's largest distributor of endoscopes has agreed to pay $646 million to settle criminal and civil claims that the company offered various kickbacks to hospitals and doctors that signed deals to purchase medical equipment, according to the Department of Justice.


Proposed rule clamps down on providers with a history of fraud

A proposed rule released by the Centers for Medicare and Medicaid Services would expand the power of government officials to deny or revoke billing privileges for providers that pose a risk to federal healthcare programs.

A passive approach to healthcare fraud? That's nothing new

Last week's report from the Government Accountability Office made waves after the agency characterized enrollment fraud detection within the federal Affordable Care Act marketplace as "passive," a word that many latched on to as way of denouncing the president's landmark healthcare legislation. Although the GAO pointed out some valid criticisms of ACA fraud detection, this submissive approach to fraud prevention seems to reflect a widespread systemic issue among government-run programs dating back to the inception of Medicare and Medicaid.

CMS upgrades fraud detection tactics through data transparency, increased site visits

Data transparency, enhanced provider screening software and additional site visits will serve as key components of the federal government's upgraded approach to fraud detection and prevention, outlined in two new programs announced by the Centers for Medicare & Medicaid Services last week.

Owners of Dallas marketing firm indicted in $65M fraud scheme

The owners of a Dallas marketing firm were arrested last week, accused of orchestrating an elaborate scheme involving a fake nonprofit organization, a non-existent medical study, and kickbacks from compounding pharmacies that led to $65 million in fraudulent payments from Tricare, according to the U.S. Attorney's Office for the Northern District of Texas.


GAO: Verification gaps leaves ACA enrollment susceptible to fraud

Federal officials' failure to appropriately verify consumers enrolling in Affordable Care marketplace plans underscores the agency's "passive approach to fraud" that compromises billions in federal spending, according to a review by the Government Accountability Office.


Imaging firm owner faces life sentence for fraud that led to two patient deaths

The owner of a imaging firm is looking at a possible life sentence after being convicted of a fraud scheme in which he instructed unqualified employees to read diagnostic images, according to the Baltimore Sun.


Addiction providers look to alter the industry's growing reputation for fraud

Providers who specialize in addiction services are scrambling to rehabilitate the industry's image following high profile fraud cases that have caught the attention of federal regulators and private insurers, according to the Palm Beach Post.


Last year's MFCU recoveries are woefully low, and that's a problem

Medicaid Fraud Control Units were notably inefficient in 2015, recovering just $744 million of an estimated $53.6 billion in improper payments. These numbers are particularly concerning given the increase in Medicaid enrollment, the projected spending within the program over the next six years and the fact that improper payment rates continue to push skyward. Is this a one-year anomaly, or is an unmanageable Medicaid budget outpacing our existing tools for controlling fraud?

GAO: Majority of fraud cases include multiple schemes

Two of three fraud cases in 2010 involved more than one scheme, including fraudulent billing, falsified patient records and kickbacks, according to a new report released by the Government Accountability Office.


CMS drafts new rules to limit home health fraud

The Centers for Medicare & Medicaid Services has proposed a rule that would allow the agency to collect baseline data on probable fraud payments in the home health industry and launch a preauthorization pilot project in five states.


Nationwide cardiac device probe wraps up with $23M settlement

The final stage of a nationwide investigation into the billing practices of cardiac device implantations added more than 50 hospitals and millions in settlement dollars to an investigation that has implicated more than 500 hospitals to date.


Texas leads the way in Medicaid fraud recoveries in 2015

According to new Medicaid Fraud Control Unit statistics and an interactive map released by the Office of Inspector General, the Texas MFCU netted more than $210 million in fraud recoveries in 2015, almost all of which came from criminal investigations.

CMS clarifies 60-day rule, lookback period for overpayments

The Centers for Medicare & Medicaid Services has finalized rules that specify when the 60-day clock begins ticking for providers to return overpayments, and shaves four years off of the overpayment lookback period, according to FierceHealthFinance.


Clinicians ensnared in multi-million dollar fraud schemes

Clinicians across the country are facing fraud charges for multimillion dollar schemes that run the gamut of medical specialties, from obstetrics and gynecology to pain medicine. 

New Texas law targets physician relationship with compounding pharmacies

Across the country, investigators are continuing their pursuit of compounding pharmacies suspected of submitting fraudulent claims to the government's military healthcare program.

DaVita faces another federal false claims investigation

DaVita Healthcare Partners Inc., the nation's largest kidney care provider, is facing yet another federal investigation after self-reporting potential billing irregularities with one of its pharmacy providers, according to the Wall Street Journal.


Imagining how a 2-for-1 deal could combat healthcare fraud

Cees Klumpler, chief risk officer for the Global Fund to Fight AIDS, Tuberculosis and Malaria, is responsible for $4 billion in annual funding that is distributed to 130 different countries. Following years of fraud and abuse that plagued the organization, Klumper has developed a unique 2-for-1 approach to recovering fraudulent payments. It's a methodology that the healthcare industry could benefit from.