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Distinct enforcement themes emerge at AHLA fraud conference

Managed care, Part D, hospice, and individual liability will be ongoing focus areas for the OIG

Last week's Fraud and Compliance Forum, hosted by the American Health Lawyers Association (AHLA), outlined current and future fraud enforcement trends straight from the mouths of Office of Inspector General (OIG) officials.

OIG chief of staff Chirsti Grimm told attendees that the enforcement agency will focus on Medicare managed care amid accusations that risk scores are making patients appear sicker in order to boost reimbursement, according to Bloomberg BNA's James Swann.

It's a significant announcement from the OIG in light of recent audits that showed Medicare Advantage overpayments reached millions of dollars and the fact that two senators have called for more rigorous investigations into Medicare Advantage risk scores. In March, Humana revealed that it was part of a Department of Justice (DOJ) investigation into Medicare Advantage risk scores, adding that it was not the only payer that was being investigated.

OIG investigator Michael Cohen indicated the agency is identifying more fraud schemes in Medicare Part D and hospice, according to the article. Medicare patients are frequently recruited for hospice, even when they aren't eligible, and Part D schemes usually include multiple perpetrators. In July, a House subcommittee highlighted two OIG reports that called on the Centers for Medicare and Medicaid Services to improve Part D fraud oversight.  

Keynote speaker Joyce Branda, deputy assistant attorney general for the commercial litigation branch of the DOJ's civil division, addressed individual liability in light of last month's memo released by Deputy Attorney General Sally Q. Yates, according to Waller Healthcare Blog. Branda noted that the civil division would also focus its attention on individual liability.

In another post, lawyers with Waller Law argued that "the government has a long way to go to institute the policy perceptions of the Yates memo," particularly in cases where it may be hard to identify just one individual responsible for a fraud scheme. However, the new approach may disrupt investigations and settlements "even those where handshake agreements have been reached," the authors said.  

Waller attorneys also said that corporate compliance was an ongoing theme throughout conference presentations by defense attorneys and government officials. Corporate compliance programs have been emphasized as a critical deterrent to fraud and abuse, particularly following OIG guidance released in April.

For more:
- here's the Bloomberg BNA article
- see coverage from Waller Law during and after the conference

Related Articles:
Amid increased federal enforcement, compliance guidelines offer foundation for fraud prevention
As fraud crackdown grows, so does need for corporate compliance
OIG to hospitals: Involve boards to strengthen compliance
House subcommittee grills OIG, CMS on Part D fraud and abuse
Government audits reveal millions in Medicare Advantage overpayments