Fraud and Abuse
Posted on March 18, 2013
Updated guidelines released by the US Department of Health and Human Services Office of the Inspector General (OIG) provide new information for evaluating state false claims act legislation. The updates adhere to various amendments made to the federal False Claims Act of 2009 and 2010. Several recent legislative endeavors, including the Affordable Care Act (ACA), have altered the foundation and scope by which the False Claims Act operates. One ACA example found within the OIG updates is how states will receive their share of any Medicaid recoveries made under the federal False Claims Act.
Posted on March 7, 2013
The US House of Representatives approved a continuing resolution (CR) yesterday that would deny necessary funding for several agencies to implement their respective portions of the Affordable Care Act (ACA). The bill, H.R. 933, was introduced on Monday by Appropriations Committee Chairman Hal Rogers (R-KY). Several specific funding denials include:
- $949 million to the US Department of Health and Human Services (HHS) to aid in paying for the federal insurance exchanges.
- $29 million to the Centers for Medicare and Medicaid Services (CMS) for Health Care Fraud and Abuse Control.
- Funds requested by the Internal Revenue Service (IRS) for ACA tax provisions.
267 Members voted in favor of the bill.
Posted on February 4, 2013
Last week, six current and former members of the Senate Finance Committee, led by Ranking Member Orrin Hatch (R-Utah) and Chairman Max Baucus (D-Mont.), released a report outlining recommendations from stakeholders in the health care community regarding potential opportunities to improve federal efforts to combat waste, fraud, and abuse in the Medicare and Medicaid programs. The other four report authors include Senators Tom Coburn (R-Okla.), Ron Wyden (D-Ore.), Chuck Grassley (R-Iowa), and Tom Carper (D-Del.). Last May, the bipartisan group of lawmakers invited stakeholders to submit white papers offering recommendations and innovative solutions to improve program integrity efforts, strengthen payment reforms, and enhance fraud and abuse enforcement efforts. The resulting report highlights a number of submitted proposals and recommendations.
Posted on February 4, 2013
The Centers for Medicare & Medicaid Services (CMS) released a final rule on Friday regarding the implementation of the Physician Payment Sunshine Act, which requires drug and device-makers to disclose financial relationships with doctors. Passed under the 2010 Affordable Care Act (ACA), the law was supposed to make a database describing these relationships available by September 2013. The final rule requires companies to begin collection of the information in August 2013, and to begin reporting it to the U.S. Department of Health and Human Services (HHS) by March 2014.
Posted on November 2, 2012
Medicare Part B expenditures, which include payment for advanced imaging services, are expected to continue growing at an unsustainable rate. In efforts to identify the root of these steep growth rates, questions have been raised about physician self-referral’s role in this growth. Self-referral occurs when a provider refers patients to entities in which the provider or the provider’s family members have a financial interest. Senators Max Baucus (D-Montana) and Chuck Grassley (R-Iowa) and Representatives Pete Stark (D-California), Sander Levin (D-Michigan) and Henry Waxman (D-California) asked the Government Accountability Office (GAO) to examine the prevalence of advanced imaging self-referral and its effect on Medicare spending. The report examines (1) trends in the number of and expenditures for self-referred and non-self-referred advanced imaging services, (2) how provision of these services differs among providers on the basis of whether they self-refer, and (3) implications of self-referral for Medicare spending.
The GAO report estimates that in 2010 alone, Medicare spent $109 million unnecessary dollars associated with physician self-referrals. Such referrals serve as an incentive for providers to order more tests than they otherwise would.
From 2004 through 2010, self-referred and non-self-referred advanced imaging services both increased, with the larger increase among self-referred services. The number of self-referred MRI services increased over this period by more than 80 percent, for example, while the number of non-self-referred MRI services increase by only 12 percent. The GAO analysis showed that providers’ referrals of MRI and CT services substantially increased the year after they began to self-refer. GAO estimates that in 2010, providers who self-referred likely made 400,000 more referrals for advanced imaging services than they would have if they were not self-referring.
Posted on October 9, 2012
The Government Accountability Office (GAO) has designated Medicare and Medicaid as high-risk programs partly because their size and complexity make them vulnerable to fraud. GAO was asked to provide information on the types of providers that are the subjects of fraud cases. The resulting GAO report identifies provider types who were the subjects of fraud cases in (1) Medicare, Medicaid, and CHIP that were handled by federal agencies, and changes in the types of providers in 2005 and 2010; and (2) Medicaid and CHIP fraud cases that were handled by Medicaid Fraud Control Units (MFCUs). To identify subjects of fraud cases handled by federal agencies, GAO combined data from three agency databases and removed duplicate subject data. GAO also reviewed public court records, such as indictments, to identify subjects’ provider types. To describe providers involved in fraud cases handled by the MFCUs, GAO collected aggregate data from 10 state MFCUs, which represented the majority of fraud investigations, indictments, and convictions nationwide.
According to data GAO collected from 10 state Medicaid Fraud Control Units (MFCU), over 40 percent of the 2,742 subjects investigated for health care fraud in Medicaid and CHIP in 2010 were home health care providers and health care practitioners. Of the criminal cases pursued by these MFCUs, home health care providers comprised nearly 40 percent of criminal convictions and 45 percent of subjects sentenced in 2010. Civil health care fraud cases pursued by these MFCUs in 2010 resulted in judgments and settlements totaling nearly $829 million. Pharmaceutical manufacturers were to pay more than 60 percent ($509 million) of the total amount of civil judgments and settlements.
Posted on September 26, 2012
According to a study recently released by Office of the Inspector General (OIG), between 2001 and 2010, Medicare payments for Part B goods and services increased by 43 percent, from $77 billion to $110 billion. During this same time, Medicare payments for evaluation and management (E/M) services increased by 48 percent, from $22.7 billion to $33.5 billion. E/M services have been vulnerable to fraud and abuse. In 2009, two health care entities paid over $10 million to settle allegations that they fraudulently billed Medicare for E/M services. The Centers for Medicare & Medicaid Services (CMS) also found that certain types of E/M services had the most improper payments of all Medicare Part B service types in 2008. The OIG report is the first in a series of evaluations of E/M services.
Posted on August 1, 2012
A new brief from Health Affairs and the Robert Wood Johnson Foundation (RWJF) focuses on efforts to combat a longstanding challenge: fraud and abuse in health care. These issues constitute compelling problems for the Medicare and Medicaid programs, with related costs of $98 billion last year.
Posted on July 25, 2012
Drug companies and medical device manufacturers commonly collaborate with physicians when developing or modifying drug or devices. These collaborations may include consulting arrangements in which physicians provide input and guidance related to drug or device development, participation in clinical trials testing the efficacy and effectiveness of the drug or device, or educational programs to train and teach physicians about the benefits of a new drug or in the case of a medical device, how to use the device effectively. In return for their services and expertise, physicians often receive payment or other items of value such as an honorarium and/or travel expenses. These financial relationships between manufacturers and physicians, while largely beneficial, raise concerns…
Posted on May 4, 2012
The Patient Protection and Affordable Care Act of 2010, as amended by the Health Care and Education Reconciliation Act of 2010 (collectively referred to as the ACA)<sup></sup> arms the federal government with significant new and enhanced tools to identify and pursue financial recovery for fraudulent, wasteful, and abusive healthcare practices. The cost of implementing other programmatic provisions of the ACA, such as coverage for the uninsured and increased fraud and abuse enforcement activities, will be paid for, in part, by monies recovered from prosecution of healthcare fraud and savings achieved from deterring fraudulent practices. Furthermore, reducing fraudulent and abusive practices is directly linked to the transformation of the health care system to a value-based system that rewards high-quality and efficient care delivery at lower cost. As the $4.1 billion recovered by the federal government in 2011 from fraud and abuse enforcement indicates, healthcare organizations, including providers (practitioners, hospitals, nursing homes), health plans, manufacturers (medical device, pharmaceutical), and suppliers (e.g., durable medical equipments companies), should expect continued aggressive enforcement in the coming years.<sup></sup> The ACA heralds a new era of compliance in healthcare that will require these organizations to monitor their operations, implement robust compliance programs, report publicly a vast array of information about their business arrangements, and face significant penalties for violations.