DOCSLIB.ORG

Healthcare Fraud & Abuse Review 2019

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text

Load more

A LOOK BACK … A LOOK AHEAD 1 NOTEWORTHY SETTLEMENTS 3 ISSUES TO WATCH 6 FALSE CLAIMS ACT UPDATE 11 STARK LAW/ANTI-KICKBACK STATUTE 31 PHARMACEUTICAL AND MEDICAL DEVICE DEVELOPMENTS 34 APPENDIX — 2019 NOTABLE SETTLEMENTS 36 Hospitals and Health Systems Behavioral Health and Substance Abuse Treatment Hospice and Home Health Specialty Care and Other Provider Entities Skilled Nursing Facilities and Nursing Homes Medical Transportation Pharmaceutical and Device Individual Providers Pharmacy Services Other Laboratory, Pathology, Radiology, and Diagnostics ABOUT BASS, BERRY & SIMS 71 DOJ’s announced results reflect that the government’s healthcare fraud enforcement efforts have continued unabated. Civil fraud recoveries by DOJ rose to more than $3 billion in the fiscal year ending September 30, 2019 (FY 2019) as compared to $2.8 billion in FY 2018, and recoveries attributable to the healthcare industry were $2.6 billion in FY 2019 – up slightly from $2.5 billion in FY 2018.1 Whistleblowers filed 633 new qui tam lawsuits under the False Claims Act (FCA) in FY 2019, which represented a slight drop-off compared with prior years, but brought the total number of FCA qui tam lawsuits filed since 2010 to more than 6,600. For their efforts, whistleblowers recovered more than $265 million in relator share awards in FY 2019, bringing the total awards to relators to more than $2.1 billion in the last five years. Throughout the year, DOJ and HHS announced a number of healthcare fraud takedowns – many of which focused on enforcement actions involving opioid distribution. In September, DOJ announced a coordinated healthcare fraud enforcement action across seven federal districts in the Northeastern United States, involving more than $800 million in losses and A LOOK BACK ... CIVIL FRAUD RECOVERIES A LOOK AHEAD FY 2015-2019 ($BILLIONS) $4.8 Turmoil at the highest levels of government served as the 5 backdrop for civil and criminal healthcare fraud enforcement efforts again last year. At the beginning of the year, this took 4 $3.7 the form of leadership changes at the U.S. Department of Justice (DOJ) and within the U.S. Department of Health and Human $3.1 $3 3 $2.8 Services (HHS). U.S. Attorney General Robert Barr was confirmed on February 14, 2019, and long-serving HHS Inspector General Daniel Levinson stepped down from his position after serving for 2 more than a decade to be replaced by Acting Inspector General Joanne Chiedi. Notwithstanding these leadership changes, 1 government enforcement efforts remained consistently focused 2015 2016 2017 2018 2019 on previously-announced priorities with significant success. 1 https://www.justice.gov/opa/pr/justice-department-recovers-over-3-billion-false-claims-act-cases-fiscal- year-2019. HEALTHCARE FRAUD & ABUSE REVIEW 2019 BASS, BERRY & SIMS | 1 the distribution of more than 3.25 million Finally, the year ended in December with a panel of the U.S. Court of Appeals for the Fifth pills in connection with “pill mill” clinics.2 Circuit striking down the individual mandate of the Patient Protection and Affordable Recoveries attributable to The announced takedown also involved the Care Act (PPACA), which imposes minimal essential coverage requirements under which the healthcare industry disclosure of guilty pleas by executives of certain individuals are obligated to purchase and maintain health insurance coverage, as were $2.6 billion in FY numerous telemedicine and durable medical unconstitutional in a 2-1 decision in Texas v. United States.4 The Fifth Circuit remanded equipment (DME) companies for their roles the case back to the district court for consideration of whether the individual mandate is 2019 – up slightly from in the submission of more than $600 million severable from the balance of PPACA. While the implications of the Fifth Circuit’s ruling $2.5 billion in FY 2018. in fraudulent Medicare claims. Earlier in the could have a far-reaching impact on healthcare broadly speaking, PPACA also included year, DOJ announced that the Appalachian key amendments to the FCA that could hang in the balance with respect to any result that Regional Prescription Opioid Strike Force imperiled PPACA. filed charges in 11 federal districts against Our firm’s annual Healthcare Fraud & Abuse Review is intended to assist healthcare 60 individuals, including 31 physicians, seven pharmacists, eight nurse practitioners, and providers in developing a greater understanding of the civil and criminal enforcement seven other licensed medical professionals stemming from 350,000 prescriptions for risks they face during a time of great uncertainty for the healthcare industry. Without opioids and other narcotics.3 question, understanding the key developments during the prior year is an important DOJ also made two key announcements in 2019. The first concerned how prosecutors step in implementing necessary safeguards designed to minimize enforcement risks for will evaluate corporate compliance programs, which followed the 2017 guidance by healthcare providers. DOJ on this same topic. The second announcement concerned how DOJ will evaluate a party’s cooperation in connection with resolution of civil FCA claims. Both of these DOJ pronouncements provide practical guidance for healthcare providers to consider in evaluating civil and criminal enforcement risks. For its part, the Centers for Medicare & Medicaid Services (CMS) provided further explanation of its approach to considering sub- regulatory guidance in connection with enforcement actions following the Supreme Court’s opinion in Azar v. Allina Health Services, which determined that substantive changes to For their efforts, whistleblowers recovered regulations need to follow notice-and-comment rulemaking procedures. more than $265 million in relator share awards in FY 2019, bringing the total awards to relators to more than $2.1 billion HEALTHCARE FRAUD TAKEDOWN IN in the last five years. NORTHEASTERN UNITED STATES BY THE NUMBERS 48 3.25M $800M 7 INDIVIDUALS OPIOID PILLS IN LOSSES FEDERAL DISTRIBUTED DISTRICTS 2 https://www.justice.gov/opa/pr/federal-health-care-fraud-takedown-northeastern-us-results-charges- against-48-individuals. 3 https://www.justice.gov/opa/pr/appalachian-regional-prescription-opioid-arpo-strike-force-takedown- results-charges-against. 4 945 F.3d 355 (5th Cir. 2019). A LOOK BACK ... A LOOK AHEAD BASS, BERRY & SIMS | 2 HOSPITALS AND HEALTH SYSTEMS There were several notable settlements involving hospitals and health systems resolving FCA allegations, many of which related to alleged violations of the Stark Law or the Anti- Kickback Statute (AKS). Improper compensation arrangements with physician referral sources remained a key area of scrutiny with inappropriate remuneration taking on various forms, such as compensation either exceeding fair market value (FMV) or accounting for the volume or value of physician referrals,6 kickbacks disguised as professional services agreements,7 and loans without repayment expectations.8 In the year’s largest series of settlements involving hospitals and health systems, Sutter Health, several of its affiliated hospitals, and a group of cardiovascular surgeons agreed to pay more than $46.1 million to resolve a number of alleged Stark Law violations, including allegations that physicians were paid in excess of FMV, space was leased at below-market rates, and physicians were reimbursed for recruiting expenses in excess of the expenses incurred. Approximately one-third of the settlement amount ($15.1 million) was attributable to the resolution of self-disclosed Stark Law violations, as well as allegations that several of Sutter’s ambulatory surgical centers double-billed Medicare.9 Hospitals and health systems also resolved several cases related to medical necessity issues, including allegations of inappropriately billing or coding claims or treating patients in an NOTEWORTHY inpatient setting when an outpatient or observation setting was sufficient.10 And, a number of SETTLEMENTS settlements involved general failures to adhere to reimbursement or coverage requirements.11 LONG-TERM CARE PROVIDERS The medical necessity of services provided continued to be the dominant focus of As in recent years, resolutions in healthcare fraud cases accounted settlements involving home health, hospice, skilled nursing, and nursing home providers.12 for the vast majority of all FCA recoveries in FY 2019. Of the $3 Several settlements resolving FCA allegations related to Stark Law and AKS violations involved improper remuneration in the form of sham medical director agreements allegedly billion in settlements and judgments, recoveries from matters used to induce referrals.13 Long-term care providers settled alleged violations of both federal involving the healthcare industry amounted to $2.6 billion (87%). This is the tenth consecutive year that recoveries in federal civil 6 See, e.g., https://www.justice.gov/usao-ndga/pr/union-general-hospital-pay-5-million-resolve-alleged- false-claims-act-violations; https://www.justice.gov/usao-md/pr/medstar-health-pay-us-35-million-resolve- healthcare fraud matters have exceeded $2 billion.5 allegations-it-paid-kickbacks-cardiology-group. 7 https://www.justice.gov/usao-md/pr/medstar-health-pay-us-35-million-resolve-allegations-it-paid- kickbacks-cardiology-group. 8 https://www.justice.gov/opa/pr/rialto-capital-management-and-current-owner-indiana-hospital-pay-36- As has been typical in recent years, newly-filed qui tam complaints accounted for the vast million-resolve-false. majority of the new civil fraud
Recommended publications
  • Health Industry Business Communications Council

    Health Industry Business Communications Council

    Health Industry Business Communications Council Registered Labelers: Accredited Auto-ID Labeling Standards Argentina New MedTek Devices Pty Ltd Oxavita SRL Norseld Pty Ltd. Novadien Healthcare Pty Ltd The following companies Odontit S.A. (and/or their subsidiaries/ PAMPAMED S.R.L. Numedico Technologies Pty Ltd divisions) have applied PATEJIM SRL Opto Global Pty. Ltd. for a Labeler Identification Orthocell Limited Code (LIC) assignment with Austria Prolotus Technologies Pty Ltd HIBCC*. By doing so, they afreeze GmbH Red Milawa Pty Ltd dba Magic Mobility have demonstrated their AMI GmbH SDI Limited commitment to patient safety Bender Medsystems GmbH Signostics Ltd. and logistical efficiency for BHS Technologies GmbH Sirtex Medical Pty Ltd their customers, the industry Metasys Medizintechnik GmbH Smith & Nephew Surgical Pty. Ltd. and the public at large. PAA Laboratories GmbH Staminalift International Limited Safersonic Medizinprodukte Handels The Pipette Company Pty. Ltd. Any organization that is GmbH Thermo Electron Corporation interested in using the HIBC W & H Dentalwerk Burmoos GmbH Vush Pty Ltd uniform labeling system may apply for the assignment of VUSH STIMULATION Australia one or more LICs. William A Cook Australia Pty. Ltd. Adv. Surgical Design & Manufacture, Ltd. Last updated 9-21-2021 AirPhysio Pty Ltd Belgium Annalise-AI Pty Ltd 3M Europe Apollo Medical Imaging Technology Pty Advanced Medical Diagnostics SA/NV Ltd Analis SA/NV Benra Pty Ltd dba Gelflex Laboratories Baxter World Trade Bioclone Australia Pty. Ltd. Bio-Rad RSL Candelis, Inc. Bio-Rad Lab Inc Clinical Diag. Group DePuy Australia Pty. Ltd. Biosource Europe SA For more information, please dorsaVi Ltd Cilag NV contact the HIBCC office at: EC Certification Service GmbH Coris Bioconcept Fink Engineering Pty Ltd Fuji Hunt Photographic Chemicals NV 2525 E.
  • United States of America Ex Rel. Dr. Peter Rost V. Pfizer

    United States of America Ex Rel. Dr. Peter Rost V. Pfizer

    UNITED STATES DISTRICT COURT DISTRICT OF MASSACHUSETTS UNITED STATES OF AMERICA ex rel. * DR. PETER ROST, * * Plaintiff, * * v. * Civil Action No. 03-11084-JLT * PFIZER INC and PHARMACIA * CORPORATION, * * Defendants. * MEMORANDUM August 30, 2006 TAURO, J. Plaintiff-Relator, Dr. Peter Rost, (“Plaintiff”) brings this qui tam action against Defendants Pfizer, Inc. and Pharmacia Corporation (collectively “Defendants”), alleging violations of the Federal False Claims Act1 (“FCA”) and similar state statutes.2 Plaintiff asserts that Defendants, through illegal, off-label marketing of the drug Genotropin, knowingly caused the submission of false claims to federal and state health insurance programs. Defendants now move to dismiss 1 See 31 U.S.C. § 3729 et seq. (2006). 2 See California False Claims Act, Cal. Gov’t Code §§ 12650 et seq.; Delaware False Claims and False Reporting Act, Del. Code Ann. tit. 6, §§ 1201 et seq.; District of Columbia Procurement Reform Amendment Act, D.C. Code §§ 2-308-13 et seq.; Florida False Claims Act, Fla. Stat. §§ 68.081 et seq.; Hawaii False Claims Act, Haw. Rev. Stat. §§ 661-21 et seq.; Illinois Whistleblower Reward and Protection Act, 740 Ill. Comp. Stat.175 et seq.; Massachusetts False Claims Law, Mass. Gen. Laws ch. 12, §§ 5 et seq.; Nevada False Claims Act, Nev. Rev. Stat. §§ 357.010 et seq.; Tennessee Medicaid Fraud Prevention Law, Tenn. Code Ann. §§ 71-5-181 et seq.; Texas Medicaid Fraud Prevention Law, Tex. Hum. Res. Code Ann. §§ 36.001 et seq.; Virginia Fraud Against Taxpayers Act, Va. Code Ann. §§ 8.01-216.1 et seq. 1 Plaintiff’s complaint, arguing that this court lacks subject matter jurisdiction and that Plaintiff’s complaint fails to allege fraud with sufficient particularity.
  • Largest 25 Whistleblower Rewards Paid Under the False Claims Act

    Largest 25 Whistleblower Rewards Paid Under the False Claims Act

    Top 25 Largest Whistleblower Rewards paid under the False Claims Act and Qui Tam Whistleblower Reward Program Here is a list of the top 25 largest Federal and State False Claims Act qui tam whistleblower reward cases. The government pays rewards to whistleblowers a portion ranging from 15% to 25% of the civil False Claims Act recovery. More details about whistleblower rewards can be found at www.HowToReportFraud.com. Rank Company FCA Settlement Reward Date 1. GlaxoSmithKlinei $2 billion $300 million≈ July 2012 2. Bank of Americaii $1.85 billion $275 million≈ November 2014 3. Johnson & Johnsoniii $1.72 billion $167 million November 2013 4. Pfizeriv $1 billion $102 million August 2009 5. Tenet Heathcarev $900 million $150 million June 2006 6. Abbott Labsvi $800 million $84 million May 2012 7. Eli Lillyvii $800 million $79 million January 2009 8. HCAviii $745 million $150 million December 2000 9. Merckix $650 million $100 million≈ February 2008 10. HCAx $641 million $151 million June 2003 11. JP Morganxi $614 million $90 million≈ February 2014 12. Amgenxii $612 million $90 million≈ December 2012 13. GlaxoSmithKilnexiii $600 million $90 million≈ October 2010 14. Seronoxiv $567 million $50 million October 2005 15. TAPxv $540 million $95 million October 2001 16. New Yorkxvi $540 million $10 million* July 2009 17. AstraZenecaxvii $520 million $45 million April 2010 18. Abbott Labsxviii $414 million $60 million≈ July 2003 19. Freseniusxix $385 million $65 million January 2000 20. NMExx $379 million $65 million July 1994 21. Cephalonxxi $375 million $46 million September 2008 22. Ranbaxyxxii $350 million $49 million May 2013 23.
  • Health Care Enforcement 2020 Year in Review & 2021 Outlook

    Health Care Enforcement 2020 Year in Review & 2021 Outlook

    HEALTH CARE ENFORCEMENT 2020 Year in Review & 2021 Outlook TABLE OF CONTENTS Introduction ......................................................................................................................................3 Statistical Trends in Civil False Claims Act Litigation in 2020 .................................................................4 Qui Tam Case Volume Decreased While Government-Initiated Matters Increased .................................4 Hospitals and Physicians Continue to Be the Leading Targets of Qui Tam Cases ...................................7 Current and Former Employees Continue to Bring the Vast Majority of Health Care Qui Tam Cases ...............................................................................................................................7 Health Care Qui Tam Suits Are Concentrated in Major Metropolitan Areas ............................................8 Health Care Fraud Enforcement Priorities in 2020 ................................................................................9 Opioids .........................................................................................................................................9 Purdue Pharma ............................................................................................................................9 Indivior Solutions ....................................................................................................................... 10 Practice Fusion .........................................................................................................................
  • Qui Tam Relators, the First Amendment, and the False Claims Act Joshua Patrick Mahoney Joshua.Mahoney@Chicagounbound.Edu

    Qui Tam Relators, the First Amendment, and the False Claims Act Joshua Patrick Mahoney [email protected]

    University of Chicago Legal Forum Volume 2012 | Issue 1 Article 13 Qui Tam Relators, the First Amendment, and the False Claims Act Joshua Patrick Mahoney [email protected] Follow this and additional works at: http://chicagounbound.uchicago.edu/uclf Recommended Citation Mahoney, Joshua Patrick () "Qui Tam Relators, the First Amendment, and the False Claims Act," University of Chicago Legal Forum: Vol. 2012: Iss. 1, Article 13. Available at: http://chicagounbound.uchicago.edu/uclf/vol2012/iss1/13 This Comment is brought to you for free and open access by Chicago Unbound. It has been accepted for inclusion in University of Chicago Legal Forum by an authorized administrator of Chicago Unbound. For more information, please contact [email protected]. Comments Qui Tam Relators, the First Amendment, and the False Claims Act Joshua Patrick Mahoneyt INTRODUCTION The False Claims Act (FCA)1 allows a private citizen to file suit "for the person and for the United States government." 2 The citizen sues to recover damages for "false or fraudulent claim[s]" submitted to the government for payment.3 While the Attorney General is also authorized to bring claims under the FCA, 4 pri- vate citizen suits, also called "qui tam"5 suits, comprise a signifi- cant majority of FCA claims filed.6 Qui tam suits account for the largest portion of funds recovered under the FCA.7 To bring a qui t BA 2009, University of Northern Iowa; JD Candidate 2013, The University of Chicago Law School. 1 31 USC §§ 3729-33. 2 31 USC § 3730(b)(1). 3 31 USC § 3729(a).
  • I4i Makes the Patent World Blind Michael J

    I4i Makes the Patent World Blind Michael J

    COMMENTS i4i Makes the Patent World Blind Michael J. Conway† All patents receive a presumption of validity pursuant to 35 USC § 282. Courts have traditionally put this presumption into practice by requiring inva- lidity to be established by clear and convincing evidence. The Supreme Court reaffirmed this understanding of the presumption in Microsoft Corp v i4i Ltd Partnership. District courts have divided, however, on whether to require clear and con- vincing evidence when the challenger seeks to invalidate a patent for covering inel- igible subject matter. The conflict originates from a concurrence written by Justice Stephen Breyer in i4i, in which he stated that a heightened standard of proof—like the clear and convincing standard—can apply only to issues of fact, not issues of law. Because subject-matter eligibility has traditionally presented an issue of law, some courts hold that subject-matter-eligibility challenges cannot be subjected to the clear and convincing standard. Other courts agree with that sentiment but would apply the clear and convincing standard to resolve any underlying issues of fact. Still others maintain that subject-matter-eligibility challenges must be estab- lished by clear and convincing evidence. This Comment resolves this ambiguity by showing that subject-matter- eligibility challenges must be established by clear and convincing evidence. It com- pares subject-matter-eligibility challenges to two other patent validity challenges: the on-sale bar and nonobviousness. These two comparisons show that patent law has consistently failed to confine the clear and convincing standard to issues of law. In fact, the standard has been imposed without regard for the distinction be- tween issues of law and fact.
  • Zerohack Zer0pwn Youranonnews Yevgeniy Anikin Yes Men

    Zerohack Zer0pwn Youranonnews Yevgeniy Anikin Yes Men

    Zerohack Zer0Pwn YourAnonNews Yevgeniy Anikin Yes Men YamaTough Xtreme x-Leader xenu xen0nymous www.oem.com.mx www.nytimes.com/pages/world/asia/index.html www.informador.com.mx www.futuregov.asia www.cronica.com.mx www.asiapacificsecuritymagazine.com Worm Wolfy Withdrawal* WillyFoReal Wikileaks IRC 88.80.16.13/9999 IRC Channel WikiLeaks WiiSpellWhy whitekidney Wells Fargo weed WallRoad w0rmware Vulnerability Vladislav Khorokhorin Visa Inc. Virus Virgin Islands "Viewpointe Archive Services, LLC" Versability Verizon Venezuela Vegas Vatican City USB US Trust US Bankcorp Uruguay Uran0n unusedcrayon United Kingdom UnicormCr3w unfittoprint unelected.org UndisclosedAnon Ukraine UGNazi ua_musti_1905 U.S. Bankcorp TYLER Turkey trosec113 Trojan Horse Trojan Trivette TriCk Tribalzer0 Transnistria transaction Traitor traffic court Tradecraft Trade Secrets "Total System Services, Inc." Topiary Top Secret Tom Stracener TibitXimer Thumb Drive Thomson Reuters TheWikiBoat thepeoplescause the_infecti0n The Unknowns The UnderTaker The Syrian electronic army The Jokerhack Thailand ThaCosmo th3j35t3r testeux1 TEST Telecomix TehWongZ Teddy Bigglesworth TeaMp0isoN TeamHav0k Team Ghost Shell Team Digi7al tdl4 taxes TARP tango down Tampa Tammy Shapiro Taiwan Tabu T0x1c t0wN T.A.R.P. Syrian Electronic Army syndiv Symantec Corporation Switzerland Swingers Club SWIFT Sweden Swan SwaggSec Swagg Security "SunGard Data Systems, Inc." Stuxnet Stringer Streamroller Stole* Sterlok SteelAnne st0rm SQLi Spyware Spying Spydevilz Spy Camera Sposed Spook Spoofing Splendide
  • False Claims Act Practice Guide 2021 ©2021 Smith Pachter Mcwhorter PLC

    False Claims Act Practice Guide 2021 ©2021 Smith Pachter Mcwhorter PLC

    False Claims Act Practice Guide 2021 ©2021 Smith Pachter McWhorter PLC. This publication is not intended to provide legal advice but to provide information on legal matters. Transmission is not intended to create and receipt does not establish an attorney-client relationship. Readers should seek specific legal advice before taking any action with respect to matters mentioned in this publication. SMITH PACHTER McWHORTER PLC Table of Contents Introduction Part One: FCA Statutory Framework and Legal Elements A. FCA Statute and Elements of Proof .............................................................................................. 1 B. Elements of Proof and Judicial Interpretations of Terms ................................................................... 2 C. Qui Tam Provision ................................................................................................................... 4 D. FCA’s Statute of Limitations ....................................................................................................... 6 E. Damages ............................................................................................................................... 6 Part Two: Risk Areas and Enforcement A. Theories of Liability ................................................................................................................. 8 1. Improper Performance on Deliverables ................................................................................... 9 2. Truth in Negotiations Act Violations ......................................................................................
  • Astrazeneca to Pay $520 Million for Off-Label Drug Marketing

    Astrazeneca to Pay $520 Million for Off-Label Drug Marketing

    U.S. Department of Justice United States Attorney Eastern District of Pennsylvania 615 Chestnut Street Suite 1250 Philadelphia, Pennsylvania 19106-4476 (215) 861-8200 April 27, 2010 PHARMACEUTICAL COMPANY ASTRAZENECA TO PAY $520 MILLION FOR OFF-LABEL DRUG MARKETING WASHINGTON – The Department of Justice today announced a $520 million civil settlement with pharmaceutical company AstraZeneca LP and AstraZeneca Pharmaceuticals, LP (AstraZeneca) to resolve allegations made under the civil False Claims Act that AstraZeneca illegally marketed the anti-psychotic drug Seroquel for uses not approved as safe and effective by the Food and Drug Administration (FDA). Such unapproved uses are also known as “off-label” uses because they are not included in the drug’s FDA approved product label. United States Attorney General Eric Holder, Assistant Attorney General for the Civil Division Tony West, and United States Attorney Michael L. Levy of the Eastern District of Pennsylvania announced the settlement today. They were joined by Special Agent-in-Charge Nick DiGiulio of the Office of Inspector General of the Department of Health and Human Services. AstraZeneca, headquartered in Wilmington, Delaware, signed a civil settlement to resolve allegations that by marketing Seroquel for unapproved uses, the company caused false claims for payment to be submitted to federal insurance programs including Medicaid, Medicare, and TRICARE programs, and to the Department of Veterans Affairs, the Federal Employee Health Benefits Program, and the Bureau of Prisons. The civil settlement agreement provides that AstraZeneca will pay up to $520 million to the federal government and the states to resolve civil allegations originally brought in a lawsuit under the qui tam provisions of the federal False Claims Act and various state False Claims Act statutes.
  • Healthcare & Life Sciences Industry Update

    Healthcare & Life Sciences Industry Update

    Healthcare & Life Sciences Industry Update August 2011 Member FINRA/SIPC www.harriswilliams.com What We’ve Been Reading August 2011 • The biggest story from inside the Beltway over the last month was the battle and eventual deal to raise the U.S. debt ceiling to avoid an impending August 2nd default. The Budget Control Act of 2011 will raise the debt ceiling by $2.1-$2.4 trillion, while reducing spending by approximately $2.1 trillion over the next decade. In an interesting post-deal analysis, Michael Hiltzik of the Los Angeles Times notes that despite the protracted negotiations over a broad spectrum of cost-cutting measures, healthcare was not raised as a primary issue. Some have found this especially concerning, considering the outsized portion of the Federal Budget currently allocated to healthcare spending, which is forecast to rise in the coming years. A recent article in The Economist, entitled “Looking to Uncle Sam” makes this point and goes further to suggest that Centers for Medicare & Medicaid Services (CMS) actuaries may be underestimating future increases in Medicare and Medicaid spending. • One potential reason CMS actuaries may be underestimating the future costs of Medicare and Medicaid relates to healthcare reform’s effect on employee benefits, and specifically, the 2014 switch to subsidized exchange policies. A recent report by McKinsey & Company estimates that approximately 30% of employers will stop offering employer- sponsored insurance (ESI) when this switch is made, as opposed to the 7% estimated by the Congressional Budget Office. An ESI exodus of this magnitude could cause substantial strain on an already robust government healthcare budget.
  • Healthcare Fraud & Abuse Review 2017

    Healthcare Fraud & Abuse Review 2017

    HEALTHCARE FRAUD & ABUSE REVIEW 2017 i | BASS, BERRY & SIMS HEALTHCARE FRAUD & ABUSE REVIEW 2017 1. A LOOK BACK…A LOOK AHEAD 4. NOTEWORTHY SETTLEMENTS 7. ISSUES TO WATCH 12. FALSE CLAIMS ACT UPDATE 37. STARK LAW/ANTI-KICKBACK STATUTE 40. PHARMACEUTICAL AND MEDICAL DEVICE DEVELOPMENTS 42. APPENDIX – 2017 NOTABLE SETTLEMENTS Hospitals and Health Systems Managed Care/Insurance Hospice Laboratory, Pathology, Radiology and Diagnostics Home Health Specialty Care and Other Provider Entities SNFs and Nursing Homes Individual Providers Pharmaceutical and Device Miscellaneous/Non-Providers Pharmacy Services 70. ABOUT BASS, BERRY & SIMS General (HHS-OIG), along with federal and state law enforcement entities, including 30 Medicaid Fraud Control Units, charged more than 400 defendants, including 115 healthcare professionals, A LOOK BACK… in 41 federal districts for allegedly participating in fraudulent healthcare arrangements resulting in over $1.3 billion in false claims.6 A LOOK AHEAD Occurring in the context of combatting the opioid crisis, the takedown focused on individuals allegedly involved in fraudulent billing of Medicare, Medicaid and TRICARE for medically While the uncertainty associated with legislative efforts to repeal unnecessary prescription and compounded drugs that were not actually purchased or distributed to patients covered by a federal healthcare program. In total, more than 120 the Patient Protection and Affordable Care Act (PPACA) dominated defendants, including physicians, were charged in connection with prescribing and distributing most of the headlines for the healthcare industry last year, it was opioids and narcotics. Nearly 300 individuals—including physicians, nurses and pharmacists— mostly business as usual for the government’s healthcare fraud received exclusion notices from HHS-OIG barring future participation in federal healthcare 7 enforcement efforts.
  • Educational Outreach Workbook Notes ______Iowa Fraud Fighters – Shield Your Savings

    Educational Outreach Workbook Notes ______Iowa Fraud Fighters – Shield Your Savings

    IOWA FRAUD FIGHTERS EDUCATIONAL OUTREACH WORKBOOK NOTES ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ IOWA FRAUD FIGHTERS – SHIELD YOUR SAVINGS Welcome to the Iowa Insurance Division’s Iowa Fraud Fighters