Category Archives: Fraud & Abuse

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DOJ and OIG Focus on Opioid Abuse: Medical Professionals Who Overprescribe May Be Targets

Two recent announcements reflect that the U.S. Government is taking aggressive steps to address opioid abuse by identifying and targeting the involvement of medical professionals in facilitating opioid abuse involving Federal health care program beneficiaries.  The U.S. Department of Justice announced on July 13, 2017 fraud charges involving 412 defendants in 41 federal districts across … Continue reading this entry

CMS Revokes Billing Privileges for Competitive Bid Supplier

The Centers for Medicare and Medicaid Services (CMS) has demonstrated that it will not hesitate to use one of its most crippling administrative enforcement tools—the revocation of Medicare billing privileges—against one of its largest suppliers, as is evident in its case against Arriva Medical, LLC. Medicare billing privileges may be revoked for any one (or … Continue reading this entry

Supreme Court Implied False Certification Case Reargued to First Circuit

On Tuesday, October 25, 2016, a three-judge panel of the United States Court of Appeals for the First Circuit heard argument in United States ex rel. Escobar, et al. v. Universal Health Services, Inc.  This case was sent back to the First Circuit by the United States Supreme Court in Universal Health Servs., Inc. v. … Continue reading this entry

The EpiPen Controversy Signals Intensifying Scrutiny of Drug Classification Under Medicaid Rebate Program

Price increases threatening the availability of EpiPen® and EpiPen Jr® Auto-Injectors (“EpiPen”) have touched off the latest firestorm over drug pricing. Lost amid the public outcry, however, is a thorny regulatory issue: EpiPen’s classification as a generic drug for purposes of the Medicaid Drug Rebate Program (“MDRP”).  Resolution of the classification issue carries significant risk for segments of … Continue reading this entry

Ransomware Reporting Requirements & New HHS Guidance

New York Office of the Medicaid Inspector General Releases 2014-2015 Work Plan
Ransomware is malicious software that denies access to data, usually by encrypting the data with a private encryption key that is only provided once a ransom is paid. Sometimes the ransomware will actually destroy, steal, or export data from information systems. Ransomware has become a significant threat to all U.S. businesses and individuals, and a … Continue reading this entry

Health Care IT Program Discusses Alternative Payment Model Opportunities

A distinguished panel of providers, consultants and IT firms convened on Tuesday, June 21st  in New York at the Foley and Lardner LLP offices to share a discussion focused on the convergence of IT spend and new value based purchasing models (“VBP”) coming out of CMS in increasing frequency—ACOs, BPCI, CJR and CCM.  Key Takeaways … Continue reading this entry

Finance Committee Report Place Medical Device Arrangements under Increasing Scrutiny

Hospitals and providers participating in physician-owned distributorships, or “PODs” may be at increased risk for government investigation or enforcement. A Senate Finance Committee (SFC) Report issued this month highlights the SFC’s concerns that certain POD structures may violate fraud and abuse statutes, including the Anti-Kickback Statute, Stark Law, as well as the Sunshine Act. According … Continue reading this entry

FCA Penalties Slated to Nearly Double This Year

A little known federal agency, the Railroad Retirement Board (“Board”), which administers retirement-survivor and unemployment-sickness benefit programs for railroad workers, published an interim final rule on May 2, 2016 raising the amounts of penalties “under the Board’s jurisdiction.” Among these are the penalties authorized by the Federal False Claims Act (“FCA”).  The Board proposes increasing the … Continue reading this entry

Supreme Court Hears Argument on Scope of False Claims Act

New York Office of the Medicaid Inspector General Releases 2014-2015 Work Plan
Companies doing business with the government are facing an unprecedented increase in liability risk as federal authorities and individual whistleblowers (called “relators”) aggressively use the Federal False Claims Act (“FCA”), 31 U.S.C. §§ 3729-3733, to allege an array of frauds on a broad range of government programs. The FCA exposes companies to millions of dollars … Continue reading this entry

What to Expect From HHS-OIG's New Litigation Team

CMS Releases Medicare Part B Supplier Billing and Payment Data
The Office of Inspector General at the U.S. Department of Health and Human Services (“HHS-OIG”) announced, on June 30, 2015 (during a health care conference), the creation of a new litigation team that will focus solely on levying fraud-based civil money penalties and excluding providers from Medicare and Medicaid for committing fraud. The point is to … Continue reading this entry

Recent OIG Audits of Home Health and Hospice Surveys May Signal Increased Scrutiny on Worker Qualifications

Recent audits by the Department of Health and Human Services Office of Inspector General (“OIG”) conclude that state survey agencies in a number of states and a leading national accrediting agency serving the home health and hospice industry failed to identify a significant number of deficiencies related to worker qualifications. Based on these findings, OIG … Continue reading this entry

Physicians Face Increased Anti-Kickback Enforcement Focus

It appears that the Office of Inspector General (“OIG”) now has physicians squarely in the crosshairs of one of its most powerful enforcement tools: the Anti-Kickback Statute (“AKS”). The AKS is a criminal statute with stiff penalties. It prohibits the offer or payment of anything of value with the intent to induce the referral of … Continue reading this entry

The Medicaid Fraud Control Units: Fiscal Year 2014 Report

The Department of Health and Human Services (HHS) Office of Inspector General (HHS-OIG) has released its Fiscal Year (FY) 2014 Annual Report (Report) on the performance of the Medicaid Fraud Control Units (MFCUs) (OEI-06-15-00010, April 2015). Although the MFCUs reported another strong year in civil recoveries, criminal recoveries were significantly lower than last year, when … Continue reading this entry

SEC Turns Up the Heat on Issuer Officials

New York Office of the Medicaid Inspector General Releases 2014-2015 Work Plan
Two recent SEC enforcement actions demonstrate that the Securities and Exchange Commission remains intently focused on the municipal market and, in particular, on officials participating in financings that fail to accurately and completely disclose material information. In an action arising from defaulted bonds sold by a Michigan city to develop a soundstage, the SEC successfully brought … Continue reading this entry

Government's Health Care Fraud "Cash Cow" Keeps Mooing

Recent Decision Underscores Need for Involvement of Counsel in Internal Investigations
In a conversation with Lee Pacchia from Mimesis Law, Foley & Lardner Partner, Lisa Noller, discusses the Government’s approach to health care fraud prosecutions and what companies can expect in 2015. Since 2007, the Department of Justice (DOJ) has increased its affirmative civil and criminal enforcement priorities. Rather than relying on whistleblowers to come forward and … Continue reading this entry

Happy Holidays!

Thank you for reading, subscribing and being a part of our blog community in 2014. We hope you have a happy holiday season and a wonderful new year! – The Health Care Law Today Team We will be back with new posts the week of January 5.… Continue reading this entry

OIG Releases Fiscal 2014 Report to Congress

The Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (DHHS) released its Semiannual Report to Congress (Report) last week summarizing health care fraud investigation activities for the second half of fiscal year 2014 and the full year’s achievements. OIG reported expected recoveries of over $4.9 billion for fiscal year … Continue reading this entry

How to Prepare Your Hospital or Medical Practice for a Meaningful Use Audit

New York Office of the Medicaid Inspector General Releases 2014-2015 Work Plan
For the past several years, the Centers for Medicare and Medicaid Services (“CMS”) has incentivized hospitals and eligible professionals to adopt and make “meaningful use” of certified electronic health records (“EHR”) technology through the Medicare and Medicaid Meaningful Use programs. Since the inception of these programs, over $16.6 billion in Medicare incentive payments and $8.6 … Continue reading this entry

Happy Thanksgiving!

The Health Care Law Today team is thankful for you, our readers and subscribers. Thank you all for reading, contributing to, and sharing our blog. We hope you have a safe and happy holiday. Have a great weekend!… Continue reading this entry

Medicare's Fraud Prevention System: CMS Issues Second-Year Report to Congress

The Small Business Jobs Act of 2010 (pertinent sections of which are codified at 42 U.S.C. Section 1320a-7m) directed the Centers for Medicare & Medicaid Services (CMS) to use predictive modeling and other analytics technologies to identify and prevent fraud, waste, and abuse in the Medicare fee-for-service program. The statute required CMS to implement a … Continue reading this entry

OIG's Proposed Rule to Expand Civil Monetary Penalties

The Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) on May 12, 2014 published a proposed rule (Proposed Rule) that would implement the OIG’s expanded authority under the Affordable Care Act (ACA) to impose Civil Monetary Penalties (CMPs) on providers and suppliers for “false and fraudulent claims and other … Continue reading this entry

CMS's Focus on DMEPOS Fraud and Abuse Risks Continues

The focus by the Centers for Medicare & Medicaid Services (CMS) on Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) as an area rife with unnecessary utilization and a high improper payment rates continues. CMS on May 28, 2014 published in the Federal Register a proposed rule to greatly expand prior authorization reviews for certain … Continue reading this entry

New York Office of the Medicaid Inspector General Releases 2014-2015 Work Plan

The New York State Office of the Medicaid Inspector General (OMIG) is the New York State (NYS) Medicaid program’s “watchdog” agency. (Last year they recovered in excess of $851 million from providers and others.) It is one of the most prominent state OMIG’s in the country, so providers in other states keep an eye on what the … Continue reading this entry

Recent Decision Underscores Need for Involvement of Counsel in Internal Investigations

A recent federal court decision raises concerns about the ability of companies to maintain privilege over materials generated in connection with internal investigations. The case, United States ex rel. Barko v. Halliburton Company et al., No. 1:05-CV-1276 (D.D.C. Mar. 6, 2014), involved allegations by a qui tam relator that his employer committed abuses in connection … Continue reading this entry