Health Law Blog

A report recently released shows that federal health care fraud prosecutions so far this year are on pace to rise 85% over last year, according to an article appearing this week in USA Today.  This drastic increase does not come as a shock to many health care law insiders.  The federal government has made clear its objectives to ramp up anti-fraud efforts in the health care sector and to recover payments made for fraudulent claims billed to federal health care programs including Medicare and Medicaid.

A recent article by Ricardo Alonso-Zaldivar of the Associated Press reported that federal enforcement authorities have begun targeting individual corporate executives in alleged health care fraud cases across the country.  Previously, only companies themselves were the subject of federal investigations and penalties for incidents of health care fraud.  A company found to have committed health care fraud violations could simply negotiate a settlement and pay a fine.

The Centers for Medicare and Medicaid Services (CMS), which protects the Medicare Trust Fund from improper payments, is now using Comparative Billing Reports to educate providers.  Comparative Billing Reports reveal utilization patterns and provide comparative data on how one individual health care provider varies from other providers within their state and across the nation.  CMS then communicates these findings to the providers by written correspondence.  Essentially, the Comparative Billing Report (CBR) is used to show that a health care provider’s billing patters are excessive or otherwise outside the norm. 

 Yesterday marked the six-month anniversary of the new federal health care law, the Patient Protection and Affordable Care Act (PPACA).  Under Section 6401, PPACA requires health care providers to develop and implement a formal health care compliance program as a condition of enrollment in federal health care programs. 

Voluntary compliance programs are a thing of the past.  On March 23, 2010, President Obama signed into law HR 3590, the Patient Protection and Affordable Care Act (PPACA).  Section 6401 of PPACA states, “…a provider of medical or other items or services or supplier within a particular industry, sector or category shall, as a condition of enrollment in the program under this Title…establish a compliance program…[t]he Secretary, in consultation with the Inspector General of the Department of Health and Human Services, shall establish core elements for a compliance program…”

Laws that Impact Health Care Business Models