An Active Forecast for Healthcare Enforcement

Here is a good summary of the state of affairs when it comes to healthcare fraud and compliance. The bottom line is it continues to be a high priority for government.

The highlights?

  1. Follow the money. For fiscal year 2015, Congress more than doubled the funding of the government’s Health Care Fraud and Abuse Control program to $672 million. The HCFAC, as it were, was created under HIPAA to join the Department of Justice and Department of Health and Human Services in leading efforts at all levels—federal, state, and local—to address healthcare fraud, waste, or abuse. The new funding means more money for agents, prosecutors, and data analytics, including predictive analytics, to help bring cases.
  2. Let the sunshine in. It may not be the Age of Aquarius, but the Sunshine Act has spotlighted the relationships among physicians and vendors, and CMS has begun to publish Medicare claims and utilization data. It’s the dawning of a new world, and the greater scrutiny and transparency suggest greater activity to come by plaintiffs both public and private. Which brings us to the next point.
  3. Listen for the whistle. In 1987, there were 30 whistleblower lawsuits brought under the False Claims Act; since 2000, the number’s closer to 400 per year, and the past two years have seen more than 700 apiece. Meanwhile, the Justice Department announced last fall that the criminal division would automatically review new whistleblower lawsuits alongside the civil division rather than wait for the civil division to refer a case for prosecution. In other words, the filing of a whistleblower lawsuit now opens, in essence, a parallel civil-criminal investigation.

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