VIEW ON FRAUD AND ABUSE

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VIEW ON FRAUD AND ABUSE

• David E. Matyas
• Epstein Becker Green
• Washington, DC

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What Does The Future Hold?
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Whos Responsible for Fighting Fraud?

• Federal Government (DOJFBI DHHS US Postal
  Service)
• State Agencies
• Congress
• Private Third Party Payors
• Private Citizens

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A Climate of Enforcement

• 1992 1999
• Criminal health fraud matters 343 1,994
• Criminal convictions 90 396
• Pending Civil matters 270
  2,278pending
• FBI resources devoted 112 420(agent
  work years)
• Source HHS DOJ Health Care Fraud Abuse
  Control Program Annual Report for FY 1999

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FBI Health Care Fraud Resources
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Increased Criminal Civil Monetary Penalties

• In FY 1997 alone, 1.087 billion was collected
  and in FY 1998, over 480 million was won or
  negotiated in criminal fines, and civil
  judgments and settlements.
• In FY 1999, the OIG and DOJ collected over 490
  million.

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Increased Program Exclusions and Criminal
Convictions

• In 1999, federal prosecutors convicted over 300
  individuals (including physicians and hospital
  executives) in health care fraud cases, an
  increase of 16 percent from the prior year.
• Since 1997, more than 8,600 individuals and
  entities have been excluded from participation in
  federal and state health care programs.

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Significant Factors
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The Fraud And Abuse Control Program

• Enacted as part of HIPAA, the Program gives DHHS
  and DOJ responsibility for coordinating public
  and private enforcement activities.
• Congress created a new expenditure account (named
  the Health Care Fraud and Abuse Control
  Account) in which DHHS and DOJ jointly certify
  moneys needed each year to finance anti-fraud
  initiatives

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Program Goals

• coordinating law enforcement program
• conducting audits, evaluations and
  investigations
• helping facilitate enforcement of laws

• providing guidance to the industry on fraudulent
  practices
• establishing a national data bank to receive and
  report adverse actions

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The Federal False Claims Act

• The Ultimate Legal Weapon In Prosecuting Health
  Care Cases

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Whistleblower Actions
Over half of the 480 million the DOJ was awarded
in health care fraud cases in FY 1998, involved
judgements or settlements related partially or
completely to allegations in qui tam cases.
DOJ Health Care Fraud Report (FY99)
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Govt Fraud Hotline and the Establishment Of
Monetary Reward Program

• Individuals who provide info. that leads to
  recovery of at least 100 may be eligible for a
  reward equaling the lesser of 1000 or 10 of the
  overpayments recovered
• In 1997, over 32,000 complaints that warranted
  follow-up action were received on this hotline
• Now with the additional incentive of a monetary
  reward, more people will consider reporting
  possible wrongdoing

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THE FUTUREThe Question Should Not Be

• Will the governments fraud enforcement
  activities against health care providers continue
  into the future?

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Rather the Question Should Be

• What will the governments fraud enforcement
  activities focus on in the future?

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Predictions

• Continued Emphasis on Billing
• More Emphasis on Kickbacks
• Managed Care Activities
• E-Health
• Research
• Private Payor Fraud Actions
• Scrutiny of CIA Compliance

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View on Fraud and Abuse

• David E. Matyas
• Epstein Becker Green
• Washington, DC