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VIEW ON FRAUD AND ABUSE

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Source: HHS & DOJ Health Care Fraud & Abuse Control Program Annual Report for FY ... which DHHS and DOJ jointly certify moneys needed each year to finance anti-fraud ... – PowerPoint PPT presentation

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Title: VIEW ON FRAUD AND ABUSE


1
VIEW ON FRAUD AND ABUSE
  • David E. Matyas
  • Epstein Becker Green
  • Washington, DC

2
What Does The Future Hold?
3
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4
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5
Whos Responsible for Fighting Fraud?
  • Federal Government (DOJFBI DHHS US Postal
    Service)
  • State Agencies
  • Congress
  • Private Third Party Payors
  • Private Citizens

6
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

7
FBI Health Care Fraud Resources
8
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.

9
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.

10
Significant Factors
11
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

12
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

13
The Federal False Claims Act
  • The Ultimate Legal Weapon In Prosecuting Health
    Care Cases

14
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)
15
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

16
THE FUTUREThe Question Should Not Be
  • Will the governments fraud enforcement
    activities against health care providers continue
    into the future?

17
Rather the Question Should Be
  • What will the governments fraud enforcement
    activities focus on in the future?

18
Predictions
  • Continued Emphasis on Billing
  • More Emphasis on Kickbacks
  • Managed Care Activities
  • E-Health
  • Research
  • Private Payor Fraud Actions
  • Scrutiny of CIA Compliance

19
View on Fraud and Abuse
  • David E. Matyas
  • Epstein Becker Green
  • Washington, DC
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