Fraud and Abuse

News & Analysis as of

The Federal Government Holds Individuals Responsible for Involvement in Corporate Healthcare Fraud and Abuse

In September 2016, three corporate officers in two healthcare fraud and abuse cases settled allegations that they were personally liable for violations of federal fraud and abuse laws. These settlements come one year after...more

When Does An Overpayment Become Fraud? How Simple Inattention Can Expose You to Penalties for Fraudulent Activities

If you are involved in any way in the health care system, it should be obvious by now that the government has committed ever increasing resources to the prosecution of fraud and abuse cases. Simply put, from a governmental...more

Looking Ahead to a Trump Administration: Health Care and Life Sciences Industry Perspectives

Observers are digesting what the Trump Administration will mean for the health care and life sciences industry. Forecasting is more challenging for this incoming Administration than most given the relatively sparse policy...more

Managing the Transition to Transformation: Old Dog, New Tricks: Fraud and Abuse in the Age of Payment Reform

McDermott’s Managing the Transition to Transformation series is designed to help health systems and other health care industry leaders address the many challenges presented by the transformation in payment and care delivery...more

OIG Determines Most Medicare Chiropractic Service Claims Don’t Comply with Medicare Rules

The OIG estimates that, CMS made $358.8 million in improper Medicare payments for chiropractic services in 2013 – totaling 82 percent of Medicare chiropractic services in that period (note, however, that these findings were...more

Billing Companies Beware – OIG Signals a Crackdown on Fraud and Abuse at All Levels

In an unprecedented administrative action, the U.S. Department of Health & Human Services Office of the Inspector General (“HHS-OIG”) penalized a medical billing company for preparing and submitting claims to Medicare for...more

CMS Re-proposes Ban on Per-Click Fees for Space and Equipment Leases under Stark

In the CY 2017 Medicare Physician Fee Schedule (CY 2017 MPFS), the Centers for Medicare & Medicaid Services (CMS) issued proposed updates to the physician self-referral law (Stark law). The primary Stark law update focused on...more

Proposed Cardiac, Hip, and Femur Episode Payment Models Are Next Generation from BPCI and CJR

The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule on July 25, 2016, entitled, Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and...more

OIG Gives Green Light to Hospice Provider’s Payment to Nursing Facilities

Last week, the OIG issued a favorable opinion to a hospice provider seeking to make supplemental payments to skilled nursing facilities. Under the proposed arrangement, the hospice provider would make a supplemental payment...more

Senate Finance Committee Report Concludes Stark Law Change Is Necessary to Drive Health Care Reform

In its report, Why Stark, Why Now? [PDF], released June 30, 2016, the Senate Committee on Finance outlines suggested changes to the physician self-referral law, 42 U.S.C. § 1395nn, (the Stark law) in order to facilitate and...more

Health Care Fraud Prosecutions: Strong Seas and High Winds Ahead for Individuals and Corporations

During the past nine months, the U.S. Department of Justice (DOJ) has made several significant policy pronouncements that impact health care organizations and individual providers. These directives and initiatives reflect...more

Senate Committee Releases Report on Potential Stark Law Changes, Hearing Scheduled

On June 30, 2016, the Senate Finance Committee’s Republican staff issued a 20-page report discussing comments made by industry stakeholders after a December 2015 round-table on the future of the physician self-referral law,...more

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...more

OIG Approves Wholly Owned Group Purchasing Organization

In Advisory Opinion 16-06, the Office of Inspector General (OIG) approved a proposal whereby the ownership of a group purchasing organization (GPO) would be restructured so that the GPO will be wholly owned by the same...more

Administration Releases Spring 2016 Regulatory Agenda with Timeline for Rulemaking

The Obama Administration has posted its updated 2016 regulatory agenda, which lists major pending or planned rulemaking and the expected timing for action. The latest agenda includes numerous rules in the pipeline impacting...more

OIG Updates Permissive Exclusion Criteria – Suggests Compliance Programs Are Expected

On April 18th, the Office of Inspector General (OIG) issued updated guidance describing the factors it will consider in determining whether to exercise its permissive authority to exclude individuals and entities from federal...more

Legal Issues Associated with Multi-Provider Alternative Payment Model

Since the passage of the Affordable Care Act (ACA), both federal and state policies have promoted the adoption of alternative payment models (APMs), providing financial incentives for groups of providers to improve care...more

"New HHS OIG Criteria to Guide Resolution of Health Care Investigations"

The Office of Inspector General of the Department of Health and Human Services (OIG) has issued updated guidance on the use of its so-called permissive exclusion authority under Section 1128(b)(7) of the Social Security Act...more

All Right Stop, Collaborate and Listen! CMS Is Back with Its Brand New Invention, Preparing for CJR Gainsharing

Understandably, there is anticipation surrounding the April 1st start date for CMS’s newest bundled payment program, the Comprehensive Care for Joint Replacement (CJR) program. As participant hospitals consider gainsharing...more

Health Care Fraud and Abuse Control (HCFAC) Program Logs $2.4 Billion in Recoveries for FY 2015

The federal government won or negotiated more than $1.9 billion in judgments and settlements, and attained additional administrative impositions in health care fraud cases and proceedings in FY 2015, according to the latest...more

Health Care Fraud and Abuse Enforcement Priorities in Minnesota

United States Attorney for the District of Minnesota, Andrew Luger, spoke at a public event on March 3, 2016, at Mitchell-Hamline School of Law on the topic of health care fraud & abuse enforcement priorities in Minnesota....more

Legislation Proposed to Reform H-1B and L-1 Visa Programs

In November, Senator Dick Durbin (D-Ill.), Chairman of Senate Judiciary Committee, and Senator Chuck Grassley (R-Iowa), Assistant Democratic Leader, introduced a new bipartisan legislation seeking to reform and reduce fraud...more

Centers for Medicare & Medicaid Services Finalizes New Comprehensive Care for Joint Replacement Payment Model

Effective April 1, 2016, acute care hospitals located in 67 geographic areas will be subject to the new mandatory payment model for lower extremity joint replacement (“LEJR”) services. Under the new Comprehensive Care for...more

CMS and OIG Issue Final Rule on Fraud and Abuse Waivers for ACOs

On October 29, 2015, the Centers for Medicare & Medicaid Services (CMS) and the Office of the Inspector General (OIG) of the Department of Health and Human Services published a final rule related to fraud and abuse law...more

VA Proposes Significant Changes to Its VOSB/SDVOSB Verification Program

On November 6, the Department of Veterans Affairs (VA) issued a proposed rule amending its regulations governing the VA’s verification program for veteran owned small businesses (VOSBs) and service-disabled veteran owned...more

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