Healthcare Fraud

News & Analysis as of

CMS Issues Final Rule on ACOs Participating in the Medicare Shared Savings Program

The Centers for Medicare & Medicaid Services (“CMS”) issued a final rule (the “Final Rule”) for accountable care organizations (“ACOs”) participating in the Medicare Shared Savings Program (“MSSP”) on June 6, 2016. In the...more

OIG Delivers Home Care a One – Two Punch: Release of Report and Alert on Home Health Fraud Highlights Increased OIG Scrutiny of...

On June 22, 2016, the Office of Inspector General (“OIG”) issued two communications that underscore its continued focus on fraud in home health care, along with the role of physicians as “gate keepers” in authorizing...more

Jury Acquits Former Pharma Exec in One of the First Post-Yates Memo Health Care Fraud Prosecutions

Like many before it, this year has been one to watch in government health care fraud enforcement efforts. In September 2015, the Department of Justice (DOJ) released the “Yates Memo,” which reaffirmed the government’s...more

Contactors Beware: New Supreme Court Decision on False Claims Act

The Supreme Court recently issued a decision in Universal Health Services v. United States ex rel. Escobar, and construction contractors should take note in order to better understand the broad reach of liability and hefty...more

Health Update - June 2016

Real-Time Data Analytics in Government Investigations and Reducing Exposure - It is not every day that the words “innovative” and “nimble” are used when referring to an agency of the federal government bureaucracy. Yet,...more

Compliance Reminder — DOJ Announces Largest Healthcare Fraud Takedown

On Wednesday, June 22, 2016, the DOJ announced the largest nationwide heath care fraud takedown in history, which resulted in criminal and civil charges against 301 individuals for alleged participation in health care fraud...more

Does the Medical-School-to-Prison Pipeline Widen in Middle Age?

The trend of holding physicians personally responsible for healthcare crimes has continued unabated over the past year. As noted in a previous article, physicians are particularly attractive targets for federal prosecutors...more

Recent New York Medicaid Settlement with Pharmacy Shows Importance of Checking Excluded Provider List Prior to Filling...

A New York pharmacy has agreed to pay approximately $500,000 to the State of New York for improperly billing New York Medicaid for prescriptions written by a physician who had been excluded from the Medicaid program. This...more

Good News on the Horizon? FCA Reform Could Signal Relief for Health Care Providers

Good news may be in sight for businesses and health care providers. On April 28, 2016, the House Judiciary Committee's Subcommittee on the Constitution and Civil Justice once again considered potential updates to the...more

Health Law Insights Newsletter - Issue 9 - May 2016

NATIONAL - Medicare Proposes New Part B Payment System - The Center for Medicare and Medicaid Services (CMS) on April 27 proposed a new rule that would transform Medicare Part B reimbursement to practitioners into...more

New Exclusion Guidance Includes Presumption of Compliance Plan

Section 1128 of the Social Security Act (42 U.S.C. 1320a–7) (available here) established mandatory and permissive authority for exclusion of health care providers from Federal health care programs based on provider conduct. ...more

OIG Issues New Criteria for Implementing its Section 1128(b)(7) Exclusion Authority

The Office of Inspector General (OIG) of the Department of Health and Human Services has issued new, non-binding “Criteria for Implementing Section 1128(b)(7) Exclusion Authority” updating the factors OIG will consider in...more

Biblical Name No Shield Against Fraud Charge

On May 2 a New Orleans federal jury found that Psalms 23 DME, LLC—its Biblical name notwithstanding–was part of a fraud scheme that illegally billed Medicare $3.2 million. In 2013 the government indicted Psalms 23 owner...more

New OIG Exclusion Guidance

On April 18, 2016, the Department of Health and Human Services Office of the Inspector General (“OIG”) issued revised criteria for implementing permissive exclusion authority. These revisions are a non-binding policy...more

U.S. Department of Health and Human Services Updates Criteria for Permissive Exclusion Under Section 1128(b)(7) of the Social...

The HHS-OIG issued new guidelines on April 18, 2016 regarding the Secretary's exercise of the Department's permissive exclusion authority pursuant to Section 1128(b)(7) of the Social Security Act. The HHS-OIG's new guidance...more

Trove of SNF Claims Data Released By CMS – Ready for Mining By Auditors and Whistleblowers

Over recent years, the Federal government has trained its sights on potential billing abuses in the Medicare Part A program for Skilled Nursing Facilities (“SNFs”) in the provision of rehabilitation therapy services. The...more

OIG Releases Revised Policy Statement on Exclusion Authority

On April 18, 2016, the Office of Inspector General of the Department of Health and Human Services (OIG) released a revised policy statement on its exclusion authority, entitled Criteria for Implementing Section 1128(b)(7)...more

Illinois Governor Initiates Fight Against Health Care Fraud Amid Growing Deficit

As Illinois' finances continue to deteriorate and the budget crisis remains unsolved, the Rauner administration recently announced an initiative to focus on identifying and recouping health care fraud in Illinois. On April 5,...more

Reforming Medicaid Could Become Toughest Job Ever for Baker Administration

Anyone who follows politics or government in Massachusetts has seen these numbers. They bear repeating: - ..Over the past seven years, spending on Medicaid (MassHealth) has increased 65%. ..Next year, total...more

Insurer Actions Cut the Heart Out of Out-of-Network Providers

Aetna Life Insurance Company recently won a $37 million verdict against a group of Northern California surgical centers, Bay Area Surgical Management, LLC and its affiliates (collectively, Bay Area), for an alleged...more

OIG laments failure to comprehensively address EHR fraud

The U.S. Department of Health & Human Services (HHS) Office of Inspector General (OIG) recently released a compendium (Compendium) of its top unimplemented recommendations. The Compendium comprises 25 unimplemented past OIG...more

Texas-Size Sentences for Texas-Size Medicare Fraud

They do things big in Texas. The latest example is the punishments being handed out for a Medicare fraud scheme at Riverside General Hospital in Houston. Let’s start with the fraud scheme. It was Texas-size, too,...more

DOJ Targets Nursing Fraud with New Task Forces

On March 30, 2016, the U.S. Department of Justice launched 10 regional task forces targeting “grossly substandard care” in nursing homes and other long-term care facilities across the country. The task forces combine federal,...more

You Can Pay Your Lawyer: Supreme Court Recognizes Limits on Pretrial Asset Restraints

Before the U.S. Supreme Court’s ruling last week in Luis v. United States, the government could freeze a criminal defendant’s assets before trial even if they bore no connection to the alleged crimes. With the ruling, if the...more

Supreme Court Update: Luis V. United States (14-419)

Here's a line-up you don't see in every (read: any) syllabus: "BREYER, J., announced the judgment of the Court and delivered an opinion, in which ROBERTS, C.J., and GINSBURG and SOTOMAYOR, JJ., joined. THOMAS, J., filed an...more

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