Bloomberg BNA Talks with Partner Linda Baumann About the Top Health Care Fraud Issues in 2015

BNA reported that, according to its advisory board, the top issues in 2015 will include:

1. an increase in False Claims Act cases involving Stark issues, Medicare Advantage and managed care and pharmaceuticals;
2. an increase in prosecutions of health care executives;
3. an increase in cases alleging fraud within the insurance exchanges;
4. the expansion of fraud enforcement into Medicare Part C and Part D;
5. increased scrutiny of Open Payments data and the CMS Part B database;
6. more litigation resulting from the publication of the final 60-day repayment rule;
7. the growth in state False Claims Act enforcement;
8. the growth in state Medicaid enforcement;
9. increased use of CMS enforcement tools; and
10. more data breach and cybersecurity investigations.

The article stated that, “Providers increasingly are self-disclosing potential Stark and anti-kickback violations to both the CMS and the OIG” and that the “CMS’s 60-day repayment rule will likely be the biggest driver for self-disclosures in 2015.”

In light of the costs and potential risks associated with self-disclosures, Ms. Baumann noted that a number of compliance issues can be resolved in other ways. However, regardless of the methodology used, many providers are taking a comprehensive approach to correction action, i.e., “In light of increasing government enforcement efforts, fewer providers are willing to simply fix potential issues going forward, while not addressing prior problems in hopes they won’t be noticed,” she said.

BNA also focused on the Open Payments data collected pursuant to the Physician Payments Sunshine Act portion of the Affordable Care Act. “The new year will bring a full year of Open Payments data to the public, and with it, associated risks to providers and drug and device manufacturers.”

Ms. Baumann told BNA that it is only a matter of time before whistleblowers start filing lawsuits based on information from the Open Payments program. “There may be some start up time while relators and their counsel develop strategies for working with the data, but once they establish a system, numerous qui tam cases could be filed.”

She added that drug and device manufacturers, as well as providers and suppliers, could protect themselves from potential lawsuits by ensuring they have documentation that demonstrates that payments made/received are “reasonable, accurate, and based on fair market value.”

To read the Health Care Fraud Report, click here.