Fraud and Abuse

Implementation Briefs

Update: Physician Payment Sunshine Act

Categories: Fraud and Abuse

Posted on July 10, 2013

Drug companies and medical device manufacturers commonly collaborate with physicians when developing or modifying drugs or devices. These collaborations may include consulting arrangements through which physicians provide input and guidance related to drug or device development, participation in clinical trials testing the efficacy and effectiveness of the drug or device, or educational programs to train and teach physicians about the benefits of a new drug or in the case of a medical device, how to use the device effectively. In return for their services and expertise, physicians often receive payment or other items of value such as an honorarium and/or travel expenses. These financial relationships between manufacturers and physicians, while largely beneficial, raise concerns about conflicts of interest as physicians’ treatment decisions may be improperly influenced by their financial relationship with a manufacturer. There is also concern in the industry that these types of arrangements are used to disguise illegal kickbacks (e.g., providing money or other items of value in return for prescribing a particular drug or using a particular medical device).

Physician Payment Sunshine Act

Categories: Fraud and Abuse

Posted on July 25, 2012

Drug companies and medical device manufacturers commonly collaborate with physicians when developing or modifying drug or devices. These collaborations may include consulting arrangements in which physicians provide input and guidance related to drug or device development, participation in clinical trials testing the efficacy and effectiveness of the drug or device, or educational programs to train and teach physicians about the benefits of a new drug or in the case of a medical device, how to use the device effectively. In return for their services and expertise, physicians often receive payment or other items of value such as an honorarium and/or travel expenses. These financial relationships between manufacturers and physicians, while largely beneficial, raise concerns...

A New Era of Healthcare Corporate Compliance

Categories: Fraud and Abuse, Implementation Update

Posted on May 4, 2012

The Patient Protection and Affordable Care Act of 2010, as amended by the Health Care and Education Reconciliation Act of 2010 (collectively referred to as the ACA)<sup>[1]</sup> arms the federal government with significant new and enhanced tools to identify and pursue financial recovery for fraudulent, wasteful, and abusive healthcare practices. The cost of implementing other programmatic provisions of the ACA, such as coverage for the uninsured and increased fraud and abuse enforcement activities, will be paid for, in part, by monies recovered from prosecution of healthcare fraud and savings achieved from deterring fraudulent practices. Furthermore, reducing fraudulent and abusive practices is directly linked to the transformation of the health care system to a value-based system that rewards high-quality and efficient care delivery at lower cost. As the $4.1 billion recovered by the federal government in 2011 from fraud and abuse enforcement indicates, healthcare organizations, including providers (practitioners, hospitals, nursing homes), health plans, manufacturers (medical device, pharmaceutical), and suppliers (e.g., durable medical equipments companies), should expect continued aggressive enforcement in the coming years.<sup>[2]</sup> The ACA heralds a new era of compliance in healthcare that will require these organizations to monitor their operations, implement robust compliance programs, report publicly a vast array of information about their business arrangements, and face significant penalties for violations.

HHS Office of Inspector General’s Top Management and Performance Challenges for Fiscal Year 2010

Categories: Department of Health and Human Services, Fraud and Abuse, Key Developments, Office of Inspector General

Posted on March 18, 2011

The complexity and size of the U.S. health care system makes it susceptible to fraud and abuse in both the public and private insurance markets. According to the National Health Care Anti-Fraud Association (NHCAA), an estimated 3% of all health care spending is lost to fraud; government and law enforcement agencies have estimated fraud-related loses to be as high as 10% of annual health care expenditures. The financial ramifications of these fraudulent schemes are enormous to patients, providers and the federal government. Indeed, the U.S. Government Accountability Office (GAO) estimates that for 2010, Medicare alone had $48 billion in improper payments (underpayments and overpayments). In response to its findings, the GAO recommended that the Centers for Medicare and Medicaid Services find ways to address the vulnerabilities to improper payments and enhance program integrity.

Fraud and Abuse: Revisions to Anti-Kickback Statute

Categories: Fraud and Abuse

Posted on May 20, 2010

The health reform law revises the anti-kickback statute to broaden the reach of the law and enhance enforcement.