Last summer, I wrote about the Department of Justice (DOJ) and Department of Health and Human Services (HHS) launching a joint False Claims Act Working Group focused on Medicare fraud enforcement. At the time, the government identified several priority enforcement areas, including Medicare Advantage risk adjustment, kickbacks, drug and device arrangements, and the use of data analytics to identify potentially improper billing.
Earlier this year, we saw one significant example of that enforcement strategy when Aetna agreed to pay $117.7 million to resolve False Claims Act allegations involving inaccurate diagnosis codes submitted through the Medicare Advantage program.
Since then, the enforcement activity has accelerated.
Over the past several months, CMS and DOJ have announced a series of enforcement actions involving billions of dollars in suspected or allegedly improper Medicare claims. Although the cases involve different types of providers and different alleged conduct, several themes are beginning to emerge.
For healthcare providers, the message is increasingly clear: federal enforcement is becoming more data-driven, more proactive, and increasingly focused on identifying suspicious billing patterns before the money is paid.
The Aetna settlement was not an isolated Medicare Advantage case.
In June, Matrix Medical Network, HealthFair, and HealthFair’s founder agreed to pay a combined $56.5 million to resolve False...
Ken Ranta, CEO of the District of Thunder Bay Social Services Administration Board, is advising the public some election candidates are making inaccurate statements regarding the board and the work...