Healthcare News & Insights

Where is fraud enforcement headed in 2015?

Hospital leaders will have to beef up their compliance efforts over the year because indicators show the feds are turning up the heat on fraud enforcement. 

GettyImages_460407425In the finalized version of the 2015 budget, the government approved a large influx of money to the Health Care Fraud and Abuse Control program. That means federal oversight agencies will be getting a healthy dose of funding to expand their fraud investigations and crack downs.

Three agencies in particular received large chunks of the budget allotment, including:

  • the Centers for Medicare & Medicaid Services (CMS) — $477 million
  • the Department of Justice (DOJ)  — $60 million, and
  • the Department of Health & Human Services Office of the Inspector General (OIG)  — $67 million.

Tracking anti-fraud action

Reading the financial writing on the wall, several healthcare attorneys for the firm McDermott, Will & Emery interpreted how those budget dollars will translate into enforcement action during 2015 for the firm’s FCA Update Blog.

Overall, the attorneys believe the agencies will increase the number and intensity of False Claims Act (FCA) investigations during the year.

Providers can expect that CMS and OIG will continue to expand their use of automated predictive analytic systems to review massive amounts of claims data for billing patterns that could hint at fraud. CMS will also continue publishing data on Medicare payment rates, which may lead to some providers being scrutinized if their rates fall outside what’s considered average.

One newer area that will receive special attention from CMS in particular, is Medicare overpayments and “reverse false claims.” Under the Affordable Care Act, any Medicare overpayment not returned within 60 days of identification could put the provider on the hook for FCA penalties.

Additionally, the DOJ announced last year that both its criminal and civil divisions will now review FCA complaints to decide whether or not to conduct parallel investigations. That means hospitals could be hit with double the document requests, an administrative burden, for the same FCA issue.

Strategies to prepare

With this increasing amount of scrutiny coming from regulators, hospital leaders should plan now before one of these agencies shows up at your door for an audit.

The attorneys at the firm offered three strategies hospital executives can use to ensure their facilities survive the increased regulation:

  1. Reevaluate and strengthen compliance plans. Your plan should be reviewed on a regular basis to correct any errors and reflect the most recent regulation updates from oversight agencies. Plans should also account for staff training on payment rules, internal reporting mechanisms and what to do if an auditor contacts your hospital.
  2. Create internal auditing programs. Self audits can help you better understand the billing data agencies will be scrutinizing. More importantly, they help you identify weak or problematic areas in your billing or operations before they escalate into bigger issues.
  3. Develop a comprehensive disclosure strategy if you discover problems. Effective compliance and internal auditing programs will most likely find problems, such as overpayments. It’s important for facilities to have a process in place for analyzing the severity of problems, what to do to correct issues and how best to inform regulators.

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