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Author: rwillis

Launch of the Criminal Division’s In-House Health Care Data Analytics Team

In its “2017 Year in Review” ( fraud/file/1026996/download), the Fraud Section in the Criminal Division of the US Department of Justice announced the launch of its Health Care Fraud Unit’s Data Analytics Team. While the use of data analytics is not new to the Department of Health and Human Services and civil enforcement section of the Department of Justice, the addition of an in-house data analytics team as part of its official structure for criminal prosecutions is significant. The Data Analytics Team will assist prosecutors on two fronts: (1) identifying individuals and entities for prosecution and (2) learning about emerging health care fraud trends. Notably, the Team will train U.S. Attorney’s Offices on customized fraud data analytics. Among many other things, you can expect the Data Analytics Team to play a big role in specific public health issues such as the opioid epidemic. If your compliance department does not currently use data analytics as part of its risk assessment and compliance program effectiveness review, it is behind the game. Compliance departments should include data analytics in its annual plan and use all data available to it as an integral part of its compliance toolbox. The use of data analytics is not strictly limited to health care. For example, the Securities and Exchange Commission has embraced the use of data analytics in its investigations for approximately a decade and touts...

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The Trump Administration Proposes a Budget Increase to Fight Healthcare Fraud

The Trump administration proposed a budget increase of 19 million to aid in the fight against health care fraud. This showcases the continued (and heightened) importance of anti-fraud programs, especially compared to the suggested $18 billion in cuts to other health-care related programs. If approved by Congress, the budget increase will result in an increase in fraud and employee investigations, which in recent years, has shown a good return on investment for the Federal government. The remaining funds will go to the Health Care Fraud and Abuse Control Program (HCFAC). This program manages all federal, state, and local law enforcement activities linked to health-care fraud and abuse. This additional funding will be split between the Centers for Medicare & Medicaid Services, the Department of Justice and the Health and Human Services Office of Inspector General. The budget proposal included several recommendations to Congress to help reduce the threat of fraud: Cutting Medicare and Medicaid costs. Punishing doctors or physicians filing claims with inadequate documentation. Expanding Medicare’s previous program to include more services that have high risk for health fraud. Permitting Medicaid Fraud to receive equal funds to investigate fraud in home-health care settings. Halting the coverage and reimbursement of drugs prescribed to high risk patients or given by doctors with a history of overprescribing. At a minimum, the proposal shows the Federal government’s continued emphasis on the importance (both...

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Obligations and Expectations Surrounding Healthcare Compliance Programs

The phrase “healthcare compliance program” is commonly used to describe those processes and procedures implemented by a healthcare provider to prevent submission of erroneous claims and combat fraudulent conduct. The expectation is that providers using internal controls will more efficiently monitor adherence to legal and regulatory requirements than providers without such controls in place1. However, confusion remains over whether a healthcare compliance program is legally required for many healthcare providers, particularly those in clinical practice. Some healthcare providers may believe a formal compliance program is not necessary until a clear, legal requirement is established involving detailed parameters and penalties. This perspective primarily comes from those who don’t have the time, energy or resources to implement a program unless they understand it as an enforced legal mandate tied to penalties. Understandably, the same perspective surrounded compliance with HIPAA until the 2009 HITECH Act issued a clear enforcement rule with sizeable penalties for noncompliance2. Unlike HIPAA, currently there exists no clear enforcement rule setting forth explicit penalties against all types of providers for failure to implement a formal healthcare compliance program. While Section 6401 of the Patient Protection and Affordable Care Act requires as a condition of participation, all healthcare providers participating in a federal healthcare program establish a compliance program, such mandate is subject to when the Secretary of the Department of Health and Human Services (“HHS”) determines the timeline...

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Frequently Asked Questions on the Certificate of Need Process for Surgical Services

Michigan is among many states that require entities to obtain a Certificate of Need (“CON”) before performing most surgical services. While a CON is just one out of several legal and regulatory requirements that must be addressed in these situations, the process of applying for and winning approval of a CON from the Michigan Department of Health and Human Services’ CON Program (“CON Program”) can be time consuming and challenging. However, failure to properly comply with the CON process can result in unnecessary liability, additional costs, and delays to the project. Some of the frequently asked questions relating to CONs for surgical services include: Do I need a CON for this type of surgery? Only those surgical services that would be performed in an operating room, and more particularly, in a freestanding surgical outpatient facility, certified ambulatory surgical center and licensed hospital site are covered by the CON Program. Surgeries that may be performed in the physician’s office are expressly excluded from the services covered by the CON Program. The state defines “surgery” broadly to include among other things cutting into any part of the body, reducing fractures or dislocations, repairing malformations or defects, and endoscopic procedures. With such a broad definition, when determining whether a CON is required, the focus is really on the location in which the service would be performed, and not on the type of...

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The Health Law Blog is published by Dickinson Wright PLLC to inform the public of important developments within the firm and practice areas. The content is informational only and does not constitute legal or professional advice. We encourage you to consult a Dickinson Wright attorney if you have specific questions or concerns relating to any of the topics covered in this blog.