The Department of Justice (DOJ) has ramped up its efforts to combat health-care fraud, resulting in a significant uptick in enforcement activities. The recently concluded 2024 National Health Care Fraud Enforcement Action saw criminal charges brought against 193 defendants, including 76 medical professionals, who were involved in schemes totalling approximately $2.75 billion in intended losses and $1.6 billion in actual losses. Key areas of fraud identified include misuse of wound grafts, unlawful prescriptions of stimulants such as Adderall, and fraudulent telemedicine and laboratory schemes.
The DOJ has outlined its continuing focus areas, with priorities such as addressing the opioid crisis, enforcing standards on unnecessary services and substandard care, and tackling infractions related to Medicare Advantage, unlawful kickbacks, Stark Law violations, and Covid-19-related fraud. Given the substantial revenue generated from fraud settlements, it is anticipated that enforcement will continue to be a high priority under any administration.
Although changes in political leadership can bring shifts in policy, the fact-intensive nature of fraud cases often insulates them from administrative transitions. However, President Trump’s approach, including the nomination of Mehmet Oz as the new administrator for the Centers for Medicare and Medicaid Services, could influence enforcement strategies, particularly with respect to Medicare Advantage plans. Democratic lawmakers have already raised concerns regarding overcharges by Medicare Advantage insurers, estimating an $83 billion hit due to improper billing practices.
Physicians and clinical practices are urged to exercise diligence in their business arrangements, especially when involvement with federal health-care programs is evident. Engaging with legal counsel to vet business deals and payment sources is recommended to ensure compliance with Medicare regulations and the False Claims Act. Many practitioners are opting to exit “traditional” models in favor of cash-based or “hybrid” practices to lessen compliance burdens while still adhering to other regulatory requirements.
As health systems continue to navigate this robust enforcement landscape, they must maintain comprehensive compliance programs, scrutinize all business dealings for legal standing, and secure approval from legal professionals for their contracts and arrangements. With the government watchful over suspect practices, diligence remains imperative for all stakeholders.
For a deeper analysis on the implications of recent fraud enforcement, refer to the insights by Amanda Hill of Hill Health Law Group on the Bloomberg Law platform.