How data mining is uncovering healthcare fraud

What does your data say about your healthcare practice? Does it show that you bill considerably more than your colleagues for certain types of procedures? What about your facility? Is it performing more of a particular procedure than nearby competitors? These days, healthcare fraud investigators increasingly rely on data to root out healthcare fraud. They […]

Finalized DME rule targets fraud, abuse

The Centers for Medicare and Medicaid Services has finalized a rule that creates a prior authorization process for some durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) that it has determined are often subject to unnecessary utilization – i.e. healthcare fraud. The rule was first proposed in May 2014 and included a Master List of […]

Government cracks down on pharmacies, home health agencies, medical directors for medically unnecessary services

It’s no secret that in recent years the number of healthcare fraud investigations and prosecutions in the U.S. has rocketed. Clearly, the amount of taxpayer dollars being lost to fraud and abuse, coupled with the potential for big payoffs when fraud is detected, is a great motivator. Every year that the government racks up successful […]

Feds to increase exclusion and civil monetary penalty enforcement cases

When it comes to exclusion and civil monetary penalty cases, the federal government is preparing to take an even harder line than in the past. During the recent Health Care Compliance Association’s Healthcare Enforcement Compliance Institute, Gregory Demske, chief counsel at the Health and Human Services Office of Inspector General, told an audience his agency […]

How whistleblowers are helping to fight healthcare fraud

Earlier this month, the Department of Justice announced it had resolved a $237 million judgment against Toumey Healthcare System in South Carolina for violations of the Stark Law. In this particular case, the hospital was alleged to have entered into contracts with 19 specialists that required them to refer their outpatient procedures to the hospital […]

Healthcare executives on notice, DOJ cracking down on individuals for corporate misconduct

The federal government has taken a tough stance on healthcare fraud for many years. For the most part, companies caught up in the net have responded by paying huge fines and promising not to engage in fraudulent activities again. Despite the billions of dollars paid out, corporate fraud persists. Now, the feds are turning up […]

Florida ALFs latest target of Medicaid fraud investigators

Assisted Living Facilities (ALFs), and the patient placement agencies with which they work, have become the latest target of Florida’s Medicaid Fraud Control Unit (MFCU) investigators. Recently, these agencies have been conducting interviews with ALF owners, managers and marketing personnel at facilities where they suspect possible kickbacks in violations of the Florida Patient Brokering Statute […]

Compounding pharmacies in the eye of investigative storm

In the last year or so there have been a number of stories in the media about investigations into wrongdoing by compounding pharmacies, marketing companies and physicians. At last count there were nearly 100 federal investigations underway for what the feds believe are questionable financial relationships involving these three entities. In some instances, physicians are […]

CMS’ fraud crackdown relies on high-tech analytics

The government’s crackdown on Medicare fraud is paying off and healthcare providers that bill the government program would be well advised to know that the Centers for Medicare & Medicaid Services is using a high-tech analytics system to identify inappropriate payments. Aptly named the “Fraud Prevention System,” the program has identified or prevented $820 million […]

Federal prosecutors increasingly target individual healthcare execs in anti-fraud efforts

Last month’s sentencing of the former president and CEO of OtisMed Corporation to two years in prison should serve as yet another example that federal prosecutors are not holding back when it comes to holding corporate executives accountable. Charlie Chi was sentenced for intentionally distributing a medical device used in knee replacement surgery despite the […]

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