In the past couple of years, law enforcement agencies have recovered billions of dollars through judgments and settlements related to healthcare fraud investigations. In the fiscal year 2015, the DoJ recovered more than $3.5 billion in judgments and settlements from cases that involved fraud and false claims against the government. As time goes by, government officials are planning to continue with their aggressive fraud recovery efforts.
At the CBI conference held on 15th – 17th August 2016, Laura M. Kidd Cordova & R. David Walk, Jr. of the U.S. Department of Justice and David M. Scheffer from the Massachusetts Office of the Attorney General stated that the government plans on investigating more sophisticated kickback schemes, indirect payments and payments through intermediaries in a more aggressive manner. With healthcare fraud as a focus, the pharmaceutical industry can expect an increase in criminal prosecution, data analysis, and usage of a greater variety of tools for prosecution purposes by the DoJ.
A More Proactive Approach
With the passage of time, the government has encouraged federal enforcers to work harder in order to proactively identify potential fraud and abuse of the healthcare system. Apart from individual convictions, Laura Cordova from the DoJ stated that law enforcement agencies will continue investigating and convicting corporations at large.
As stated by the representatives of the U.S. Department of Justice and the Massachusetts Office of the Attorney General, law enforcers will continue to forge through Open Payments data for the detection of health care fraud. For them, it is of utmost importance to analyze data more effectively and efficiently and aggregate it in ways that would make it possible for them to identify wrongdoings.
Let’s not forget CMS has also added a data analytics lead role to its employee pool for efficient data analysis and the identification of emerging healthcare fraud patterns.
What Will the Government Look at in Open Payments Data?
In the past three years, CMS has published over 28 million records that amount to nearly $17 billion. Now that the DoJ has decided to up the ante against healthcare fraud, this treasure trove of data is not going to be left unmined by fraud investigators. According to representatives of the DoJ at the CBI conference, the government will look for outliers in a more stringent manner to begin with. Payments that stand out are usually considered a possible indicator of wrongdoing.
Another target for prosecutors, over time, are going to be anti-kickback violations, particularly those that would induce physicians to order more expensive drugs that are to be reimbursed through Medicare. For this, law enforcers will be looking for elements within Open Payments data for things that do not make sense – anything that makes them step back and question what is really going on here is bound to trigger an investigation. It is also possible that federal and state enforcement authorities may cross-reference information and data to conduct pressure tests in terms of compliance with applicable laws and requirements.
As the government increases its enforcement actions focused on the healthcare industry, both pharma manufacturers and physicians should ensure that they remain in compliance with federal laws governing Medicare and Medicaid fraud and abuse.
