Administration redoubles fraud-fighting efforts
With the Obama administration out to prove it can be a responsible steward of healthcare dollars, the government dials up the heat on healthcare fraud. The health reform act dedicates an additional $350 million over 10 years to fraud enforcement, and HHS Secretary Kathleen Sebelius and Attorney General Eric Holder launch a road show across the country to talk about ways their agencies are getting tough on corporations, providers and flat-out criminals that take advantage of Medicare and Medicaid. They reach out to the industry to crack down on fraud elsewhere in the system. In November, the U.S. Justice Department announces that its haul from healthcare-related False Claims Act cases reaches a record $2.5 billion in fiscal 2010. The figure includes $669 million from drugmaker Pfizer settling allegations of off-label marketing and, in the largest hospital settlement, Christ Hospital in Cincinnati agrees to pay $108 million in a case involving a scheduling arrangement for cardiologists that is alleged to be a mechanism for kickbacks.
The Justice Department’s antitrust division takes aim at consolidation and business practices in the health insurance industry and then pulls the trigger in Michigan. First, the division threatens a lawsuit and effectively scuttles the acquisition of a Sparrow Health System-owned HMO in Lansing to Blue Cross and Blue Shield of Michigan. Months later, the government returns to Michigan to file a lawsuit alleging the Michigan Blues engaged in anti-competitive contracts with hospitals. The lawsuit specifically targets socalled most-favored-nation clauses, in which the hospitals agree to demand higher rates from the Blues’ competitors.
The government works to determine whether the nation’s fraud and competition laws could impede the integration sought by several provisions of the health reform law and promoted by the Obama administration and others as a key to higher quality and lower costs. The CMS, HHS’ inspector general’s office and the Federal Trade Commission convene a daylong workshop with panelists representing hospitals, physicians and insurers, to puzzle over how providers can work together without getting so big that they stifle competition, are aligned in ways that allow price-fixing, or create referral patterns violating the anti-kickback statute or the Stark law. Guidance and regulatory relief are promised but unspecified.