Ad­min­is­tra­tion re­dou­bles fraud-fight­ing ef­forts

Modern Healthcare - - Special Report -

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.

Other high­lights:

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.

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