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Health Care Fraud and Abuse Enforcement - It's Not Just Hypothetical Anymore

health care fraud and abuse enforcementOn February 11, 2013, the Departments of Justice and Health and Human Services jointly released a report stating that the government recovered $4.2 billion in fiscal year 2012 and for every dollar spent on health care-related fraud and abuse investigations in the last three years, the government recovered $7.90. The report indicates that this is the highest 3-year average return on investment in the 16 year history of the Health Care Fraud and Abuse program. The Health Care Fraud Prevention and Enforcement Action Team (“HEAT”), which has operations in Detroit, was instrumental in this recovery effort.

The report affirms that President Obama is making the elimination of fraud, waste and abuse, particularly in health care, a top priority for the administration.  In addition, the government will continue to improve its efforts to reduce fraud and abuse using new tools and resources provided by the Affordable Care Act.

Moreover, the report discloses that the Department of Justice and U.S. Attorney’s Office have obtained settlements and judgments under the False Claims Act. The matters settled include:

  • Unlawful pricing by pharmaceutical manufacturers;
  • Illegal marketing of medical devices and pharmaceutical products for uses not approved by the Food and Drug Administration;
  • Medicare fraud by hospitals and other institutional providers; and
  • Violations of laws against self-referrals and kickbacks.

We cannot stress enough the importance of structuring agreements between physicians, hospitals, and other institutional providers within the federal Stark law exceptions, when physicians are involved, and the Anti-Kickback statute safe harbors.

Providers may not always appreciate the importance of analyzing whether these laws apply to their transactions and structuring them within the applicable exceptions and safe harbors when they do. Often, providers may have structured relationships for many years without considering the applicability of these regulations. Other parties may not want to consider them because they may hinder their interests financially. However, this news release underscores that compliance with these laws isn’t just a theoretical exercise; non-compliance can result in very real financial and criminal consequences.

If you have questions regarding these laws and how they may affect your next business deal, please contact a member of our Health Care Practice Group, which is very experienced in analyzing these situations and recommending how to comply with the applicable laws.

Categories: Fraud & Abuse, Health Care Reform

 has particular expertise in health law and she represents providers with emphasis in the areas of physicians, hospice, home care and long term care, including one of the country’s largest long-term care organizations. She has a vast array of experience in teaming with providers in the areas of regulatory compliance and contracts. 

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Best Lawyers® 2021

Congratulations to the attorneys of the Health Care practice group at Foster Swift Collins & Smith, PC for their inclusion in the Best Lawyers in America 2021 edition. Firm-wide, 44 lawyers were listed. Best Lawyers lists are compiled based on an exhaustive peer-review evaluation and as lawyers are not required or allowed to pay a fee to be listed; inclusion in Best Lawyers is considered a singular honor. Health Care practice group members listed in Best Lawyers are as follows:

To see the full list of Foster Swift attorneys listed in Best Lawyers 2021, click here.