Bloomberg BNA Publishes Outlook for Health Care Fraud in 2016

Bloomberg BNA has published its Outlook for Health Care Fraud for 2016, which includes information gathered from interviews with health care attorneys, trade association executives and health care consultants and recommendations on what health care providers can do to protect themselves.

The report focuses on the following health care fraud trends:

False Claims Act litigation — more cases will be filed in 2016, particularly those that include a Stark law violation. Stark prohibits doctors from referring Medicare patients to entities with which they or a member of their family have a relationship.

Individual enforcement — the federal government will continue to push for the prosecution of individuals per a Department of Justice policy memo in 2015 that said prosecutors must focus on individuals from the beginning of any investigation. With this new policy now in place, organizations will also need a stronger plan for conducting investigations of potential wrongdoing.

Medicare 60-Day rule — the anticipated release of the final Medicare 60-day rule, which requires a provider to return Medicare overpayments to the agency within 60 days, may lead to a flood of self-disclosures from providers. The final rule is anticipated to include a six-year look-back period.

In addition, other top issues for 2016 include:

  • Release of new regulations revising fraud and abuse laws.
  • Increased enforcement of civil monetary penalties.
  • Focus on specialty pharmacy fraud.
  • Aligning alternate payment models with the Stark law and the anti-kickback statute.
  • Use of statistical sampling to support FCA cases.
  • Kickbacks to pharmaceutical and medical device manufacturers.
  • Attention on defective medical devices.

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