Last weekend, our team had the privilege to participate in and sponsor the Healthcare Enforcement Compliance Institute presented by HCCA in the nation’s capital. Over 350 Compliance Officers and legal counsel converged in Washington to hear directly from leaders of the enforcement arms of the Department of Justice, U.S. Attorney’s offices, Department of Health and Human Services, the Inspector General’s office and from Centers for Medicare and Medicaid Services.

Each year, we look forward to attending this event – meeting new faces, hearing the latest industry standards and stories, and connecting with like-minded professionals looking to keep improving healthcare. We had a blast and would like to walk through some of the key themes and takeaways from this year’s conference, and hopefully, open up the conversation for your thoughts! 

Once again, this year did not disappoint with exceptional keynote speakers:

  • Joseph Beemsterboer, Chief, Healthcare Fraud Unit, Fraud Section, U.S. DOJ
  • Michael Granston, Director, Commercial Litigation Branch, Fraud, U.S. DOJ
  • James Sheehan, Chief, Charities Bureau, NY Attorney General’s Office
  • Michael Horowitz, Inspector General, U.S. DOJ
  • Kimberly Brandt, Principal Deputy Administrator for Operations, CMS

There were 38 breakout sessions ranging from “Cyber Security Best Practices” to “Avoiding Corporate Integrity Agreements” to Opioid Enforcement to name a few. You can check out the full agenda and lineup of speakers at the following link: 2017 HCCA Healthcare Enforcement Compliance Institute Agenda.

One thing is for sure, enforcement is here to stay and the government is combing through all kinds of data to find those who commit healthcare fraud and abuse. This central theme was hammered home throughout the three-day conference, geared specifically around 3 core elements for compliance professionals:

  1. Going beyond legal analysis.
  2. Learning how to implement processes to stay within the law.
  3. Gaining practical advice in this one-of-a-kind forum for attorneys and compliance officers.

The biggest take away our team received, was the power and coordination of these federal agencies in collecting and interpreting data analytics, sharing of resources and combined Strike Forces in healthcare across the nation. Stories of how these combined efforts cull through billing records, quality data, as well as comparing national data benchmarks for opioid prescribers to see who the biggest prescribers are. In one session, it was explained how billing data is compared to flight and hotel records to see if a provider was even physically in the state where he/she claimed to have worked that day, or even out of the country. This was a fascinating session to witness the attention to detail and rigorous pursuit of bad actors with actionable and creative data aggregation and analysis.

Data Mining: The Power of Data

Did you know that under the Affordable Care Act, Congress provided OIG with $350M to step up its efforts to hire more investigators and to deploy a data analytics team to comb through records and data to find patterns of billing abuse, quality of care cases, and false claim submissions? There is even a Chief Data Officer employed by the Department of Health and Human Services to conduct and manage these specific efforts. The Department of Health and Human Services has Ph.D. level economists to aid in trends and fiscal planning to protect the integrity and longevity of the Medicare trust funds.

Did you know that healthcare Medicare Strike Forces exist in the metroplexes of Dallas, Los Angeles, Houston, Baton Rouge, South Florida, Detroit, Brooklyn, New York, Tampa, and Chicago? In fact, in July 2017, we witnessed the largest healthcare fraud takedown in history involving more than 400 defendants in 41 federal districts who were charged with participating in fraud schemes involving about $1.2B in false billings to Medicare and Medicaid.

Did you know that OIG can exclude an entity or business if it is controlled by owners or managers who own 5% or more of the business? Government agencies have really stepped up their game in respect to mapping data points and finding a clear story to investigate further. One would assume that these efforts and resources will only continue to grow as technology advances.

Focus of Department of Justice – Civil False Claims Act

The fiscal year 2017 has just come to an end but it is the 8th straight year that annual recoveries exceeded $2B per year in False Claims Act recoveries by the DOJ. In those same eight years, nearly $20B has been recovered, representing 60% of the total recoveries since 1986. The biggest factor and contributor to the False Claims Act cases are actually whistleblowers through a Qui Tam case. Since 2011, there have been over 400 cases filed annually by whistleblowers and in two of those years, there were over 500 cases. The recoveries under these cases represent a total of $17B and are 90% of the total False Claims Act recoveries in that period.

Top industries that have been affected by Qui Tam cases are:

  • Pharma and DME providers – recent cases of note are the Epi-Pen pricing cases
  • Anti-kickback cases – $500M recoveries in 2016 (One settlement was $340 million)
  • Unnecessary or ineligible services provided
  • Electronic health records software cases
  • Medicare Part C (Medicare Advantage Plans)
  • Opioid epidemic
  • Preventing elder abuse

Department of Justice – Criminal Fraud Unit

The criminal cases of enforcement have focused mainly on avoiding patient harm and large financial losses to the fund due to fraud. This includes hospice providers and even ambulance service providers. In 2016, the Department of Justice charged 146 cases of criminal fraud and utilized data analytics to zero in on the biggest abusers.  

Take the Tenet Health case for example, in which executives have been penalized $513M, a criminal forfeiture of $145M, and a civil settlement totaling $368M. The case should be a wake-up call to hospital CEO’s as Mr. Holland, of Tenet Hospital was personally charged as CEO for his role in the fraud that took place in north Georgia.

Overall Compliance Message from the DOJ:

  1. Create and maintain legitimate and enforceable compliance programs.
  2. Constantly analyze and review data to spot trends.
  3. Constantly review existing and proposed relationships for anti-kickback and Stark violations.
  4. It all comes down to the trustworthiness of the provider. So conduct exclusion monitoring and have an effective compliance program.

Summary: We learned a lot this past week, but the most helpful and comforting takeaway is the fact that there are caring and compassionate professionals in healthcare that do the right thing and are serious about providing compliant and high-quality care. It is these compliance professionals that we are proud to support and to spend quality time with one-on-one. It was a joy to walk through some of the ways that our team is addressing many compliance problems and constraints with quality healthcare software solutions.

We plan to make the trip again next year and want to hear what you thought of the conference in the comments below! Didn’t get to attend? Tell us what you thought was interesting or if we can help answer any questions.


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Written by Michael Rosen, ESQ

ProviderTrust Co-Founder, mrosen@providertrust.com

Michael brings over 20 years of experience founding and leading risk mitigation businesses, receiving numerous accolades such as: Inc Magazine’s Inc 500 Award and Nashville Chamber of Commerce Small Business of the Year.

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