Here are eight takeaways from the article:
1. The 2024 National Health Care Fraud Enforcement Action resulted in criminal charges against 193 defendants, including 76 medical professionals, for approximately $2.75 billion in intended losses and $1.6 billion in actual losses.
2. Many of these fraud claims were related to wound grafts, unlawful prescription of Adderall and other stimulants, and frauds involving telemedicine and laboratories.
3. Cases related to healthcare comprised the largest portion of False Claim Act settlements and judgements in 2023, according to the article.
4. The department has also listed opioid issues, unnecessary services, substandard care, Medicare Advantage, unlawful kickbacks, Stark Law violations and COVID-19-specific fraud as enforcement priorities in the future.
5. Ms. Hill writes that it remains uncertain whether these efforts will be impacted by President Donald Trump and his administration, as these healthcare fraud cases can take years to build.
She speculated that a regulatory freeze, pauses on policies instituted under former president Joe Biden and hiring restrictions could have an impact on fraud enforcement. On the other hand, she writes, efforts to modernize and streamline government programs by the recently created Department of Government Efficiency may prove more effective in proving fraud and abuse cases.
6. She adds that it remains unclear whether Mehmet Oz, MD, Mr. Trump’s proposed nominee to lead CMS, has proposed to expand Medicare Advantage. Democratic lawmakers wrote an open letter to Dr. Oz in December saying that MA insurers overcharged CMS by $83 billion in 2024 due to upcoding and other improper billing, but it remains unclear how Dr. Oz may alter MA fraud enforcement efforts.
7. Ms. Hill strongly recommends that physicians have strong legal counsel review any “side deals” and evaluate any payment sources to ensure that they are legitimate and up to date.
8. “Physicians are beginning to leave ‘traditional’ medicine and starting up cash-based practices to avoid these onerous burdens and stop feeling like they have to look over their shoulders,” she writes. Hybrid plans are also still bound by compliance rules found in traditional insurance agreements.
