Last year also saw continued efforts to pursue civil and criminal enforcement against individuals in fraud cases. Physicians and healthcare executives settled civil and criminal allegations related to medical necessity, services not provided, inflated bills, kickbacks and other allegedly fraudulent activity. Two executives were part of a $41 million settlement resolving allegations of submitting false claims for presumptive and definitive urine drug testing that was not medically reasonable or necessary.
“Holding individuals accountable in healthcare fraud cases is now a well-established fraud enforcement priority,” said Lisa S. Rivera, a Healthcare Fraud Task Force member and former federal prosecutor. “The increased liability of executives for corporate actions makes the need to lead on compliance all the more personal. Making this a top leadership priority within an organization is a critical element of building and maintaining a culture of compliance.”
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For long-term-care facilities, the focus of regulators and whistleblowers likely will turn to fraud theories related to quality of care. For its part, DOJ announced its National Nursing Home Initiative in furtherance of its previously announced Elder Justice Initiative and has forecast increased civil and criminal enforcement efforts focused on nursing homes where grossly substandard care to residents has been provided.
“The current COVID-19 crisis will accelerate regulators’ focus on quality-of-care issues,” said Jeff H. Gibson, a member of the Healthcare Fraud Task Force. “Whistleblowers recognize this reality and likely will be pursuing cases based on inadequate care. Skilled-nursing providers must closely monitor quality metrics and complaints regarding quality and work to address identified shortcomings proactively.”
Comprehensive review of settlements
Bass, Berry & Sims’ Healthcare Fraud & Abuse Review 2020 will assist healthcare companies in developing a greater understanding of the civil and criminal enforcement risks they face during a time of great uncertainty for the healthcare industry. The Review offers analysis of major trends in False Claims Act case law, issues to watch as 2021 unfolds, and a comprehensive review of settlements in the following categories:
Hospitals and Health Systems
Hospice and Home Health
Skilled Nursing Facilities and Nursing Homes
Pharmaceutical and Device
Laboratory, Pathology, Radiology and Diagnostics