What are the trends in the healthcare regulatory risk landscape? How is this risk evolving? The latest reports from the governments Annual Health Care Fraud and Abuse, and Medicaid Fraud Control Units Annual Reports provide insight in to regulatory enforcement trends impacting healthcare providers.
Overall, the 2017 DOJ report shows increases in the number of new civil investigations and actions, a slight downturn in the number of excluded providers, and a large reduction in the total recoveries for over the past year.
| Year | New Civil Investigations |
New Civil Actions |
Excluded Providers |
Total Recoveries |
|---|---|---|---|---|
| 2016 | 930 | 690 | 3,635 | $3,354,067,657 |
| 2017 | 948 | 818 | 3,244 | $2,559,854,859 |
| Change | 18 | 128 | -391 | -$794,212,798 |
| % | 1.94% | 18.55% | -10.76% | -23.68% |
The Medicaid Fraud Control Units report indicates slight decreases in convictions, settlements, and total recoveries, as well.
| Year | Convictions | Settlements | Recoveries |
|---|---|---|---|
| 2016 | 1,564 | 998 | $1,876,532,842 |
| 2017 | 1,528 | 961 | $1,793,000,000 |
| Change | -36 | -37 | -$83,532,842 |
| % | -2.30% | -3.71% | -4.45% |
Some more specific trends found in the reports include:
Personal Accountability
The both the 2016 and 2017 DOJ reports highlight many cases in which individuals were targeted for prosecution. Some of the 2017 cases cited included;
- NJ Ambulance provider sentenced to 18 years in prison, ordered to pay $8.8 million and excluded from Medicare or Medicaid for a min. of 11 yrs.
- CA owner of physical and occupational therapy clinics sentenced to over 5 years in prison and ordered to pay more than $2.4 million to Medicare.
- LA Home Health Agency owner and medical director sentenced to 8 years and 6 years in prison, and ordered to pay a combined $9 million.
- OH provider of rehabilitation therapy and hospice services and two of its executives, who agreed to pay $19.5 million to settle civil FCA allegations.
Drug Diversion
The new DOJ report states “Opioid related matters are a substantial portion of HHS-OIG’s investigations”, and highlights the formation of a special unit to target providers engaged in drug diversion activities in 12 specific jurisdictions. Also mentioned is the 2017 National Health Care Fraud Takedown which “resulted in charges against 412 individuals, including 115 doctors, nurses, 78 and other licensed medical professionals, involving approximately $1.3 billion in fraudulent billings of opioids.
Whistle Blowers
Possibly the most striking trend is the large decline in payments to relators in whistle blower cases. After many years of increases in these payments 2017 saw a decrease of over 50% in amounts paid to whistle blowers.
Summary
While the large decrease in relator payments signal a welcome development for providers, the reality of risks involving the opioid epidemic and personal exposure of providers and owners are severe and on the rise for many providers.
These are just a few of the insights contained in the annual reports, which are recommended reading for all healthcare providers and healthcare executives.
More info and the most recent annual reports from the Dept. of Health and Human Services and Dept. of Justice can be found at:
Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2017
Medicaid Fraud Control Units Fiscal Year 2017 Annual Report