In this eye-opening episode of Corruption, Crime and Compliance, Michael Volkov takes a deep dive into the world of healthcare compliance and fraud. He explores the history, the transformation, and the unique challenges of healthcare compliance. He also sheds light on the alarming rate of fraud in the healthcare industry and the efforts to combat it.
You’ll hear him discuss:
- Compliance in healthcare traces back to the 1990s. Its rise is largely due to aggressive federal enforcement programs and increasing regulation.
- Four significant trends in healthcare compliance include:
- Rising consumer demand, escalating prices, and increasing regulation during the era of HMO controversies.
- The DOJ’s use of criminal tools and prosecutions to combat healthcare fraud and circumvent government regulations.
- The growing importance of the False Claims Act as an enforcement tool.
- The establishment of a robust regulatory enforcement regime through the Center for Medicare Services and the HHS-OIG.
- As the healthcare industry comes increasingly under federal government regulation and control, the risks of healthcare fraud are escalating. Despite the development of proactive compliance programs, the industry struggles to keep pace with the level of fraud, waste, and abuse.
- Beyond the traditional elements of compliance programs, the healthcare industry faces unique challenges. These include managing interactions with physicians, ensuring data privacy, avoiding the employment of ineligible persons, and navigating the complexities of billing, coding, and overpayments.
- The False Claims Act poses a significant risk for healthcare providers, with nearly 99% of all cases each year immediately settled. The Act has been applied beyond billing and reimbursement issues to include false representations incorporated into a product or a drug.
- The DOJ regularly conducts nationwide crackdowns on healthcare fraud, arresting numerous defendants involved in healthcare fraud and opioid abuse schemes. A growing area of concern is telemedicine fraud, which has seen a surge with the rise of remote work during the pandemic.
KEY QUOTES:
“Healthcare is becoming increasingly under federal government regulation and control. And as this occurs, the federal healthcare risks of fraud are going to be increasing significantly. Private insurance companies are also experiencing continuous growth of fraud and the healthcare industry is really developing proactive compliance programs, but they struggle to keep up with the level of fraud, waste, and abuse that they sort of have to pursue.” – Michael Volkov
“…one of the most significant risk areas is physician interactions.” – Michael Vokov
“Nearly 99% of all False Claims Act cases each year where the government decides to intervene are immediately settled.” – Michael Volkov
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