Federal and state governments are under increasing pressure to recover funds alleged to have been lost on fraud and abuse in federal and state health care programs. In today’s environment, governments have increased the mechanisms they use to detect fraudulent billing by, and erroneous payments to, health care providers and suppliers.
The media reports on a daily basis the millions of dollars that health care providers are paying out in fines and penalties to the federal government. Some governmental enforcement actions result from audits and data mining by private insurance carriers and Medicare and Medicaid contractors. Other actions stem from whistleblowers — many of whom work in or with provider organizations — seeking bounties under the federal False Claims Act (FCA). These whistleblowers allege violations of fraud statutes such as the federal Anti-Kickback statute and the Stark Law (prohibiting physicians from making referrals for certain services payable by Medicare to an entity in which the physician has a financial stake).
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