1 VIEW ON FRAUD AND ABUSE David E. Matyas Epstein Becker & Green Washington, DC

2 What Does The Future Hold?

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5 Who’s Responsible for Fighting Fraud? n Federal Government (DOJ;FBI; DHHS; US Postal Service) n State Agencies n Congress n Private Third Party Payors n Private Citizens

6 A Climate of Enforcement Criminal health fraud matters 343 1,994 Criminal convictions Pending Civil matters 270 2,278 pending FBI resources devoted (agent work years) Source: HHS & DOJ Health Care Fraud & Abuse Control Program Annual Report for FY 1999

7 FBI Health Care Fraud Resources

8 Increased Criminal & Civil Monetary Penalties n In FY 1997 alone, $1.087 billion was collected and in FY 1998, over $480 million was won or negotiated in criminal fines, and civil judgments and settlements. n In FY 1999, the OIG and DOJ collected over $490 million.

9 Increased Program Exclusions and Criminal Convictions n In 1999, federal prosecutors convicted over 300 individuals (including physicians and hospital executives) in health care fraud cases, an increase of 16 percent from the prior year. n Since 1997, more than 8,600 individuals and entities have been excluded from participation in federal and state health care programs.

10 Significant Factors

11 The Fraud And Abuse Control Program n Enacted as part of HIPAA, the Program gives DHHS and DOJ responsibility for coordinating public and private enforcement activities. n Congress created a new expenditure account (named the “Health Care Fraud and Abuse Control Account”) in which DHHS and DOJ jointly certify moneys needed each year to finance anti-fraud initiatives

12 Program Goals n coordinating law enforcement program n conducting audits, evaluations and investigations n helping facilitate enforcement of laws n providing guidance to the industry on fraudulent practices n establishing a national data bank to receive and report adverse actions

13 The Federal False Claims Act The Ultimate Legal Weapon In Prosecuting Health Care Cases

14 Whistleblower Actions Over half of the $480 million the DOJ was awarded in health care fraud cases in FY 1998, involved judgements or settlements related partially or completely to allegations in qui tam cases. DOJ Health Care Fraud Report (FY99)

15 Gov’t Fraud Hotline and the Establishment Of Monetary Reward Program n Individuals who provide info. that leads to recovery of at least $100 may be eligible for a reward equaling the lesser of $1000 or 10% of the overpayments recovered n In 1997, over 32,000 complaints that warranted follow-up action were received on this hotline n Now with the additional incentive of a monetary reward, more people will consider reporting possible wrongdoing

16 THE FUTURE: The Question Should Not Be Will the government’s fraud enforcement activities against health care providers continue into the future?

17 Rather the Question Should Be What will the government’s fraud enforcement activities focus on in the future?

18 Predictions n Continued Emphasis on Billing n More Emphasis on Kickbacks n Managed Care Activities n E-Health n Research n Private Payor Fraud Actions n Scrutiny of CIA Compliance

19 View on Fraud and Abuse David E. Matyas Epstein Becker & Green Washington, DC