Spotlight

Spotlight

Learn more about our recent work and accomplishments.

Image depicting an opioid takedown
Appalachian Regional Prescription Opioid Strike Force Actions to Combat Unlawful Prescribing Amidst the Continuing Opioid Epidemic

On May 4, 2022, the Department of Justice, together with federal and state law enforcement partners, today announced criminal charges against 14 defendants in eight federal districts across the United States for their alleged involvement in crimes related to the unlawful distribution of opioids. Twelve of the defendants were licensed medical professionals at the time of these alleged offenses.

Additionally, the Centers for Medicare & Medicaid Services’ (CMS) Center for Program Integrity has taken six administrative actions against providers for their alleged involvement in these offenses.

"Patient care and safety are top priorities for us, and CMS has taken administrative action against eight providers to protect critical resources entrusted to Medicare while also safeguarding people with Medicare,” said CMS Administrator Chiquita Brooks-LaSure. "These actions to combat fraud, waste, and abuse in our federal programs would not be possible without the close and successful partnership of the Centers for Medicare & Medicaid Services, the Department of Justice, and the U.S. Department of Health and Human Services Office of Inspector General."

Read the DOJ press release.

 
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COVID-19 Coordinated Law Enforcement Action and CMS Administrative Actions

On April 20, 2022, the Department of Justice announced criminal charges against 21 defendants in nine federal districts across the United States for their alleged participation in various health care related fraud schemes that exploited the COVID-19 pandemic. These cases allegedly resulted in over $149 million in COVID-19-related false billings to federal programs and theft from federally-funded pandemic assistance programs. This announcement builds on the success of the DOJ’s May 2021 COVID-19 Enforcement Action and involves the prosecution of various COVID-19 health care fraud schemes.

Additionally, the Center for Program Integrity, Centers for Medicare & Medicaid Services (CPI/CMS) separately announced today that it has taken an additional 28 administrative actions against providers for their alleged involvement in fraud, waste and abuse schemes related to the delivery of care for COVID-19, as well as schemes that capitalize upon the Public Health Emergency.

“We are committed to working closely with our law enforcement partners to combat fraud, waste and abuse in our federal health care programs,” said CMS Administrator Chiquita Brooks-LaSure. “The administrative actions CMS has taken protect the Medicare Trust Funds while also safeguarding people enrolled in Medicare.”

Read the DOJ press release.

 
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Just Released: Fraud, Waste, and Abuse in the Context of COVID-19 White Paper

The Healthcare Fraud Prevention Partnership (HFPP) released its newest White Paper, “Fraud, Waste, and Abuse in the Context of COVID-19 (PDF)” in collaboration with Stanford University School of Medicine.

This new HFPP white paper provides a background on COVID-19 and its impact on healthcare delivery. The paper then highlights trending fraud schemes and offers strategies for healthcare payers to consider and apply.

Broadly, this white paper outlines important steps that federal and state agencies, private payers, and law enforcement have taken in identifying and responding to fraud, waste, and abuse related to the delivery of care for COVID-19. These actions and lessons learned may allow these parties to anticipate vulnerabilities moving forward, providing a foundation for navigating a changed healthcare landscape and future healthcare challenges.

For additional information, please see:

 
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False Claims Act Cases Against P-Stim Providers and Suppliers

On October 14, 2021, Acting United States Attorney Jennifer Arbittier Williams of the Eastern District of Pennsylvania announced three settlements and the filing of a complaint under the False Claims Act. These are the latest law enforcement actions in the national investigation into the scheme of improper billing involving P-Stim electro-acupuncture devices. Federal healthcare programs do not reimburse for P-Stim devices, whether they are characterized as an electro-acupuncture device or as an implantable neuro-stimulator.

The four enforcement actions announced by U.S. Attorney Williams allege that certain parties sold P-Stim devices and/or promoted them as billable to Medicare and other federal healthcare programs, which then caused providers to submit fraudulent claims. The United States alleges that these promoters profited by conspiring together to make false representations to providers that P-Stim was reimbursable under billing codes that paid thousands of dollars per procedure. Those codes were meant for legitimate, surgically implanted neuro-stimulators to manage chronic pain. However, P-Stim devices can be applied in a few minutes in an office setting without anesthesia by someone with minimal training. The promoters allegedly had knowledge that the P-Stim devices were not reimbursable by federal healthcare programs but pushed the non-surgical devices anyway.

“CMS is dedicated to removing fraudulent actors and protecting the people who rely on our programs,” said CMS Administrator Chiquita Brooks-LaSure. “We thank our partners at the Department of Justice and Department of Health and Human Services Office of Inspector General for collaborating with us to identify, investigate, and eliminate waste, fraud, and abuse in our federal health care programs.”

CMS aggressively investigates providers and suppliers to ensure appropriate payments are billed to federal healthcare programs, including through the use of data-analytic investigative tools. The U.S. Attorney’s Office for the Eastern District of Pennsylvania and other law enforcement partners have pursued and settled various False Claims Act cases against P-Stim providers and suppliers, recovering millions. Including the three settlements, the national P-Stim initiative has so far produced over 15 False Claims Act settlements across the country worth approximately $15 million. Additionally, outside of DOJ litigation, there are administrative enforcement actions by other federal agencies as well. In particular, CMS, through its Program Integrity Contractors, is auditing and recovering improperly paid P-Stim claims. HHS-OIG is also pursuing civil money penalties and exclusion remedies.

 
Image Depicting Fraud Takedown
DOJ Charges 138 in $1.4 Billion Health Care Fraud Enforcement Action

On Sept. 17, 2021, the Department of Justice announced criminal charges against 138 defendants in 31 federal districts across the U.S. The defendants were doctors, nurses, and other licensed medical professionals who allegedly participated in health care fraud schemes resulting in more than $1.4 billion in losses.

The charges include approximately $1.1 billion in telemedicine fraud, $29 million in COVID-19 health care fraud, $133 million in fraud arising from substance abuse treatment facilities (“sober homes”), and $160 million from illegal opioid distribution and other health care fraud schemes across the nation.

“Every dollar saved is critical to the sustainability of our Medicare programs and meeting the needs of seniors and people with disabilities,” said Chiquita Brooks-LaSure, Centers for Medicare & Medicaid Services (CMS) administrator. “CMS has taken actions against 28 providers on behalf of people with Medicare coverage and to protect the Medicare Trust Fund. Actions like this to combat fraud, waste, and abuse in our federal programs would not be possible without the successful partnership of the Centers for Medicare & Medicaid Services, the Department of Justice, and the U.S. Department of Health and Human Services Office of Inspector General.”

Read the DOJ press release.

 
Image Depicting the Open Payments Video
Open Payments – New Feature Video

Open Payments has released a new, short video to show how Open Payments works, what’s in the data, and how to use the search tool.

Open Payments is a national disclosure program that promotes a transparent and accountable health care system by making the financial relationships between the health care industry and health care providers available to the public. To date the Open Payments data houses more than 76 million records accounting for $53.01 billion of payments or transfers of value.

Check out the video to learn more!

 
Annual Wellness Visit
Coverage of an Annual Wellness Visit

This video was created to emphasize the differences between an Initial Preventive Physical Examination (IPPE), Routine Physical Exam (RPE), and Annual Wellness Visit (AWV). The video provides health care professionals with guidance to understand expectations and requirements when submitting documentation for Annual Wellness Visits (AWV) for Medicare beneficiaries.

Watch the video.

For more information about health risk assessments, coding, diagnosis, billing, and initial and subsequent components of an Annual Wellness Visit, visit the MLN Matters booklet Annual Wellness Visit, on the CMS website. This article can be found at MLN Matters® booklet (PDF).

 
 

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Page Last Modified:
05/05/2022 08:42 AM