In 2023, the Department of Justice (DOJ) kept a close watch on healthcare fraud and abuse. According to DOJ reports, $2.68 billion was paid in settlements or penalties under the False Claims Act in fiscal year 2023. About $1.8 billion, or 67%, came from healthcare cases. This is a little less than past years when healthcare made up 90% of such payments in 2021 and 80% in 2022.<\/p>\n
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Even with fewer payments overall, enforcement is still active. There were 348 healthcare FCA cases filed by whistleblowers and 94 filed directly by the government. That means about eight to nine new cases appeared each week. The problems being looked into mostly involved wrong financial deals, false billing, and other fraud.<\/p>\n
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Labs:<\/strong> Laboratories were often checked, especially if they billed for tests that were not needed. Some labs billed for respiratory-pathogen panel tests that doctors did not order. The DOJ took both civil and criminal actions against labs involved in these billing problems.<\/p>\n<\/li>\n <\/p>\n Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Providers:<\/strong> These suppliers were watched closely for giving kickbacks linked to prescriptions and referrals. They were often accused of paying doctors or others to get patient referrals or of pushing equipment use when it was not needed.<\/p>\n<\/li>\n <\/p>\n Telemedicine Providers:<\/strong> With telehealth growing, regulators increased oversight of these companies. Enforcement actions often involved billing for services that did not happen, enrolling patients who did not need to be enrolled, and not following coding rules. Some telehealth companies had to pay settlements for billing unnecessary evaluation and management services.<\/p>\n<\/li>\n <\/p>\n Mobile Cardiac PET Companies and Specialty Medical Practices:<\/strong> For example, one mobile cardiac PET company agreed to pay $85.48 million after claims that it paid doctors more than fair value to get referrals. A dermatology management company paid $8.9 million for inflating purchase prices to gain patient referrals. Both cases involved violations of the Anti-Kickback Statute and Stark Law.<\/p>\n<\/li>\n<\/ul>\n The False Claims Act is a strong law used against healthcare fraud. It holds people responsible if they knowingly submit false claims to programs like Medicare and Medicaid. The penalties can be three times the damages plus other fines.<\/p>\n <\/p>\n Common violations include billing for services not given, unnecessary services, or services that are not documented properly. For example, some hospitals billed for surgeries that overlapped in time even though medical rules did not allow it.<\/p>\n The Anti-Kickback Statute bans giving or receiving anything valuable to get patient referrals from federal healthcare programs. In 2023, many cases involved paying doctors to refer patients improperly. Companies that had unfair payment setups faced big settlements.<\/p>\n <\/p>\n For example, the dermatology and cardiac PET company cases showed they paid more than fair price to encourage referrals, which led to large penalties.<\/p>\n The Stark Law stops doctors from sending patients to certain services paid by Medicare or Medicaid if they, or family members, have financial ties to the business unless exceptions apply.<\/p>\n <\/p>\n In 2023, enforcement looked at payments that were too high or linked to how many referrals a doctor made. One case led to a $345 million settlement, the largest so far. Healthcare providers also reported problems themselves to reduce penalties.<\/p>\n The DOJ and OIG have shown more concern about the role of third parties in healthcare fraud. This includes private equity firms, electronic health record (EHR) software makers, coding consultants, and billing companies. These groups can affect patient care and federal healthcare expenses a lot.<\/p>\n <\/p>\n According to Brian Boynton from the DOJ, oversight is growing beyond regular healthcare providers to include these outside partners. For example, a billing company paid over $300,000 for faulty claims involving respiratory-pathogen panel tests.<\/p>\n <\/p>\n New companies in healthcare, such as tech firms and investors, are advised to create strong compliance plans because they are at higher risk of FCA investigations.<\/p>\n <\/p>\nLegal Risks Related to Key Healthcare Compliance Laws<\/h2>\n
False Claims Act (FCA)<\/h2>\n
Anti-Kickback Statute (AKS)<\/h2>\n
Stark Law<\/h2>\n
Renewed Focus on Third Parties and New Market Entrants<\/h2>\n