Naples Quoted on DOJ Health Fraud Enforcement

Pat said that using data-driven enforcement tools have actually been standard for more than a decade. With claims data mining having been added to federal regulation as a potential basis for fraud allegations in 2011, the recent action is “really the continuation of a trend that’s been in place for a number of years, and we’ve seen it across administrations.”

Pat added that while preparing for enforcement actions, the DOJ tends to look for “large outliers in the data set,” rather than a single odd claim. The distinction matters because a credible allegation of fraud is the threshold CMS must clear to suspend a practice’s payments. A physician whose payments are withheld “can submit a written rebuttal statement,” Pat said.

For independent practices, Pat said that the most practical step is straightforward. 

“Check your own data and be on top of it and be monitoring it,” he said, so a practice can catch problems early and, if necessary, take advantage of voluntary self-disclosure, which the department’s policies reward with reduced penalties.

Pat noted that the effects of the DOJ’s policies will be felt by practices, even if they are not targets. He added that the current policies are not solely a function of the current Administration. 

“This is something that’s not going away,” he said.

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