The government incentivizes whistleblowers in order to increase healthcare recoveries under the False Claims Act.  See our analysis here of how the Act’s qui tam provisions work by Colin Jennings, Marisa Darden, and Ayako Hobbs.  …

Once again, healthcare leads other industries for recoveries by the government and whistleblowers under the False Claims Act.  Enforcement actions span the entire health care supply chain.  See our report here in the Anticorruption blog.…

CMS said it plans to audit risk-adjustment payments that Medicare Advantage (MA) plans received based on having identified additional diagnoses in beneficiary medical chart reviews. CMS’s action was spurred by a recent report from the HHS Office of Inspector General (OIG) entitled, “Billions in Estimated Medicare Advantage Payments From Chart Reviews Raise Concerns.” (Click here for the report). As the OIG’s report explains, MA insurers receive risk-adjustment payments, based in part on diagnoses, to account…

Recent years have seen significant vertical integration in the healthcare space, whether megamergers such as CVS-Aetna and Cigna-Express Scripts, or the numerous hospital and health system acquisitions of physician groups and other non-hospital healthcare providers. These vertical mergers—combining assets that are used at different levels of the supply chain—have largely escaped significant antitrust scrutiny since they do not reduce the number of competitors in the market and often have pro-competitive justifications that would result in…

 Suspicious of the practices of one of its cardiologists, a hospital hired an independent expert to investigate. The expert examined records of 12 patients but “could not find support in any of the twelve cases” to implant pacemakers. The hospital terminated the doctor, and the government indicted him for health care fraud. During trial the government deployed an array of evidence including data mining, expert testimony, and evidence of an expensive lifestyle.  A report of the decision upholding conviction…

In a unanimous decision, the United States Court of Appeals for the Tenth Circuit reversed a district court decision holding that HHS’ use of the statewide premium average to calculate Affordable Care Act (ACA) risk adjustment charges and payments from 2014 to 2018 was arbitrary and capricious.  See N.M. Health Connections v. U.S. Dep’t of Health & Human Servs., Case No. 18-2186, 2019 U.S. App. LEXIS 38739 (10th Cir. Dec. 31, 2019).  New Mexico…

The Sixth Circuit has joined other circuits in unanimously holding that HIPAA creates no private right of action. That was the easy part. The panel divided 2-1 in ruling that a Tennessee statute likewise provides no remedy for patients allegedly overcharged by Ciox, a medical-records company. But Faber v. Ciox Health wasn’t a complete blowout: the court flagged Ciox’s attempt to spike the football by requiring a remand for classwide notice that…the class members lost.…