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There’s been distinct shift in healthcare fraud enforcement over the last seven years thanks to the Affordable Care Act, coordinated federal takedowns and a renewed emphasis on prosecuting executives who oversee fraud schemes.
Federal enforcement officials are investigating healthcare fraud more forcefully thanks to the Obama administration’s reliance on Medicare Fraud Strike Force teams and new data analytics that can home in on emerging schemes, according to The Fiscal Times. Earlier this year, a coordinated nationwide takedown led to the arrest of more than 300 individuals involved in various schemes totaling more than $900 million.
New ACA rules have also injected more funding into antifraud efforts, implemented stricter repayment rules and offered more protections to whistleblowers, which make up the majority of healthcare fraud referrals.
Following the release of the Yates memo last year, federal prosecutors have focused more intently on individual accountability. Venson Wallin, the managing director of the healthcare advisory practice at BDO, an international consulting company, told Becker’s Hospital Review that federal prosecutors are far more willing to pursue individuals who personally benefit from a scheme, a notable departure from previous years in which fraud settlements created a “buffer between the corporation and the individuals that worked for said corporation.”
In the wake of the Yates memo, Wallin expects to see more individuals cooperate with investigations or blow the whistle rather than risk liability.
Gejaa Gobena, a partner at Hogan Lovells and the former deputy chief of the fraud section of the Department of Justice’s criminal division, has previously told FierceHealthPayer: Antifraud that the Yates memo emphasizes the need for proactive cooperation during an investigation, and highlighted the way data has “revolutionized” fraud enforcement activities. Although prosecutors have tested the waters of the Yates memo, recent cases have shown how difficult it may be to litigate individual accountability.