New England Journal of Medicine Advocated for Stronger Whistle-Blower Protections

The May 13, 2010 issue of the the NEJM included an article written by physicians and public policy experts which illuminated the experiences of whistle-blowers who uncovered wrong-doing primarily by the pharmaceutical industry. The authors dubunked a commonly held myth that whistle-blowers are in it for the money, and that their "frivolous" lawsuits are lottery-like windfalls. In reality, many whistle-blowers actually come forward at personal cost and would have earned more over time had they remained silent.

The intent of the study was to obtain empirical data on the experience of whistle-blowers and through such, they hope to provide policy makers with content to create more informed health policy. No myths- just the facts.

Needed Tools for Combating Fraud

In addition to other new tools and strategies for attacking evolving healthcare fraud schemes, Lew Morris, Chief Counsel at the Office of Inspector General- Health and Human Services, is seeking statutory authority to remove corporate executives from Medicare for fraud.

http://oig.hhs.gov/testimony/docs/2010/morris_testimony61410.pdf

KPR Reports KS Lawmakers struggling to cover $500 million deficit-

Kansas Public Radio
Controlling Costs In Medicaid Date: May 10, 2010

Kansas lawmakers are struggling to cover a 500-million dollar budget deficit. One of the largest—and fastest growing—programs in state government is Medicaid. But as lawmakers look for ways to rein in the cost of that program, they’re finding it’s not so easy to do. As part of our series, “Kansas Health: A Prescription for Change”, Health Reporter Bryan Thompson has more on the struggles that lie ahead.

DoJ Recovers Over $5 billion But Announces Just $2.4 Billion in "Official" FCA Recoveries

DoJ Recovers Over $5 billion But Announces Just $2.4 Billion in "Official" FCA Recoveries

Fiscal Year 2009 has been a record year in False Claims Act recoveries, with well over $5.6 billion in overall recoveries announced. So why do "official" DoJ numbers show only $2.4 billion in False Claims Act recoveries? Simple: The U.S. Department of Justice does not count criminal recoveries (in the Pfizer matter alone, this was $1 billion), nor do they count money disbursed to the states in settlements (about 45% of all money collected in Medicaid cases), nor do they count money not actually collected this Fiscal Year. Bottom line: Total "official" False Claims Act recoveries in 2009 were $2.4 billion, though more than $5 billion in False Claims Act case recoveries were announced by Uncle Sam and the States.

Department of Justice, HHS Boosts Number of Investigators, Prosecutors Looking at Medicare, Medicaid Fraud

HHS and the Department of Justice on Wednesday launched the Health Care Fraud Prevention and Enforcement Action Team to detect and prevent fraud in Medicare and Medicaid, the Washington Post reports (Johnson, Washington Post, 5/21). DOJ also plans to establish teams to address fraud in the Medicare Part D program and CHIP (Kennedy, AP/Houston Chronicle, 5/20). Wednesday's announcement also included a recommendation by President Obama's administration to include $311 million in the fiscal year 2010 budget to address health care fraud, which is a 50% increase from FY 2009. According to Attorney General Eric Holder, efforts to combat health care fraud will contribute to the administration's health care overhaul plans (Clark/Weaver, McClatchy/Kansas City Star, 5/20).

The task force, which will include HHS and DOJ staff members, law enforcement agents and prosecutors, will meet biweekly, CQ HealthBeat reports (Norman, CQ HealthBeat, 5/20). Under the plan, existing enforcement teams in Miami and Los Angeles will be expanded and new teams will be established in Houston and Detroit, where officials say suspicious billing patterns have emerged. In addition, the plan will set up task forces in 10 other major cities, which were not named (AP/Houston Chronicle, 5/20). The enforcement teams will increase site visits to durable medical equipment suppliers upon their enrollment. In addition, officials will expand training to help providers identify and prevent fraud or other mistakes (CQ HealthBeat, 5/20). The task force will use electronic claims data to detect "unusual billing problems," according to the Post (Washington Post, 5/21). HHS Secretary Kathleen Sebelius said the task force also intends to simplify billing systems and assist state officials in conducting Medicaid audits (CQ HealthBeat, 5/20). According to Holder, the joint task force will allow officials to share real-time intelligence data on health care fraud by monitoring claims payments, billing patterns and targeted surveillance (AP/Houston Chronicle, 5/20).

Health Care Fraud Costs U.S. Taxpayers at Least $60 Billion Annually

According to the Miami Herald, health care fraud costs U.S. taxpayers at least $60 billion annually (Clark/Weaver, Miami Herald, 5/20). In the past, the largest sums recovered by the federal government have resulted from DOJ interventions in lawsuits against pharmaceutical companies filed under the False Claims Act. According to attorneys involved with the cases, such settlements are likely to reach record highs in FY 2009 (Washington Post, 5/21). In southern Florida, a task force created in 2007 helped convict 146 defendants and generated $186 million in fines and penalties. In addition, a Los Angeles team established in 2008 charged 37 defendants and generated $55 million for Medicare (CQ HealthBeat, 5/20).

Tony West, head of DOJ's Civil Division, said, "There is an incredible amount of money that can be recovered and returned to the health care trust fund, and that has a real impact" (Washington Post, 5/21). Sebelius said, "For every dollar we invest in fraud prevention and oversight, at least $1.55 comes back for the taxpayer" (CQ HealthBeat, 5/20). West added that health care has the "biggest single impact on the budget," and that pursuing health care fraud cases and recouping losses are "consistent with the president's agenda on health care reform" (Washington Post, 5/21).

Payment Errors Continue to Plague Medicare Program

Payment Errors Continue to Plague Medicare Program
Associated Press
Matthew Perrone