“Healthcare fraud is an issue that affects us all; it’s not just the insurance companies who are losing money due to fraud; it’s the taxpayer who ultimately foots the bill,” said John LeBlanc of Manatt. LeBlanc is a healthcare attorney whose expertise includes counseling clients on healthcare compliance and enforcement issues, including Medicare and Medicaid fraud and abuse laws and regulations.
“The numbers are staggering – every year, billions of dollars are lost due to healthcare fraud,” LeBlanc said. “The good news is, there are a lot of laws in place designed to prevent and punish those who commit healthcare fraud. In addition, the Office of Inspector General (OIG) has been working closely with federal and state law enforcement agencies and Congress to ensure that those individuals committing this type of fraud are being held accountable.
“These are exciting times for healthcare compliance,” LeBlanc said. “Look at some of the healthcare reform law changes, some of the new regulations issued by CMS, and you will see that real teeth have been put in place to go after those individuals who commit these types of crimes.”
LeBlanc went on to say, “In addition, CMS is working with law enforcement to improve the timeliness of fraud referrals from CMS to the OIG for investigation. Also, there have been many recent high profile prosecutions that show the government agencies are taking these issues seriously and will prosecute individuals who commit healthcare fraud.”
Most people believe that doctors and healthcare providers commit healthcare fraud, but this is not always the case. In addition to those filing false claims for payment, many other players in the healthcare system may be committing fraudulent activity concerning billing or making false statements on reimbursement submissions.
“It’s important to understand that healthcare fraud isn’t just the numbers game, but rather an issue that has real victims,” LeBlanc said. “Healthcare fraud puts patient lives at risk, adds unnecessary costs to our healthcare system, and diverts money away from those who need it most.”
Another way that healthcare fraud is committed by various players in the healthcare system, according to LeBlanc, is through kick-back schemes where money or benefits are paid to lure patients who may be referred for goods and services. “It’s important that those involved in the healthcare industry understand that there are laws in place that prohibit billing for unnecessary medical procedures or services that don’t meet professionally recognized standards of treatment,” LeBlanc said.
“The best way to combat healthcare fraud is for health care providers and suppliers to understand their compliance obligations, including billing rules and regulations, as well as the laws prohibiting corruption,” LeBlanc said. “It’s also crucial that those involved in the industry stay current on developments and changes that occur on an ongoing basis. It’s important to remember that even something as simple as a change in billing codes can lead to compliance and enforcement issues.”
LeBlanc went on to say, “As the adage goes, ‘Ignorance of the law is no excuse,’ which means healthcare providers, suppliers, and others involved in the industry have a responsibility to understand their compliance obligations as well as new laws and regulations. Those who don’t abide by the law simply aren’t going to be allowed to conduct business.”