The Department of Justice’s new “West Coast” strike force targets Arizona, Nevada and Northern California — regions flagged for rising Medicaid, hospice and tech-enabled fraud risks. Legal experts say the effort signals a broader shift toward data-driven enforcement, as regulators ramp up their scrutiny of telehealth companies and billing automation software.
At the Medicarians Conference, Ricardo Carcas, assistant special agent in charge of the Office of Investigations, discussed cases of fraud in the ACA and how the DOJ is combatting it.
By reducing administrative burden and redesigning workflows around human needs, it creates space for what matters most: connection between clinicians and patients.
The Department of Justice filed an antitrust lawsuit against NewYork-Presbyterian, alleging the hospital used “all-or-nothing” contracts that blocked lower-cost plans and limited competition. The case comes just five weeks after the Justice Department filed a similar lawsuit against OhioHealth.
The Department of Justice has reached a proposed settlement with UnitedHealth Group and Amedisys regarding UnitedHealth’s acquisition of the home health provider, which includes the divestiture of 164 home health and hospice locations.
The Department of Justice has filed a complaint against Aetna, Elevance Health, Humana, eHealth, GoHealth, and SelectQuote, alleging that the insurers paid illegal kickbacks to brokers to boost enrollment in their Medicare Advantage plans.
Experts aren’t sure what the outcome of the DOJ’s recent lawsuit against the proposed UnitedHealth Group/Amedisys merger will be under the incoming Trump administration. The Biden administration has focused more on supporting clinicians, while the previous Trump administration favored corporations. Additionally, one expert noted that this case differs from other antitrust lawsuits because it does not seem to focus on a potential price increase.
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The U.S. Department of Justice recently launched a task force on healthcare monopolies. Experts have varying opinions on how it will impact the healthcare industry.
Generic drugmakers Teva and Glenmark recently became the sixth and seventh drugmakers to resolve criminal charges as a result of the DOJ’s yearslong investigation into generic drug price fixing. The settlement agreement requires both companies to pay hefty fines as well as divest their drug lines for pravastatin, a widely used statin that lowers cholesterol.
Covid-19 may have hampered investigations and led authorities to shift resources to more obvious frauds, attorneys said. But the pandemic also created new targets to investigate, including telemedicine and CARES Act funding.
In addition to monetary damages and the guilty pleas, the government is seeking to transform the maker of OxyContin into a public benefit company that would fund efforts to curb opioid abuse and give away drugs to prevent overdose deaths.
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After an eight-week trial, Philip Esformes was found guilty for his role in a fraud scheme that involved more than $1.3 billion in fraudulent claims to Medicare and Medicaid for services that weren't provided, weren't medically necessary or were procured through the payment of kickbacks.
The indictment alleges that as part of the scheme, which ran from June 2015 to April 2018, the defendants submitted no less than $931 million in fraudulent claims for payment.
eClinicalWorks and some of its employees will pay $155 million to settle claims that the EHR vendor misrepresented the capabilities of its software and paid kickbacks to certain customers in exchange for promoting its product.
There's been a new development in the Anthem-Cigna merger saga: On Friday, a U.S. appeals court upheld a lower court's earlier decision to block the $54 billion deal.
Mylan settled with the U.S. Department of Justice to head off potential Medicaid liability claims by federal and state governments.