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Health care fraud in 2020: What will the feds investigate?

The United States Department of Justice (DOJ) recently announced the recovery of over $3 billion in False Claims Act (FCA) violations for health care fraud cases last year. Although this seems like a large number, it is in line with previous years. In fact, this is the tenth year in a row the agency reports recovering more than $2 billion from its work pursuing these cases.

Why is this such a steady area of recovery?

The DOJ notes its efforts “substantially strengthened” in 1986 after lawmakers allowed whistleblowers a larger portion of winnings if a claim proved successful. Today, these whistleblower cases make up a significant percentage of FCA cases.

What type of recovery was common in 2019?

Top areas of recovery during 2019 included:

  • Opioid misuse. The agency states one of the largest recoveries from 2019 came from a case against an opioid manufacturer for the use of illegal kickbacks to medical professionals. In exchange for cash payments and other benefits, physicians and nurse practitioners would prescribe the manufacturer’s opioid painkiller instead of other, less addictive options.
  • False marketing. Another case involved a drug manufacturer who made false claims about a medication’s ability to treat dementia, which is not an approved use of the medication.
  • Technology programs. The agency also notes a substantial recovery from a company who paid kickbacks to physicians who referred others to use its electronic health records systems.

These are just a few examples of recoveries from larger companies. The agency also recovered millions from individual executives, physicians and other professionals accused of FCA violations.

What does this mean for 2020?

The agency will likely continue its efforts to investigate, litigate and take FCA violation cases for similar matters as noted above to trial in 2020. As such, those who are accused of FCA violations are wise to take the matter seriously.