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3 important things to know about healthcare kickback cases

The feds are aggressive in their pursuit and prosecution of Anti-Kickback Statute (AKS) violations. Recently, the Department of Justice (DOJ) prosecuted three pharmacy owners for their alleged role in a healthcare scheme that led to unnecessary prescriptions for expensive compound medications. In another example, prosecutors accused six pharmacy owners from Texas of bilking the government of over $14 million through AKS violations.

These examples are just a few of the many cases the government pursued this past year and will likely be similar to those it pursues in 2021. Healthcare leaders can mitigate the risk of similar allegations by keeping the following in mind:

  • Workers can file a claim. The government allows qui tam lawsuits for these types of cases. These whistleblower suits incentivize disgruntled employees to file a claim in the hopes of getting a portion of any winnings or future settlement agreements. As such, it is important to make sure those within the organization are following the rules to help mitigate the risk a worker will find some evidence of wrongdoing.
  • Medical necessity is important. Make sure any service or product is medically necessary. A large portion of these claims hinge on the argument that the patient either never received the product or service or, if they did receive it, did not need it.
  • You are being watched. The government is keeping an eye on claims and has software checking for any outliers. These will result in red flags and additional questions.

In addition to these tips, you can further mitigate the risk of a violation by reviewing collaborative efforts with other healthcare providers before making the agreement official.