“The Department of Justice’s enforcement focus on the healthcare industry has been consistently intense over the last 20 years, though the specific areas of scrutiny shift and evolve.”
“In the last five years, the DOJ has invested significantly in investigating and pursuing potential fraud by providers and plans that provide services under the Medicare Advantage (MA) program. In particular, those matters which are public center on the submission of allegedly unsupported diagnosis codes to inflate reimbursements and the retention of resulting overpayments.”
“While the department has experienced judicial setbacks to these enforcement efforts, providers and plans that operate in the MA space continue to face significant potential exposure…”
“While this decision is under appeal, at least one other court has relied on the reasoning in denying a motion for summary judgment by the DOJ on the question of whether a plan is obligated by contract or regulation to identify and delete unsupported diagnosis codes…” Read the full article here.
Source: Industry Voices—A look at DOJ fraud enforcement efforts in the Medicare Advantage space – By Jaime L.M. Jones, Jennifer M. Haney, May 20, 2019. FierceHealthcare.