Navigating Healthcare Enforcement: Key Insights and Trends You Need to Know | JD Supra

There’s a lot happening in healthcare enforcement today. While some things have changed, many remain the same, according to Greg Demske, a partner at Goodwin Proctor and former Chief Counsel at HHS.

The US Department of Justice (DOJ) is adjusting its focus on issues like anti-corruption. However, they, along with the Office of Inspector General (OIG) at Health and Human Services, are still dedicated to fighting fraud in healthcare. This bipartisan effort has a long history and continues to evolve.

One notable shift is at the Centers for Medicare & Medicaid Services (CMS). Previously, they audited about fifty Medicare Advantage plans each year. Now, they aim to audit all roughly six hundred plans annually. To support this, the number of coders has increased dramatically from 40 to 2,000. This change is significant for both plans and healthcare providers.

The DOJ and HHS have also teamed up to create a False Claims Act working group. This initiative is part of their broader strategy to enhance enforcement. Qui tam claims, which allow individuals to sue on behalf of the government, reached a record high in 2024. This reflects a growing awareness and vigilance regarding healthcare fraud.

So, what does this mean for compliance teams? Demske advises them to closely monitor government messaging. This will help ensure that their programs stay proactive and responsive to the evolving landscape.

Recent statistics show that healthcare fraud is a pressing concern. A 2022 report by the federal government estimated that healthcare fraud costs the US around $100 billion annually. This alarming number highlights the need for robust enforcement strategies.

In the world of social media, conversations about healthcare fraud have gained traction. Platforms like Twitter and LinkedIn are buzzing with discussions about transparency and accountability in healthcare. Users are calling for stricter regulations and real-time reporting to curb fraudulent activities.

By staying informed and adapting to these changes, compliance teams can better navigate the complex world of healthcare enforcement. For more insights, you can check out Greg Demske’s experiences and advice.

For additional details, here’s a link to a 2023 DOJ report on healthcare fraud.

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