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The Compliance Landscape: What’s at Stake

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The Current Climate

The government’s health care fraud prevention and enforcement efforts recovered a record-breaking $4.3 billion in FY 2013 and $19.2 billion over the last five years, up from $9.4 billion over the prior five-year period. The latest Health Care Fraud and Abuse Control (HCFAC) Program reports for every dollar spent on health care-related fraud and abuse investigations through this and other programs in the last three years, the government recovered $8.10.  This is the highest three-year average ROI in the program’s 17-year history.

The Risks

Financial – Fines; Loss of revenue
Regulatory – Criminal charges; Exclusion from federal programs
Reputation – Loss of trust; loss of good faith

The Penalties

False Claims – Act Up to 3X the programs’ loss plus $11,000/claim
Anti-Kickback Statute – Criminal fines, jail time and/or exclusion from Federal programs
Stark – Potential for exclusion; potential false claims liability; civil monetary penalties of $15,000 for knowingly presenting or causing another to present an improper claim, and up to $100,000 for scheming to circumvent the regulations
Civil Monetary Penalties Law – The Office of the Inspector General seeks civil monetary penalties for Anti-Kickback and Stark violations, and false or fraudulent claims