DOJ targets managed care and nursing homes

The U.S. Department of Justice’s (DOJ) anti-fraud agenda will largely be driven by whistleblowers, DOJ’s Special Counsel for Health Care Fraud, John Bentivoglio, reported at the national Health Care Compliance Association conference in Washington, DC, on March 9.

Bentivoglio cited three DOJ priorities in the health care arena — managed care, nursing homes, and prescription drugs.

Here is a rundown of DOJ’s new enforcement agenda for these areas:

I. Managed care. According to Bentivoglio, the growing trend toward Medicare managed care means more anti-fraud enforcement activity in that area. He says most current investigations in this area involve straightforward fraud, such as kickbacks and false cost reports. But he adds that a handful of investigations are also under way into a knowing failure to deliver promised health care services.

II. Nursing homes. Bentivoglio credits the October 1998 meeting between DOJ, the Department of Health and Human Services’ Office of Inspector General (OIG) and state enforcement authorities with bringing federal and state oversight and survey bodies into the nursing home investigative process. Several regional meetings have "done wonders" in uncovering conduct that in some cases is "truly horrific," he says.

Note: The OIG is set to release the final nursing home compliance plan later today. Look for analysis in the next issue of Compliance Hotline.

III. Pharmaceuticals. The latest target of government anti-fraud efforts in health care is no doubt pharmaceuticals, according to Bentivoglio. He said this area of growing concern ranges from "pill mills" to far more sophisticated scams. Bentivoglio said specific targets include substitution scams, automatic and partial refills, and failure to disclose rebates.