We have previously discussed the California Insurance Frauds Prevention Act (IFPA)–a state antifraud statute that, while modeled on the False Claims Act (FCA), is unique in targeting fraud in the commercial health insurance...more
On April 4, the Centers for Medicare & Medicaid Services (CMS) issued the Contract Year (CY) 2025 Medicare Advantage (MA) Final Rule (Final Rule), which will have significant implications for MA plans and other industry...more
4/16/2024
/ Agents ,
Anti-Competitive ,
Beneficiaries ,
Brokers ,
Centers for Medicare & Medicaid Services (CMS) ,
Equity ,
Final Rules ,
Healthcare ,
Marketing ,
MCOs ,
Medicaid ,
Medicare Advantage ,
Medicare Part D ,
Mental Health ,
Shareholders ,
Third-Party Service Provider
We are pleased to bring you our 12th annual Healthcare Fraud & Abuse Review. Our Review provides comprehensive coverage of the most significant civil and criminal enforcement issues facing healthcare providers. Each year, we...more
2/27/2024
/ Anti-Kickback Statute ,
CARES Act ,
Coronavirus/COVID-19 ,
Department of Justice (DOJ) ,
Enforcement Actions ,
False Claims Act (FCA) ,
Fraud and Abuse ,
Health Care Providers ,
Healthcare ,
Healthcare Fraud ,
Kickbacks ,
Medical Devices ,
Pharmaceutical Industry ,
Physicians ,
Prescription Drugs ,
Qui Tam ,
Settlement ,
Stark Law ,
Telemedicine
Two recent opinions released by the Department of Justice (DOJ) serve as a reminder that even under the strictly enforced Foreign Corrupt Practices Act (FCPA), payments to government officials are permissible in certain...more
Last week, the U.S. Department of Justice (DOJ) announced a $22.4 million settlement resolving allegations that Martin’s Point Health Care, Inc. (Martin’s Point) violated the False Claims Act (FCA) by submitting inaccurate...more
On February 1, the Centers for Medicare & Medicaid Services (CMS) published the Medicare Advantage (MA) Risk Adjustment Data Validation (RADV) Program Final Rule (Final Rule), which will take effect on April 3, 2023. The...more
In the past several years there has been a significant decrease in Foreign Corrupt Practices Act (FCPA) enforcement efforts. Reports suggest that corporate criminal cases have decreased by roughly 50% since 2012. FCPA...more
12/22/2022
/ Anti-Bribery ,
Books & Records ,
Corporate Crimes ,
Corporate Governance ,
Criminal Investigations ,
Criminal Penalties ,
Department of Justice (DOJ) ,
Enforcement ,
Foreign Corrupt Practices Act (FCPA) ,
Fraud ,
Popular ,
Securities and Exchange Commission (SEC) ,
Settlement ,
Third-Party Risk
On December 14, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule that contemplates several changes to, and clarifications of, guidance for the Medicare Advantage (MA) program in coverage year 2024....more
12/21/2022
/ Centers for Medicare & Medicaid Services (CMS) ,
Comment Period ,
Department of Health and Human Services (HHS) ,
Equity ,
Health Care Providers ,
Marketing ,
Medicare ,
Medicare Advantage ,
Medicare Part A ,
Medicare Part B ,
Medicare Part C ,
Medicare Part D ,
Notice Requirements ,
Overpayment ,
Proposed Rules ,
Star Ratings ,
Termination Clauses ,
Translations ,
Utilization Review
On November 14, Judge Edward Chen in the Northern District of California issued rulings on the pending motions to dismiss in U.S. ex rel. Osinek v. Kaiser Permanente, granting in part and denying in part Kaiser’s motion to...more
In a decision issued on September 30, Judge Andrew Carter of the U.S. District Court for the Southern District of New York denied Anthem Inc.’s motion to dismiss a government lawsuit filed in March 2020 claiming Anthem...more
10/7/2022
/ Anthem Insurance ,
Dismissals ,
Failure to Comply ,
False Claims Act (FCA) ,
Insurance Litigation ,
Kaiser Permanente ,
Medical Billing Codes ,
Medicare Advantage ,
Medicare Part C ,
New York ,
Overpayment
In a September 2022 filing in U.S. ex rel. Osinek v. Kaiser Permanente, the Kaiser Permanente consortium defendants (Kaiser) highlighted the distinction between clinically inaccurate diagnoses (factual falsity) and clinically...more
10/7/2022
/ Clinical Evaluations ,
Enforcement ,
False Claims Act (FCA) ,
Health Care Providers ,
Kaiser Permanente ,
Managed Service Providers (MSPs) ,
Medical Billing Codes ,
Medicare Advantage ,
Objective Falsity ,
Physicians ,
Qui Tam ,
Regulatory Oversight
Since late March, the U.S. government has announced several significant enforcement actions under the Foreign Corrupt Practices Act (FCPA), the main U.S. law that prohibits bribery of non-U.S. government officials....more
There have been a relatively limited number of U.S. Foreign Corrupt Practices Act (FCPA) enforcement actions in recent years. Nonetheless, two recent announcements (one resolution, one declination) by U.S. regulators...more
Ensuring compliance with the False Claims Act has never been more important for healthcare providers. By March 2020, we saw healthcare professionals standing at the forefront of one of the greatest health crises in a...more
2/4/2021
/ Annual Reports ,
Anti-Kickback Statute ,
CARES Act ,
Coronavirus/COVID-19 ,
Criminal Investigations ,
Criminal Prosecution ,
Department of Health and Human Services (HHS) ,
Department of Justice (DOJ) ,
Enforcement Actions ,
False Claims Act (FCA) ,
Fraud and Abuse ,
Health Care Providers ,
Healthcare Facilities ,
Healthcare Fraud ,
Long Term Care Facilities ,
Medical Devices ,
Medicare ,
Medicare Advantage Organizations (MAOs) ,
Nurses ,
Nursing Homes ,
OIG ,
Opioid ,
Pharmaceutical Industry ,
Pharmacist ,
Physicians ,
Qui Tam ,
Settlement Agreements ,
Stark Law ,
Telemedicine
In recent months, the U.S. Department of Justice (DOJ) and Securities & Exchange Commission (SEC) have announced several notable penalties for violations of the U.S. Foreign Corrupt Practices Act (FCPA). The FCPA prohibits...more
1/14/2021
/ Anti-Bribery ,
Bribery ,
Compliance ,
Corruption ,
Criminal Investigations ,
Criminal Penalties ,
Criminal Prosecution ,
Department of Justice (DOJ) ,
Deutsche Bank ,
Enforcement Actions ,
Foreign Corrupt Practices Act (FCPA) ,
Penalties ,
Securities and Exchange Commission (SEC) ,
Securities Violations
Widespread testing of patients and the public for COVID-19 exposure appears to be the key to reopening society sooner rather than later. Current estimates suggest that clinical laboratories across the United States have...more
Despite the mounting pressures on healthcare entities related to the COVID-19 (coronavirus) pandemic and recent announcements of regulatory waivers and flexibility in particular areas, regulators are still showing interest in...more
The financial relief programs enacted by the Coronavirus Aid, Relief, and Economic Security (CARES) Act stand ready to provide crucial financial support to people and businesses impacted by the novel coronavirus (COVID-19)...more
As the impact of the COVID-19 pandemic continues to spread, the federal government is preparing to take unprecedented action to curb its effects on the nation’s health and economy by freeing up federal dollars for private...more
As the impact of the COVID-19 pandemic continues to spread, the federal government is preparing to take unprecedented action to curb its effects on the nation’s health and economy by freeing up federal dollars for private...more
Despite the sobering news reports on the global spread of COVID-19, companies are continuing to try to conduct operations as (relatively) normally as possible. International business is particularly affected given the...more
• A payment to a government official can take many forms.
• The SEC charges bank for books and records violation even absent a bribery charge.
• Industry-wide enforcement is a continuing tactic for U.S....more
10/24/2019
/ Accounting Controls ,
Banking Sector ,
Banks ,
Books & Records ,
Bribery ,
Enforcement Actions ,
Financial Services Industry ,
Foreign Corrupt Practices Act (FCPA) ,
Foreign Official ,
Government Officials ,
Hiring & Firing ,
Internal Controls ,
Internships ,
Quid Pro Quo ,
Securities and Exchange Commission (SEC) ,
Settlement Agreements
On March 29, 2019, the U.S. Department of Justice (DOJ) announced it had initiated the first-ever criminal prosecution of individual business executives for alleged failure to timely disclose product safety issues to federal...more
• The World Bank aggressively pursues sanctions against entities and individuals for misconduct in connection with Bank-funded projects
• Sanctions can lead to cross-debarment by other multilateral development banks and...more
In a remarkable move, the Department of Justice (DOJ) recently sought dismissal of 11 False Claims Act (FCA) cases, each of which assert that patient assistance services supplied by pharmaceutical manufacturers constitute...more