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Healthcare Fraud? The DOJ is Watching

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Healthcare Fraud? The DOJ is Watching

If you’re a healthcare provider operating in the US, it’s time to sit up and take notice: the US government is ready and willing to take on healthcare fraud in a big way, and it’s your bottom line that they could be after.

The US Department of Justice and the US Department of Health and Human Services have aligned themselves under the False Claims Act and the recent health care laws to take in $4.1 billion as a result of fraud convictions against companies willing to risk our health. And, whistleblower claims resulted in more than half of those penalties, even though the perception is that the current administration is against whistleblowers, according to a pair of articles in USAToday (“Whistle-blowers key in health care fraud fight” and “Fight against health care fraud recovers $4.1B”).

And the DoJ and HHS are looking to increase their resources. Their collective take has risen to $7 in penalty revenue for every dollar they spend to fight fraud.

All this is of course good news for the public, both in terms of curtailing health care costs and reducing corporate fraud in general. For healthcare companies, the news is mixed. It’s good news if you run an ethical shop, because your less-than-ethical competition may get slapped with huge fines when you won’t. If you’re the company whose ethics are sketchy, watch out.

Here are three steps I would suggest to get on or stay on the anti-fraud bandwagon. One, review your code of conduct and make sure that it addresses areas where fraud could occur. Two, put that code at the very top of your corporate policies and get those policies into the hands of those who deal with the areas most susceptible to fraud. And three, train your workforce, so that they know what fraud is and how to avoid it, and also how to report fraud when they see it. In all of these steps, it’s essential to make sure the Board is also properly trained on ethics and policies. It’s got to start from the top and they need to walk the walk, along with talking the talk.

I would also add escalation and follow-up are important here, too. When a fraud charge is made, make sure it follows proper procedure to get it into the hands of the appropriate authority. Then keep your employees in the loop so they retain confidence in your efforts and your anti-fraud programs.

About the Author

Jimmy Lin, VP, Product Management & Corporate Development. Jimmy leads corporate and product strategies for The Network’s Integrated GRC Solutions. He has over 14 years experience in and around software and technology, from implementing software to analyzing new markets and leading product strategies. Jimmy is a Certified GRC Professional (GRCP). Connect with Jimmy on LinkedIn

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