Health Cos. Can Reduce FCA Risk by Leveraging Data
Instead of relying solely on whistleblowers to trigger False Claims Act (FCA) investigations, the US Department of Justice (DOJ) has started running its own data analytics to identify potential fraud, resulting in a higher number of DOJ-initiated FCA suits in 2020. In a Law360 article, Analysis Group Managing Principals Paul E. Greenberg and Mihran Yenikomshian, writing with Sidley Austin LLP partner Brenna Jenny, encourage health care systems to proactively comb their own data for potential issues and manage them before the DOJ gets involved.
In “Health Cos. Can Reduce FCA Risk by Leveraging Data,” the authors point out that temporary billing flexibilities allowed due to the COVID-19 pandemic can make it more difficult to distinguish deviations from prior trends that may draw the DOJ’s attention. For example, the pandemic shift to telehealth would reasonably have changed a provider’s proportion of telehealth to office visits. However, an accompanying increase in the overall number of appointments billed could warrant a further audit. The authors emphasize the importance of choosing the most relevant datasets, such as those already related to government programs such as Medicare, and benchmarking findings against peer providers using publicly available data.