Health care fraud is big business. As much as $100 billion is siphoned out of the system by fraudsters each year, with Uncle Sam the single largest victim. Federal investigators and prosecutors have prioritized health care cases for years, and that effort will only intensify as the Patient Protection and Affordable Care Act (PPACA) phases in over the next few years.
The sprawling PPACA, the health care reform law President Obama signed in March, significantly expands criminal liability and increases key health care fraud sentencing guidelines by 20 to 50 percent. Companies are scrambling to assimilate the changes.
"That, in practical effect, allows more people to bring more cases," Vernaglia says. "It will also, we believe, create a whole new industry of lawyers and other consultants who will mine data, which is public and previously excluded under the public disclosure bar, in order to try to build a False Claims Act case."
The new provisions also make the prompt return of overpayments--previously something of a gray area--absolutely mandatory.
In addition to civil penalties for errors in required reporting, there will be criminal penalties if a provider intentionally makes false statements. But the more troubling aspect for companies is the new data category it hands to investigators.
"It opens up a whole new avenue," Adelman says. "It could possibly be a springboard for investigations under the False Claims Act and other traditional health care fraud investigations."