Medicare Plan Sponsors Not Too Big to Fail When it Comes to Enforcement, Government Official Says


Any time you get health-care attorneys and government officials in the same room, you’re guaranteed a spirited and informative discussion, and that was certainly the case at this week’s HCCA Healthcare Enforcement Compliance Institute in Washington.

Things kicked off Monday morning with a presentation from the CMS’s Jerry Mulcahy on Medicare Part C and Part D enforcement efforts. Mulcahy stressed the need for plan sponsors to do their own mock audits and be prepared for future government audits. He also said there’s no such thing as ”too big to fail” when it comes to enforcement, noting that the CMS will sanction plan sponsors when warranted, regardless of their size.

HHS OIG’s Robert DeConti reviewed some fraud and abuse trends. DeConti said the agency is seeing a lot more fraud schemes involving highly reimbursable noncontrolled drugs, which can include over-the-counter medications for high blood pressure, diabetes and infections. DeConti also said Medicare Part C fraud trends are closely tracking those observed in Medicare Part B, with similar schemes popping up in both programs.

The conference featured a slew of health-care attorneys, including Waller Lansden’s J.D. Thomas, who talked about the tension between the Stark law and new Medicare payment models. Thomas said the alternate payment models call for closer integration among providers, which in turn runs up against the Stark law.

To avoid Stark problems, Thomas recommended that providers put a detailed audit trail in place for all of their payment arrangements, and make any amendments or modifications in writing. Thomas also stressed the importance of transparency and said providers should publicly disclose their arrangement on their websites.

The Senate Finance Committee this year has talked about making changes to the Stark law, and Thomas said the drumbeat for change has been growing. A complete repeal of Stark is unlikely, but Thomas said there could be an expansion of Stark waivers for accountable care organizations.

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