Emboldened Government Pursuit and Prosecution of Healthcare Fraud and Abuse
Since 1998, the government agencies responsible for prosecuting healthcare fraud and abuse, the Department of Justice and Office of Inspector General, have demonstrated an increased willingness to pursue claims under the Anti-Kickback Statute, the Stark Law, and the False Claims Act, as well as to prosecute increasingly complicated sets of violations. Part one of this three part series introduces the statutory and regulatory framework of the relevant statutes, the teams responsible for investigating healthcare fraud and abuse, and the relevant theoretical concepts involved in healthcare fraud and abuse lawsuits. (Read more...)

Will the SGR Finally be Retired?
Medicare spending continues to be a significant contributor to soaring healthcare spending. The Sustainable Growth Rate (SGR) formula, enacted as part of the Balanced Budget Act of 1997, has become problematic for healthcare providers and policymakers alike, with many seeking "fixes" to the flawed formula. In the past decade alone, almost $150 billion has been spent by Congress by overriding annual cuts to physician reimbursement based on the SGR formula; another reimbursement cut of 24.4% has been postponed until March 31, 2014, allowing Congress sufficient time to deliberate on a permanent solution to the SGR. (Read more...)

2014 to See Reduction in Capital Healthcare Expenditures?
In a changing economic healthcare environment in the midst of healthcare reform, it may come as no surprise that many hospitals and health systems are planning to reduce capital spending amounts in 2014, as compared to prior years. A 2013 survey by Premier Healthcare Alliance found that the top drivers of healthcare costs in 2014 are expected to include: (1) legislation/mandates; (2) labor costs; (3) misalignment of quality and payment incentives; and, (4) overuse of products and services. Some of the legislative changes include the opening of health insurance exchanges, RAC audits, and the two-midnight rule. As a result of some of these cost pressures, hospitals have increasingly reported reduced capital budgets since 2010. (Read more...)

Hospital Operating Efficiency Under Healthcare Reform
Similar to identified trends regarding healthcare quality, the concerns related to the operational efficiency, or inefficiency, of hospitals have continued to be issues of paramount importance during the transition from a fee-for-service to a pay-for-performance reimbursement program. A 2011 Health Affairs article estimated that hospitals that could optimize efficiency and increase average occupancy, from an average of 65% to 80% or 90%, in lieu of adding additional beds, saving up to $1 million per bed. In an era of healthcare delivery where compensation and the bottom line can drive referrals; interventions; personnel investment; and, patient satisfaction, such tactics may become necessary to drive healthcare toward adopting streamlined and operationally efficient processes that other industries have endorsed for decades. (Read more...)