By Adam Turteltaub

There’s a lot new going on in healthcare enforcement, and, at the same, there’s a lot that hasn’t changed, reports Greg Demske (LinkedIn), partner at Goodwin Proctor and, formerly, Chief Counsel to the Inspector General at HHS.

While the US Department of Justice has changed its priorities in areas such as anticorruption, if you look at what they and the Office of Inspector General (OIG) at Health and Human Services have been doing, he observes, the long-time bipartisan effort to stop fraud in healthcare is continuing.

Yet, there are some significant changes.  At CMS a major shift has occurred when it comes to Medicare Advantage.  In the past there were audits of fifty plans a year, but now the goal is to audit all six hundred or so annually.  Backing that up is an expansion in the number of coders from 40 to 2000.  This has huge implications both for the plans and providers.

Meantime the Department of Justice and HHS have created a False Claims Act Working group to further their efforts.

Then, of course, there are qui tam claims, which hit a record high in 2024, and we have dispositions in the courts as well.

So what should compliance teams do?  He recommends keeping a close eye on what the government is saying to ensure your program is staying ahead of the curve.

And, of course, you should listen to this podcast to gain more of his insights from private practice and over 16 years at HHS.