It should not surprise any physician that more resources are now being spent on fraud and abuse enforcement than ever before. As health-care reform has hit the political forefront, various studies have indicated that fraud, waste, and abuse have taken tens of millions of dollars from the health-care system. These studies make it easy to justify increased spending on detection and enforcement programs.
Oddly enough, the end of the Cold War has also contributed to increased health-care enforcement. FBI agents previously assigned to counterintelligence are now enforcing health-care laws.
Though they may not be familiar with complex third-party payment issues such as upcoding, miscoding, and unbundling, they bring with them a plethora of law enforcement techniques that have been used only rarely in health-care enforcement. These may include undercover agents--often with hidden tape recorders--who enter a physician's office to talk to employees and locate files for future search warrants or subpoenas.
Computers and 'Whistle Blowers'
Similarly, Medicare carriers (and private third-party insurers) have developed sophisticated computer programs to detect aberrant billing patterns, and carriers are now assisted by special fraud control units. Government agencies are also the beneficiaries of private law enforcement activities.
Under the qui tam provisions of the False Claims Act, private citizens, including patients, employees (and ex-employees), and competitors may be paid a bounty of up to 30% of the government's total recovery for advising the government of the identity of physicians or other health-care providers who have submitted false claims. Well-publicized stories of individuals making millions of dollars by "blowing the whistle" have significantly increased physicians' exposure for these types of claims.
Congress has enacted several types of fraud and abuse laws, each of which has a specific purpose. Penalties for filing false claims are intended to discourage health-care providers from billing for services not provided or for services that are different from those actually provided.