Fraud & Abuse / Compliance


The advent of VBC presents particular challenges for the traditional application of the principal health care fraud and abuse laws: the federal health care programs Anti-kickback statute (AKS), the Ethics in Patient Referrals Act (Stark), and their principal enforcement vehicle, the False Claims Act (FCA).  It has been federal health care policy since the AKS was enacted in 1972 that in order to prevent financial interests from corrupting medical decision making (leading to the twin ills of increased cost and overutilization), payment arrangements between referral sources must be restricted.  This worthy goal has led to a complicated set of rules that have an important place in fee-for-service health care, but that in many cases are anathema to the need for shared monetary pain or pleasure to motivate cost efficient behavior in a value-based payment system.  CMS regulations under the Affordable Care Act recognized this by creating fraud and abuse waivers for certain financial arrangements among the members of an accountable care organization.  This section will monitor these and other legislative, regulatory, and enforcement developments that seek to adapt the fraud and abuse laws to the changing policy needs of VBC.