What West Virginia’s New Healthcare Fraud Initiative Means for You
West Virginia healthcare providers are feeling the heat of a new initiative aimed at cracking down on healthcare fraud in the state.
On Jan. 18, U.S. Attorney for the Northern District of West Virginia William Ihlenfeld announced the launch of the Mountaineer Health Care Fraud Strike Force. He said the unit, composed of state and federal law enforcement agencies, will rely on data to combat waste and abuse in the health care industry.
“The time I spent in the private sector opened my eyes to the scope of the health care fraud that is occurring in West Virginia,” Ihlenfeld said. “It made me realize that more can and should be done by law enforcement, which is why this new group has been formed.”
The group first met the day of the announcement, Ihlenfeld said. The seven agencies present discussed fraudulent billing patterns and identified new targets for investigation. In addition to enforcement, the group will work with providers and insurers so that there’s a better understanding on how to recognize and report health care fraud, he said.
Health care fraud in West Virginia is intimately linked with the state’s opioid crisis. The state has one of the highest rates of non-medical use of prescription pain relievers in young people in the country and opioids are the number one cause of overdose deaths in the state, according to West Virginia’s attorney general’s office.
Health care fraud cases in West Virginia tend to be complex. In addition to opioid and controlled substance over prescription, cases tend to involve additional layers of illegal kickback and referral schemes involving doctors, pharmacies and laboratories.
In one high-profile recent case, Wheeling Hospital, Inc., in Wheeling, West Virginia, agreed in 2020 to pay $50 million to settle alleged False Claims Act violations. The federal government alleged the hospital knowingly submitted claims to Medicare that resulted from violations of the Physician Self-Referral Law and the Anti-Kickback Statute.
The government alleged the hospital, under prior management, violated federal law by knowingly and willfully paying improper compensation to referring physicians based on the volume or value of the referrals or was above fair market value.
At Med Law Advisory Partners, we work with healthcare providers to both preempt such investigations and provide critical support to healthcare entities facing active investigations.
For decades, Med Law’s consulting nurse experts have supplemented in-house legal and compliance teams in reviewing medical records for appropriateness of care and medical necessity, resulting in measurable, positive outcomes in investigative matters.
In the area of controlled substances, the Med Law team works with our clients to ensure they implement safe prescribing practices and help minimize the fallout in the event of a compliance investigation. Our consulting nurse experts have experience in providing audit support in investigations related to allegations such as reckless prescribing of narcotics and wrongful death related to overdose from prescribed controlled substances.
We also respond to active investigations, providing critical medical record reviews that can help clients facing costly penalties.
Taking a proactive posture will be crucial for health care organizations when it comes to the current environment in West Virginia. By evaluating policies and procedures, as well as ensuring effective training and compliance programs are in place, health care organizations can reduce their exposure to such claims.
We are here to help your health care provider clients prevent and mitigate the fallout from investigations surrounding controlled substances as well as the full spectrum of healthcare fraud. Contact us today for more information.