Department of Justice Asked to Investigate False Claims Act Violations

The American Hospital Association (AHA) is asking for the creation of a task force to look into improper denials by health insurers.

AHA is calling on the Department of Justice (DOJ) to establish a task force to conduct investigations into health insurance companies that routinely deny patients access to care and payments to providers.

In a letter to acting assistant attorney general Brian Boynton, AHA states that it is time for the DOJ to exercise its False Claims Act authority to penalize Medicare Advantage organizations (MAOs) that restrict services to beneficiaries, citing a recent study by the Office of Inspector General (OIG).

In that report, the OIG found that many MAOs often delay or deny services for medically necessary care, even when prior authorization requests meet cover rules. An estimated 13% of prior authorization denials met Medicare coverage rules and 18% of payment denials met Medicare coverage and MAO billing rules.

"It is time for the Department of Justice to exercise its False Claims Act authority to both punish those MAOs that have denied Medicare beneficiaries and their providers their rightful coverage and to deter future misdeeds," AHA writes. "This problem has grown so large—and has lasted for so long—that only the prospect of civil and criminal penalties can adequately prevent the widespread fraud certain MAOs are perpetrating against sick and elderly patients across the country, as well as against the public fisc every time commercial insurers take $1,000 per beneficiary while denying medically-necessary services."

AHA point to Boynton highlighting the Civil Division's False Claims Act priorities in his remarks at the Federal Bar Association's annual conference when he took office in early 2021.

Boynton said that "another continuing priority for the Department is preventing the abuse and exploitation of our senior citizens.  A cornerstone of that effort will be the use of the False Claims Act to combat schemes that take advantage of elderly patients by providing them poor or unnecessary health care–or too often no care at all."

According to AHA, the DOJ is more than equipped to put its anti-fraud tools to use with the creation of a "Medicare Advantage Fraud Task Force" to ensure that the oldest patients get the care they need without unnecessary denials.