The rising cost of health care and of federally-funded health care programs continue to emerge as a major topic of discussion. The discussion is often focused on how to reduce the significant cost of health care while also attempting to preserve the quality of patient care.

According to Blake L. Greco, an associate with Oliver Maner LLP, the two issues that have the biggest impact in the health law field include alternative payment methods and the continued enforcement efforts related to fraud and abuse. 

The alternative payment methods are believed to be one of the hallmarks of the Patient Protection and Affordable Care Act of 2010 and the Health Care and Education Reconciliation Act of 2010—known together as the ACA or Obamacare—that will have the biggest effect on changing health care delivery.

Greco explains that an example of an alternative payment method is an accountable care organization (ACO). 

“An example of an an alternative payment method is the accountable care organization (ACO), which is a group of physicians, hospitals, and other healthcare providers, that work together to provide coordinated care to patients,” said Greco, who concentrates his practice in the areas of trusts and estates, tax, health care and business law. “These alternative payment models present a financial risk to the provider but have a focus on coordinated care and on the quality and value of the services provided.  It is a change from the fee for service model that providers have been operating under for years. Therefore, the challenge has been, and continues to be changing how health care is delivered to the patient in order to adapt the provision of health care to fit these payment models." 

Another tool used to combat the rising cost of health care includes the government’s focus on investigating health care fraud and abuse in federally-funded health care programs. 

“An estimated ten percent of Medicare’s yearly budget is lost to fraud and abuse each year,” said Greco, who earned his Juris Doctor from Pennsylvania State University Dickinson School of Law. “With a proposed budget for 2016 in excess of $600 billion, that means the anticipated fraud and abuse for 2016 will exceed $60 billion.  In its effort to curb the amount lost, the government has increased funding to investigate and recover funds lost to fraud and abuse.” 

The government has several tools in recovering overpayments made by its health care programs, including the federal physician self-referral prohibition statute (the Stark Law), the Anti-Kickback Statute and the False Claims Act.

“The Stark Law, also known as the federal physician self-referral law, was created due to the belief that a conflict of interest inherently exists anytime a physician refers a patient to a health care entity in which the physician has a financial interest,” Greco said. “The thought is that referrals based on profit motives could result in inappropriate over-utilization of Medicare funds.” 

Greco explains that in an effort to prevent this, the Stark Law prohibits physicians from referring a patient for “designated health services” to an entity in which the physician, or an immediate family member, has a “financial relationship,” unless an exception applies.  

The Anti-Kickback Statute applies to all individuals and entities, not just physicians, that knowingly and willfully offer, pay, solicit or receive remuneration, directly or indirectly, in order to induce business for which payment may be made under a Health Care Program.   

Greco said the False Claims Act imposes liability on any person who submits a claim to the federal government for payment when the person knows, or should have known, that the claim is false or fraudulent.  

“Recently, the government has even made it clear that it intends to seek individual liability for corporate wrongdoing,” said Greco. “That includes civil and criminal liability, without regard to the individual’s ability to pay the judgment. Though this appears to have the goal of continuing to reduce fraud and abuse, it will also have unintended results. Those results include deterring efforts by entities to discover and reduce inadvertent wrongdoing through self-audits due to feat that those findings may be used against them to establish liability.”   

Continued focus is also being placed on physician compensation cases.  

“There have been a growing number of these cases and the amounts of the settlements have continued to increase as well,” Greco said. “For the 2015 fiscal year, the government has reported that it was able to recover over $3.5 billion through settlements, judgments and other administrative fees involving the health care laws across the country, and it will continue trying to recover more each year.” 

Greco is a member of the State Bar of Georgia, the American Bar Association, the American Health Lawyers Association, the Savannah Estate Planning Council, the Executive Committee of the Savannah Bar Association and is a Past President of the Young Lawyers Division of the Savannah Bar Association.