department of health and human services – Duane Morris Health Law

Effective June 17, 2013, state Medicaid fraud control units (MFCU) will be permitted to use federal matching funds to pay for data mining activities to detect potentially fraudulent utilization and billing patterns. Historically, MFCUs have been prohibited from using federal matching funds to pay for the cost of data mining. Given the financial constraints facing MFCUs, this funding is likely to result in a substantial increase in activities by MFCUs across the United States. While this rule in and of itself is noteworthy, it is likely to have a more significant impact on healthcare providers when coupled with the regulation implementing the Patient Protection and Affordable Care Act (ACA) that requires states to suspend all Medicaid payments to a provider upon credible allegation of fraud during, or triggering, a Medicaid investigation.

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On June 3, 2013, the U.S. Department of Labor, Department of Health and Human Services, Internal Revenue Service, Employee Benefits Security Administration and Department of the Treasury published in the Federal Register final guidance regarding nondiscriminatory wellness programs under employer-sponsored group health plans. This final guidance was issued in the form of much-anticipated joint final regulations on such wellness programs (the “Final Regulations”). It is important to note that the Final Regulations will apply to wellness programs offered under all group health plans [regardless of whether the plan is “grandfathered” under the Patient Protection and Affordable Care Act (the “Affordable Care Act”)]. Moreover, these Final Regulations will be effective for plan years beginning on or after January 1, 2014.

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