Attorneys Anthony Argiropoulos, Gary W. Herschman, and William Gibson, with law clerk Andrew Kuder, co-authored an article in the American Health Lawyers Association (AHLA) Connections magazine, titled “New Sheriffs in Town: Commercial Payers’ Increasing Role in Addressing Fraud and Abuse.”

Following is an excerpt (see below to download the full article in PDF format):

There is a growing trend of commercial payers invoking “fraud and abuse” theories to deny health care providers’ claims or to recoup claims paid over many years. A few states even have laws that allow commercial payers to file “whistleblower” claims for alleged fraud in claims submissions with the incentive of recovering significant trebled damages, statutory penalties, and attorney’s fees. This article describes the various (and growing) methods of commercial payer fraud and abuse enforcement against health care providers, offers some practical recom­mendations for health care providers to mitigate the risk of potential exposure, and discusses potential affirmative actions that providers can launch against payers. …

While providers understandably and rightfully focus on the delivery of high-quality health care, the fact remains that every provider — irrespective of size — is a potential target of fraud and abuse claims. A culture of compliance not only will aid a provider’s defense of potential fraud accusations by payers, who may now have an additional economic incentive to make such claims, but also arm providers in the event that payers fail to pay providers what they deserve.


Jump to Page

Privacy Preference Center

When you visit any website, it may store or retrieve information on your browser, mostly in the form of cookies. This information might be about you, your preferences or your device and is mostly used to make the site work as you expect it to. The information does not usually directly identify you, but it can give you a more personalized web experience. Because we respect your right to privacy, you can choose not to allow some types of cookies. Click on the different category headings to find out more and change our default settings. However, blocking some types of cookies may impact your experience of the site and the services we are able to offer.

Strictly Necessary Cookies

These cookies are necessary for the website to function and cannot be switched off in our systems. They are usually only set in response to actions made by you which amount to a request for services, such as setting your privacy preferences, logging in or filling in forms. You can set your browser to block or alert you about these cookies, but some parts of the site will not then work. These cookies do not store any personally identifiable information.

Performance Cookies

These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. They help us to know which pages are the most and least popular and see how visitors move around the site. All information these cookies collect is aggregated and therefore anonymous. If you do not allow these cookies we will not know when you have visited our site, and will not be able to monitor its performance.