STATEMENT OF PRINCIPLES FOR THE SHARING OF HEALTHCARE FRAUD INFORMATION
STATEMENT OF PRINCIPLES FOR THE
SHARING OF HEALTH CARE FRAUD INFORMATION
BETWEEN THE DEPARTMENT OF JUSTICE
AND PRIVATE HEALTH PLANS
This statement of principles concerns the sharing of information about fraudulent activities in the health care system among and between the Department of Justice and private health plans, pursuant to the Health Care Fraud & Abuse Control Program. The Department of Justice will designate Information Exchange Coordinators to coordinate any such exchanges of information.The Department of Justice expects that private health plans likewise will designate Information Exchange Coordinators and will inform the Department of Justice as soon as possible.
1. General. The Department of Justice recognizes that fraudulent activity in the health care system can affect both public and private sector health plans, and that often cooperation between the public and private sectors can assist in the detection, investigation, prosecution and prevention of fraud. The Department of Justice considers information from private health plans as an important and valuable tool in the fight against health care fraud. The Department of Justice also considers the investigation and prosecution of fraud against private health plans as integral to its overall effort to combat health care fraud. The Department of Justice considers the exchange of information between it and private health plans to be a valuable means to improve those efforts.
2. Sharing of Information by Private Health Plans. The Department of Justice encourages private health plans to provide information concerning suspected health care fraud to the Department of Justice whenever possible. The Department of Justice further encourages private health plans to share with it information concerning useful investigative resources and services developed or offered by particular private plans or associations of private health care payors. Private health plans should provide this information to a Department of Justice Information Exchange Coordinator designated to coordinate the sharing of information pursuant to these guidelines.
3. Health Care Fraud Task Force Participation. Whenever practicable, authorized by law, and consistent with ongoing law enforcement activities, the Department of Justice will make its best efforts to include private health plans in local, regional and national health care fraud task forces, and in task force activities.
4. Sharing of Information by the Department of Justice. The Department of Justice will make its best efforts to provide general information concerning health care fraud to private health plans, and specific information concerning specific health care frauds to those private health plans that the Department of Justice believes likely are affected by the fraud ("affected private health plans"), whenever such an exchange is practicable, permitted by law, and will not jeopardize ongoing law enforcement activities.
a. Public Information. Accordingly, the Department of Justice, upon request, will provide as promptly as possible through its Information Exchange Coordinators certain public record information, including civil settlements, criminal indictments, plea agreements and compliance agreements. The Department of Justice Information Exchange Coordinators also shall make available to the Information Exchange Coordinators of affected private health plans periodic written summaries of enforcement actions in a newsletter format and through copies of reports submitted to the Healthcare Integrity and Protection Databank. In addition, the Department of Justice Information Exchange Coordinators will make this public information available to the pertinent health insurance associations or associations of private health care payors for further distribution to their member companies whenever appropriate.
b. Non-Public Information. Whenever practicable and permitted by law, and whenever the disclosure of such information will not jeopardize ongoing law enforcement activities, the Department of Justice will provide affected private health plans with available information concerning fraudulent health care schemes. Where consistent with these principles, the Department of Justice will make its best efforts to provide certain "followup" information to private health plans and associations of private health care payors that have provided the Department of Justice with verified information concerning a particular provider. Such additional information shall include any information appropriate for disclosure concerning the scope or nature of the fraud, the outcome of an investigation, the nature of any enforcement action and a summary of any facts underlying such enforcement action. The Department of Justice will consider information to be "verified" when the Department of Justice has determined that credible evidence supports the initial allegations.
5. Sharing of Information to Support Restitution Claims. Victims of health care fraud have a right to receive restitution as part of the federal criminal law enforcement process. The Department of Justice Information Exchange Coordinators will make available to private health plans relevant investigative information including, but not limited to, information concerning the nature and scope of the fraud, the outcome of the investigation, the nature of any enforcement action, and the procedures for an affected victim to make a claim for restitution. In cases in which the United States is seeking, or has obtained, an injunction affecting assets, and/or has forfeited assets attributable to health care fraud offenses, the Department of Justice Information Exchange Coordinators will make available to private health plans information concerning the procedures to petition for the remission of forfeited monies or properties, or to make a claim for restitution.
6. Suits Concerning Disclosures by Private Health Plans. In the event private health plans are sued for providing information concerning suspected health care fraud to the Department of Justice, the Department of Justice, upon written request with reasonable notice, will provide the tribunal with available factual information regarding such disclosure to assist the tribunal in determining whether the private health plan was acting within the scope of the provision creating qualified statutory immunity from civil liability for certain information disclosures.
7. Protecting Confidentiality of Private Health Plan Disclosures. Provided such efforts are consistent with obligations imposed by law, and its statutory mandates, the Department of Justice will make every reasonable effort to protect the confidentiality of the sources of information provided by private health plans in connection with the coordinated anti-fraud program, including treating this information as provided by a confidential source whenever appropriate.