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Health Care Fraud

NCJ Number
American Criminal Law Review Volume: 41 Issue: 2 Dated: Spring 2004 Pages: 751-808
Lissa Bourjolly; Erin Moak
Date Published
57 pages
This article examines Federal and State efforts to address health care fraud under statutes that target Medicare and Medicaid fraud as well as under general Federal statutes.
The section on statutes that pertain to Medicare and Medicaid fraud first discusses the Medicaid False Claims Statute, which criminalizes false statements or representations linked to any application for claim of benefits or payment, as well as the disposal of assets, under a Federal health care program. This is followed by a description of the Medicaid anti-fraud and anti-kickback statute, which prohibits knowingly and willfully paying or receiving any remuneration in cash or in kind in exchange for prescribing, purchasing, or recommending any service, treatment, or time for which payment will be made by Medicare, Medicaid, or any other federally funded health care program. Other topics considered in this section are the Stark amendments, which limit certain physician referrals, and the relevant provisions of the Health Insurance Portability and Accountability Act of 1996, which expanded the scope of health care fraud and abuse prevention in several ways. The prosecution of health care fraud with general Federal statutes is discussed with reference to the False Claims Act, false statements, and mail and wire fraud. The article concludes with a discussion of the enforcement of health-care-fraud statutes, with attention to the agencies responsible for enforcement at the Federal and State levels, intergovernmental cooperation, and compliance programs. 440 footnotes


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