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Health Care Fraud

NCJ Number
American Criminal Law Review Volume: 45 Issue: 2 Dated: Spring 2008 Pages: 607-664
Matt Altshuler; J. Kyden Creekpaum; Jim Fang
Date Published
58 pages
This article reviews Federal statutes that address Medicare and Medicaid fraud, followed by discussions of the prosecution of health care fraud under general Federal statutes and enforcement mechanisms.
This article examines the statutes enacted specifically to address Medicare and Medicaid fraud and reviews the elements, defenses, penalties, and "safe harbor" provisions for each statute. The Medicaid False Claims Statute criminalizes false statements or representations linked to any application for claims of benefits or payments, or the disposal of assets, under a Federal health care program. The Medicaid Anti-Kickback Statute prohibits knowingly and willfully paying or receiving any remuneration directly or indirectly, overtly or covertly, in cash or in kind, in exchange for prescribing, purchasing, or recommending any services, treatment, or item for which payment will be made by Medicare, Medicaid, or any other federally funded health care program. The Omnibus Reconciliation Act of 1993 prohibits physicians from referring Medicare patients to clinical laboratories in which the physician has a financial interest, absent a safe harbor provision. In 1996, Congress passed the Health Insurance Portability and Accountability Act, which is the most comprehensive attempt by the Federal Government to fight fraud in Federal health care programs and expands the scope of health care fraud and abuse prevention. In addition to using statutes that specifically target Medicare and Medicaid fraud, prosecutors can bring charges for health care fraud under a variety of other Federal statutes, including the False Claims Act, the False Statements Act, the Social Security Act, and other criminal fraud statutes. A discussion of enforcement mechanisms focuses on the entities at the Federal and State levels responsible for enforcing Medicaid and Medicare fraud statutes, with a mention of compliance programs established by health care providers in the absence of a government requirement. 442 notes


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