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Health Care Fraud

NCJ Number
American Criminal Law Review Volume: 47 Issue: 2 Dated: Spring 2010 Pages: 681-740
Bria N. DeSalvo; Katherine M. Keith; Annette Soberats
Date Published
60 pages
This overview of Federal and State efforts to address health care fraud focuses on Medicare and Medicaid fraud, general Federal statutes used to prosecute health care fraud, and Federal and State government agencies' efforts to investigate and prosecute health care fraud.
A review of statutes that address Medicare and Medicaid fraud encompasses the Medicaid False Claims Statute, the Medicaid Anti-Kickback statute, Self-Referral/Stark amendments, and the Health Insurance Portability and Accountability Act. The Medicaid False Claims Statute criminalizes false statements or representations regarding any application for a claim of benefits or payment under Medicare and Medicaid. 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 service, treatment, or item for which payment will be made by Medicare, Medicaid, or any other federally funded health care program. The Self-Referral/Stark amendments prohibit physicians from referring Medicare patients to clinical laboratories in which the physician has a financial interest, absent a "safe harbor" provision. The Health Insurance Portability and Accountability Act of 1996, the most comprehensive effort to fight fraud in Federal health care programs, expands the scope of health care fraud and abuse prevention in several ways. It is the first Federal statute to regulate private health care, and it significantly increases the enforcement power of the Federal Government by establishing programs to coordinate efforts and facilitate prosecution of health care fraud at both State and Federal levels. For all of the aforementioned statutes, this article outlines elements of the offense, defenses, and penalties. Remaining major sections of the article address the prosecution of health care fraud with general Federal statutes and the Federal and State entities responsible for enforcement of laws that target health care fraud. 443 notes