NCJ Number
214584
Journal
American Criminal Law Review Volume: 43 Issue: 2 Dated: Spring 2006 Pages: 603-661
Date Published
2006
Length
59 pages
Annotation
This article reviews the Federal statutes enacted specifically to address Medicare and Medicaid fraud as well as the general Federal statutes used to prosecute health care fraud, followed by an overview of Federal and State government agencies' efforts to investigate and prosecute health care fraud.
Abstract
The Medicaid False Claims Statute criminalizes false statements or representations made with any application for a claim of benefits or payment and 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 service, treatment, or time 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 (specified arrangements that are exempt). The Health Insurance Portability and Accountability Act of 1996 is the most comprehensive attempt to fight fraud in Federal health care programs, as it expands the scope of health care fraud and abuse prevention in several ways. For each of these statutes, this article reviews the elements, defenses, penalties, and "safe harbor" provisions. The general Federal statutes used to prosecute health care fraud are the False Claims Act, the False Statements Act, and mail and wire fraud statutes. For each of these statutes, this article describes the elements of the offense covered, available defenses, and penalties. The concluding section provides an overview of Federal and State government agencies' efforts to investigate and prosecute health care fraud. 452 footnotes