Full Answer
Who enforces the laws against health care fraud and abuse?
There are a wide range of entities at the federal, state and local levels responsible for enforcing the laws and regulations prohibiting fraud and abuse by the health care industry.
What are the Medicare-Medicaid anti-fraud and abuse amendments?
Medicare-Medicaid Anti-Fraud and Abuse Amendments - Amends Titles XVIII (Medicare) and XIX (Medicaid) of the Social Security Act to require that payments made directly to a physician or other person providing a service, pursuant to an assignment agreement, cannot be made to anyone else either through reassignment or under a power of attorney.
What are the Medicare fraud and abuse laws?
These laws specify the criminal, civil, and administrative penalties and remedies the government may impose on individuals or entities that commit fraud and abuse in the Medicare and Medicaid Programs.
What are the different entities involved in a Medicaid fraud investigation?
These entities include criminal and civil prosecutors at the federal level, state prosecutors and Medicaid Fraud Control Units, to local prosecuting attorneys, regulatory agencies and licensing boards.
Which governmental agency is responsible for monitoring Medicare?
The federal agency that oversees CMS, which administers programs for protecting the health of all Americans, including Medicare, the Marketplace, Medicaid, and the Children's Health Insurance Program (CHIP). For more information, visit hhs.gov.
Who enforces the Stark law?
Government agencies, including the U.S. Department of Justice (DOJ), the U.S. Department of Health & Human Services (HHS), the HHS Office of Inspector General (OIG), and the Centers for Medicare & Medicaid Services (CMS), enforce these laws. The civil FCA, 31 United States Code (U.S.C.)
Who enforces the Stark II?
Despite this powerful tool, the government has not utilized the FCA extensively to enforce the Stark Law. physicians with whom the medical center had prohibited financial relationships in violation of the Stark Law and the Anti-Kickback Statute. The court awarded the government $64 million in damages and penalties.
Who enforces the federal Anti-Kickback Statute?
The Department of Justice (DOJ) enforces the criminal penalties of the AKS. The criminal penalties include fines of up to $100,000 and ten-years' imprisonment. Violations of the AKS may also result in civil penalties.
When did Medicare start?
When Medicare began in 1965 , it didn’t come with nearly as many regulations as it has today. Initially, there were no agencies specifically designated to prevent or address healthcare fraud, and very few legal protections. Fairly soon after the program’s inception, it became clear that such infrastructure was greatly needed.
Why is FCA fraud a problem?
FCA fraud is usually committed in order to receive higher Medicare reimbursements. To achieve the highest possible reimbursement, offenders often create complex schemes to falsify claims. These schemes can involve the collection of Medicare information through patient recruiters or fraudulent billing practices like upcoding.
What is the anti kickback law?
The Anti-Kickback Statute makes it illegal for healthcare providers and their affiliates to pay unauthorized patient recruiters—in cash, trips, perks or otherwise—for assistance in procuring patient referrals or securing more business.
What is the False Claims Act?
The False Claims Act is a broad piece of legislation that prohibits the submission of false claims to Medicare or Medicaid. A false claim is any purposefully inaccurate billing statement submitted to the federal government.
How much can a physician be fined for violating the AKS?
The consequences are significant: in addition to criminal penalties, physicians who violate the AKS can face fines up to $50,000 for each individual kickback, in addition to triple the amount of the remuneration.
Can you get reimbursement for Medicare if you are under the OIG?
Anyone who falls under the Exclusion Statute cannot seek reimbursement for treating Medicare or Medicaid patients, nor can they receive other types of federal healthcare reimbursement.
What is Medicaid fraud control unit?
State and Local Audits: As noted above, almost all states have Medicaid Fraud Control Units (MFCUs) which are responsible for the investigation and prosecution (or referral for prosecution) of all criminal violations of state laws regarding fraud on the Medicaid program.
What is the goal of the Health Care Fraud and Abuse Program?
The overall goal of the Health Care Fraud and Abuse Program is to further enable the identification, investigation and, where appropriate, prosecution of those individuals and entities who commit fraud against the nation's health care delivery system.
What is the Department of Health and Human Services Office of Inspector General?
The Department of Health and Human Services Office of Inspector General (HHS-OIG) focuses primarily on fraud on the Medicare and Medicaid programs and the health benefits programs of the United States Public Health Service (PHS) such as the Indian Health Service.
What is the HHS OIG?
Prior to the passage of the Health Insurance Portability and Accountability Act of 1996, the HHS-OIG offered advice to the public with respect to the Medicare and Medicaid Anti-Kickback statute, 42 U.S.C. 1320a-7b (b), in the form of "safe harbor" regulations and Special Fraud Alerts.
What is the purpose of the Department of Justice and Health and Human Services?
Annually the Department of Justice and the Department of Health and Human Services will assess the effectiveness of the Program in combatting health care fraud and abuse. This assessment will include factors such as the appropriateness of the program's goals and objectives, the performance of the organizations which receive funds from the Account, and possible new areas to direct resources.
How can a health care fraud task force help?
Task Forces and Working Groups: Federal, State, local, or regional health care fraud task forces/working groups can improve health care fraud enforcement by encouraging communication and coordination among law enforcement officials in the use of criminal, civil, and/or administrative remedies.
How is health care fraud and abuse control promoted?
Health care fraud and abuse control is promoted when Federal, State, and local law enforcement entities share information about trends in health care fraud, emerging investigative and prosecutorial techniques, and other information necessary to achieve the common goal of controlling health care fraud.
How many doctors were charged with fraud in 2016?
In June 2016, the Medicare Fraud Strike Force conducted a nationwide health care fraud takedown, which resulted in criminal and civil charges against 301 individuals, including 61 doctors, nurses and other licensed medical professionals, ...
What is the federal False Claims Act?
Another powerful tool in the effort to combat health care fraud is the federal False Claims Act. In 2016, DOJ obtained over $2.5 billion in settlements and judgments from civil cases involving fraud and false claims against federal health care programs such as Medicare and Medicaid. Other steps the administration has taken to fight fraud include: ...
What is CMS's role in Medicare?
CMS is working to ensure that public funds are not diverted from their intended purpose: to make accurate payments to legitimate entities for allowable services or activities on behalf of eligible beneficiaries of federal health care programs. CMS also performs many program integrity activities that are beyond the scope of this report because they are not funded directly by the HCFAC Account or discretionary HCFAC funding. Medicare Fee-for-Service and Medicaid improper payment rate measurement and activities, the Fraud Prevention System, Recovery Audit Program activities, and prior authorization initiatives are discussed in separate reports, and CMS will submit a combined Medicare and Medicaid Integrity Program report to Congress later this year. Some of CMS’ fraud prevention efforts include:
Is CMS still conducting fraud investigations?
CMS continued to conduct Medicare and Medicaid fraud investigations and provider audits, as well as state program integrity reviews. In FY 2016, CMS continued its use of the Affordable Care Act authority to suspend Medicare payments to providers during an investigation of a credible allegation of fraud.
What is a CMP in Medicare?
1320 a-7a (a) (5), the “Beneficiary Inducements CMP,” provides for the Start Printed Page 77688 imposition of civil monetary penalties against any person who offers or transfers remuneration to a Medicare or State health care program (including Medicaid) beneficiary that the benefactor knows or should know is likely to influence the beneficiary's selection of a particular provider, practitioner, or supplier of any item or service for which payment may be made, in whole or in part, by Medicare or a State health care program (including Medicaid). Section 1128A (i) (6) of the Act, 42 U.S.C. 1320 a-7a (i) (6), defines “remuneration” for purposes of the Beneficiary Inducements CMP as including transfers of items or services for free or for other than fair market value. Section 1128A (i) (6) of the Act also includes a number of exceptions to the definition of “remuneration.”
What is the final rule for anti-kickback?
This final rule amends the safe harbors to the Federal anti-kickback statute by adding new safe harbors and modifying existing safe harbors that protect certain payment practices and business arrangements from sanctions under the anti-kickback statute. This rule is issued in conjunction with the Department of Health and Human Services' (HHS's) Regulatory Sprint to Coordinated Care and focuses on care coordination and value-based care. This rule also amends the civil monetary penalty (CMP) rules by codifying a revision to the definition of “remuneration” added by the Bipartisan Budget Act of 2018 (Budget Act of 2018).
Why are PBMs not front line providers?
Other reasons that commenters provided include that PBMs are not front-line health providers and protecting arrangements involving PBMs in the value-based safe harbors may inappropriately affect treatment decisions by health care practitioners. A commenter also suggested we require VBEs that establish relationships with PBMs to include information regarding such relationships in relevant VBE documents and reports.
How many comments did OIG receive?
OIG received 337 comments, 327 of which were unique, in response to the OIG Proposed Rule. A range of individuals and entities submitted these comments, including: Physicians and other types of clinicians, hospitals and health systems, other health care providers ( e.g., post-acute providers, laboratories, durable medical equipment suppliers, and dialysis providers), accountable care organizations, pharmaceutical and medical device manufacturers, health technology entities, pharmacies, third-party payors, trade associations, law firms, and consumer and patient advocacy groups.
What is OIG Proposed Rule?
On October 17, 2019, OIG published a notice of proposed rulemaking [ 2] (OIG Proposed Rule) to add or amend various regulatory protections under the Federal anti-kickback statute and Beneficiary Inducements CMP with the goal of proposing protections for certain value-based arrangements that would improve quality, outcomes, and efficiency. The proposals focused on arrangements to advance the coordination and management of patient care, with an aim to support innovative methods and novel arrangements, including the use of digital health technology such as remote patient monitoring and telehealth. We proposed safe harbors for value-based arrangements where the parties assume full financial risk, substantial downside financial risk, and no or lower risk. The proposed safe harbors offered more flexibility for arrangements where the parties assumed more financial risk. Consistent with OIG's law enforcement mission and section 1128D (a) (2) (I) of the Act, the proposals included safeguards tailored to protect Federal health care programs and beneficiaries from the risks of fraud and abuse associated with kickbacks, such as overutilization and inappropriate patient steering, as well as risks associated with risk-based payment mechanisms, such as stinting on care.
When was the OIG proposed rule published?
D. Summary of the OIG Proposed Rule. On October 17, 2019 , OIG published a proposed rule in the Federal Register ( 84 FR 55694) setting forth certain proposed amendments to the safe harbors under the anti-kickback statute and a proposed amendment to the Beneficiary Inducements CMP exceptions (the OIG Proposed Rule).
What is the CMP law?
1320 a-7a, as one of several administrative remedies to combat fraud and abuse in Medicare and Medicaid. The law authorized the Secretary to impose penalties and assessments on persons who defrauded Medicare or Medicaid or engaged in certain other wrongful conduct. The CMP law also authorized the Secretary to exclude persons from Federal health care programs (as defined in section 1128B (f) of the Act, 42 U.S.C. 1320 a-7b (f)) and to direct the appropriate State agency to exclude the person from participating in any State health care programs (as defined in section 1128 (h) of the Act, 42 U.S.C. 1320 a-7 (h)). Congress later expanded the CMP law and the scope of exclusion to apply to all Federal health care programs, but the CMP applicable to beneficiary inducements remains limited to Medicare and State health care program beneficiaries. Since 1981, Congress has created various other CMP authorities covering numerous types of fraud and abuse.
What are the laws that regulate the referral of patients?
Fraud and Abuse Laws and Regulations. Numerous federal laws regulate the referral of patients by healthcare providers. These laws are intended to prevent conflicts of interest between provider financial incentives and best patient care practices. Federal "fraud and abuse" law is actually a compilation of several laws, ...
What is fraud and abuse law?
Federal "fraud and abuse" law is actually a compilation of several laws, including the Federal Anti-Kickback Statute, the Stark Law, and the False Claims Act. A. The Federal Anti-Kickback Statute. The Federal Anti-Kickback Statute (42 U.S.C. § 1320a-7 (b)) prohibits providers of services or goods covered by a federal healthcare program ...
What is federal health care?
For purposes of the Federal Anti-Kickback Statute, a "Federal Healthcare Program" is defined as "any plan or program that provides health benefits, whether directly through insurance, or otherwise, which is funded directly, in whole or in part, by the United States Government; or any State health care program . . .". (42 U.S.C. § 1320a-7 (b) (f)). ...
Who is a whistleblower under the False Claims Act?
Under the False Claims Act's qui tam provisions, a person with evidence of fraud against the government (known as a "relator" or a "whistle-blower") is authorized to file a case in federal court and sue on behalf of the government.
Is Medicare a federal program?
The Medicare, Medicaid, and TRICARE Programs are all Federal Healthcare Programs. Certain transactions and arrangements are statutorily exempt from the Federal Anti-Kickback Statute (e.g., compensation paid pursuant to a bona fide employment relationship).
False Claims Act
- The False Claims Act is a broad piece of legislation that prohibits the submission of false claims to Medicare or Medicaid. A false claim is any purposefully inaccurate billing statement submitted to the federal government. The fines incurred for FCA violations can be up to three times the defrauded amount, in addition to a maximum $11,000 fee per ...
Physician Self-Referral Law
- The Stark Law prohibits physicians who own or invest in “designated health services” such as radiology, physical therapy, clinical laboratory services and home health services from referring Medicare and Medicaid patients to these service providers. Stark Law violations can be penalized without any demonstration that there was a specific intent to commit the offense. This is know…
Anti-Kickback Statute
- The Anti-Kickback Statute makes it illegal for healthcare providers and their affiliates to pay unauthorized patient recruiters—in cash, trips, perks or otherwise—for assistance in procuring patient referrals or securing more business. This statute can be violated both by the party providing the remuneration and the party receiving it. The consequences are significant: in additi…
Exclusion Statute
- The Exclusion Statute ensures than any party who has been convicted of any type of healthcare fraud, healthcare-related criminal behavior such as patient abuse, or felony charges related to controlled substances is not permitted to participate in federal healthcare programs. The statute also enables the Office of the Inspector General (OIG) to issue other exclusions at its discretion. …
Statement of Program Goals
- The overall goal of the Health Care Fraud and Abuse Program is to further enable the identification, investigation and, where appropriate, prosecution of those individuals and entities who commit fraud against the nation's health care delivery system. Also, the Program is to alert the public, service providers, industry groups, and consumers to such schemes; to identify syste…
Funding
- Control Account funds are provided by the Act to cover costs (including equipment, salaries and benefits, and travel and training) of the administration and operation of the Program, including the costs of: 1. prosecuting health care matters (through criminal, civil, and administrative proceedings); 2. investigations; 3. financial and performance audits of health care programs an…
Evaluation
- Annually the Department of Justice and the Department of Health and Human Services will assess the effectiveness of the Program in combatting health care fraud and abuse. This assessment will include factors such as the appropriateness of the program's goals and objectives, the performance of the organizations which receive funds from the Account, ...
Revisions
- This Program statement and accompanying Guidelines may be modified, as appropriate, upon agreement of the Attorney General and the Secretary. NOTE: Neither the Health Care Fraud and Abuse Control Program nor these guidelines create any rights, privileges or benefits, either substantive or procedural, enforceable at law by any person in any administrative, civil or crimin…
Definitions
- The following acronyms and definitions are used herein: 1. "AG" shall mean the Attorney General of the United States. 2. "AOA" shall mean the United States Administration on Aging within the Department of Health and Human Services 3. "CHAMPUS" shall mean the Civilian Health and Medical Program of the Uniformed Services. 4. "DCAA" shall mean the Defense Contract Audit A…
VI. Coordination and Exchange of Information
- In order to facilitate the enforcement of civil, criminal, and administrative statutes relating to fraud and abuse with respect to health plans, the following guidelines are provided to facilitate the exchange of information under the Program: 1. Guidelines for Exchange of Information 1.1. Health Plan Exchange of Information with Law Enforcement and Other Health Plans Each health plan s…