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Fraud & Abuse

Health Hippo: Fraud & Abuse

Health Hippo: Fraud & Abuse

US CODE || CFR || CASES || REPORTS || CONGRESSIONAL RECORD || BILLS || FEDERAL REGISTER

An insolent reply from a polite person is a bad sign.

Medical facilities (such as medical centers,
clinics, and practices) and durable medical equipment suppliers
are the most frequent subjects of criminal fraud cases in the Medicare,
Medicaid, and CHIP programs. Hospitals and medical facilities were the
most frequent subjects of civil fraud cases, including cases that
resulted in judgments or settlements. According to 2010 data, about
one-quarter of the 7,848 subjects investigated in criminal health care
fraud cases were medical facilities or were affiliated with these
facilities. Additionally, about 16 percent of subjects were durable
medical equipment suppliers. Among the subjects investigated in criminal
fraud cases, a small percentage (approximately 3 percent) were
individuals who were beneficiaries of health care programs. Hospitals
constituted nearly 20 percent of the 2,339 subjects of civil fraud cases
investigated in 2010, and other medical facilities accounted for about
18 percent of the subjects. Less than 1 percent of subjects involved in
civil health care fraud cases were beneficiaries of health care
programs.


U.S. Code

  • Affordable Care Act:
    Transparency and Program Integrity

    • Sec. 6001. Limitation on Medicare exception to
      the prohibition on certain physician referrals for hospitals.
    • Sec. 6002. Transparency reports and reporting
      of physician ownership or investment interests.
    • Sec. 6003. Disclosure requirements for
      in-office ancillary services exception to the prohibition on physician
      self-referral for certain imaging services.
    • Sec. 6004. Prescription drug sample
      transparency.
    • Sec. 6005. Pharmacy
      benefit managers transparency requirements.
    • Sec. 6401. Provider screening and other
      enrollment requirements under Medicare, Medicaid, and CHIP.
    • Sec. 6402. Enhanced Medicare and Medicaid
      program integrity provisions.
    • Sec.
      6403.
      Elimination of duplication between the Healthcare Integrity
      and Protection Data Bank and the National Practitioner Data Bank.
    • Sec. 6404. Maximum period for submission of
      Medicare claims reduced to not more than 12 months.
    • Sec. 6405. Physicians who order items or
      services required to be Medicare enrolled physicians or eligible
      professionals.
    • Sec. 6406. Requirement
      for physicians to provide documentation on referrals to programs at high
      risk of waste and abuse.
    • Sec. 6407.
      Face to face encounter with patient required before physicians may
      certify eligibility for home health services or durable medical
      equipment under Medicare.
    • Sec. 6408.
      Enhanced penalties.
    • Sec. 6409. Medicare
      self-referral disclosure protocol.
    • Sec.
      6410.
      Adjustments to the Medicare durable medical equipment,
      prosthetics, orthotics, and supplies competitive acquisition program.
    • Sec. 6411. Expansion of the Recovery
      Audit Contractor (RAC) program.
    • Sec.
      6501.
      Termination of provider participation under Medicaid if
      terminated under Medicare or other State plan.
    • Sec. 6502. Medicaid exclusion from
      participation relating to certain ownership, control, and management
      affiliations.
    • Sec. 6503. Billing
      agents, clearinghouses, or other alternate payees required to register
      under Medicaid.
    • Sec. 6504. Requirement
      to report expanded set of data elements under MMIS to detect fraud and
      abuse.
    • Sec. 6505. Prohibition on
      payments to institutions or entities located outside of the United
      States.
    • Sec. 6506. Overpayments.
    • Sec. 6507. Mandatory State use of national
      correct coding initiative.
    • Sec. 6508.
      General effective date.
    • Sec. 6601.
      Prohibition on false statements and representations.
    • Sec. 6602. Clarifying definition.
    • Sec. 6603. Development of model uniform report
      form.
    • Sec. 6604. Applicability of State
      law to combat fraud and abuse.
    • Sec.
      6605.
      Enabling the Department of Labor to issue administrative
      summary cease and desist orders and summary seizures orders against
      plans that are in financially hazardous condition.
    • Sec. 6606. MEWA plan registration with
      Department of Labor.
    • Sec. 6607.
      Permitting evidentiary privilege and confidential communications.
    • Sec. 10601. Revisions to limitation on
      medicare exception to the prohibition on certain physician referrals for
      hospitals.
    • Sec. 10602. Clarifications
      to patient-centered outcomes research.
    • Sec. 10603. Striking provisions relating to
      individual provider application fees.
    • Sec. 10604. Technical correction to section
      6405.
    • Sec. 10605. Certain other
      providers permitted to conduct face to face encounter for home health
      services.
    • Sec. 10606. Health care
      fraud enforcement.
    • Sec. 10607. State
      demonstration programs to evaluate alternatives to current medical tort
      litigation.
    • Sec. 10608. Extension of
      medical malpractice coverage to free clinics.
  • Medicare Modernization Act: Fraud &
    Abuse Provisions

    • Sec. 301
      Medicare secondary payor (MSP) provisions.
    • Sec. 302 Payment for durable medical equipment;
      competitive acquisition of certain items and services.
    • Sec. 303 Payment reform for covered outpatient
      drugs and biologicals.
    • Sec. 304
      Extension of application of payment reform for covered outpatient drugs
      and biologicals to other physician specialties.
    • Sec. 305 Payment for inhalation drugs.
    • Sec. 306 Demonstration project for use of
      recovery audit contractors.
    • Sec. 307
      Pilot program for national and State background checks on direct patient
      access employees of long-term care facilities or providers.
  • Health Insurance Portability and
    Accountability Act
    : Fraud & Abuse Provisions

    • Sec. 200. References in title.
    • Sec. 201. Fraud and abuse control
      program.
    • Sec. 202. Medicare
      integrity program.
    • Sec. 203.
      Beneficiary incentive programs.
    • Sec. 204. Application of certain
      health antifraud and abuse sanctions to fraud and abuse against Federal
      health care programs.
    • Sec.
      205.
      Guidance regarding application of health care fraud and abuse
      sanctions.
    • Sec. 211. Mandatory
      exclusion from participation in Medicare and State health care programs.
    • Sec. 212. Establishment of
      minimum period of exclusion for certain individuals and entities subject
      to permissive exclusion from Medicare and State health care programs.
    • Sec. 213. Permissive exclusion
      of individuals with ownership or control interest in sanctioned
      entities.
    • Sec. 214. Sanctions
      against practitioners and persons for failure to comply with statutory
      obligations.
    • Sec. 215.
      Intermediate sanctions for Medicare health maintenance organizations.
    • Sec. 216. Additional exception
      to anti-kickback penalties for risk- sharing arrangements.
    • Sec. 217. Criminal penalty for
      fraudulent disposition of assets in order to obtain Medicaid benefits.
    • Sec. 218. Effective date.
    • Sec. 221. Establishment of the
      health care fraud and abuse data collection program.
    • Sec. 231. Social Security Act civil
      monetary penalties.
    • Sec. 232.
      Penalty for false certification for home health services.
    • Sec. 241. Definitions relating to
      Federal health care offense.
    • Sec.
      242.
      Health care fraud.
    • Sec.
      243.
      Theft or embezzlement.
    • Sec. 244. False statements.
    • Sec. 245. Obstruction of criminal
      investigations of health care offenses.
    • Sec. 246. Laundering of monetary
      instruments.
    • Sec. 247.
      Injunctive relief relating to health care offenses.
    • Sec. 248. Authorized investigative
      demand procedures.
    • Sec. 249.
      Forfeitures for Federal health care offenses.
    • Sec. 250. Relation to ERISA
      authority.
  • Balanced Budget
    Act of 1997
    : Fraud & Abuse Provisions

    • Sec. 4301. Permanent exclusion for
      those convicted of 3 health care related crimes.

    • Sec. 4302. Authority to refuse
      to enter into medicare agreements with individuals or entities convicted
      of felonies.
    • Sec. 4303.
      Exclusion of entity controlled by family member of a sanctioned
      individual.
    • Sec. 4304.
      Imposition of civil money penalties.
    • Sec. 4311. Improving information to
      medicare beneficiaries.
    • Sec.
      4312.
      Disclosure of information and surety bonds.
    • Sec. 4313. Provision of certain
      identification numbers.
    • Sec.
      4314.
      Advisory opinions regarding certain physician self-referral
      provisions.
    • Sec. 4315.
      Replacement of reasonable charge methodology by fee schedules.
    • Sec. 4316. Application of inherent
      reasonableness to all part B services other than physicians’ services.
    • Sec. 4317. Requirement to
      furnish diagnostic information.
    • Sec. 4318. Report by GAO on operation
      of fraud and abuse control program.
    • Sec. 4319. Competitive bidding
      demonstration projects.
    • Sec.
      4320.
      Prohibiting unnecessary and wasteful medicare payments for
      certain items.
    • Sec. 4321.
      Nondiscrimination in post-hospital referral to home health agencies and
      other entities.
    • Sec. 4331.
      Other fraud and abuse related provisions.


Code of Federal
Regulations

  • 42 CFR
    PART 420
    PROGRAM INTEGRITY: MEDICARE (420.1 – 420.410)

    • SUBPART
      A
      General Provisions (420.1 – 420.3)
    • SUBPART B
      [Reserved]
    • SUBPART
      C
      Disclosure of Ownership and Control Information (420.200 –
      420.206)
    • SUBPART
      D
      Access to Books, Documents, and Records of Subcontractors
      (420.300 – 420.304)
    • SUBPART
      E
      Rewards for Information Relating to Medicare Fraud and Abuse
      (420.400 – 420.410)
  • 42 CFR
    PART 455
    PROGRAM INTEGRITY: MEDICAID

    • Sec. 455.1 Basis
      and scope.
    • Sec. 455.2
      Definitions.
    • Sec. 455.3 Other
      applicable regulations.
    • SUBPART
      A
      Medicaid Agency Fraud Detection and Investigation Program (455.12
      – 455.23)
    • SUBPART
      B
      Disclosure of Information by Providers and Fiscal Agents (455.100
      – 455.106)
    • SUBPART
      C
      Medicaid Integrity Program (455.200 – 455.240)
    • SUBPART
      D
      Independent Certified Audit of State Disproportionate Share
      Hospital Payment Adjustments (455.300 – 455.304)
    • SUBPART
      E
      Provider Screening and Enrollment (455.400 – 455.470)
    • SUBPART
      F
      Medicaid Recovery Audit Contractors Program (455.500 –
      455.518)
  • 42
    CFR CHAPTER V
    OFFICE OF INSPECTOR GENERAL HEALTH CARE


    • SUBCHAPTER A
      GENERAL PROVISIONS


    • SUBCHAPTER B
      OIG AUTHORITIES

      • Part 1001
        Program Integrity: Medicare And State Health Care Programs (1001.1 –
        1001.3005)

        • Sec. 1001.952
          Exceptions (“Safe Harbors”)
        • Final
          Rule: Electronic Health Records Safe Harbor Under the Anti-Kickback
          Statute
          December 27, 2013. Updating the provision under which
          electronic health records software is deemed interoperable; removing the
          electronic prescribing capability requirement; extending the sunset
          provision until December 31, 2021; limiting the scope of protected
          donors to exclude laboratory companies; and clarifying the condition
          that prohibits a donor from taking any action to limit or restrict the
          use, compatibility, or interoperability of the donated items or
          services.

      • Part 1002
        Program Integrity: State-Initiated Exclusions From Medicaid (1002.1 –
        1002.230)
      • Part 1003
        Civil Money Penalties, Assessments And Exclusions (1003.100 – 1003.135)
      • Part
        1004
        Imposition Of Sanctions By A Quality Improvement Organization
        (1004.1 – 1004.140)
      • Part 1005
        Appeals Of Exclusions, Civil Money Penalties And Assessments (1005.1 –
        1005.23)
      • Part 1006
        Investigational Inquiries (1006.1 – 1006.5)
      • Part 1007
        State Medicaid Fraud Control Units (1007.1 – 1007.21)
      • Part 1008
        Advisory Opinions By The OIG (1008.1 – 1008.59)


Cases

  • Raymond
    Lamont Shoemaker
    (2014)(extension of 10 year Medicare exclusion to
    12 years without notice deprived petitioner of due process)

  • Subramanya K. Prasad
    (2014)(reversing ALJ decision to set aside 1
    year exclusion Petitioner’s conviction for making a false statement to
    federal agents)


Reports


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