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.

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U.S. Code

• Health Care and Education Reconciliation
  Act: Fraud & Abuse
  • Sec.
    1106. Physician ownership-referral.
  • Sec. 1107. Payment for imaging
    services.
  • Sec. 1302. Medicare
    prepayment medical review limitations.
  • Sec. 1303. Funding to fight fraud,
    waste, and abuse.
  • Sec. 1304.
    90-day period of enhanced oversight for initial claims of DME suppliers.

• 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.

• 18 USC Sec. 287
  False, fictitious or fraudulent claims
• 18 U.S. Code Sec.
  1001 Statements or entries generally
• 18 U.S. Code Sec.
  1341 Frauds and swindles
• 18 U.S. Code Sec.
  1343 Fraud by wire, radio, or television
• 18 U.S. Code Sec.
  1347 Health care fraud
• 21 U.S. Code Sec.
  331 Prohibited acts
• 21 U.S. Code Sec.
  333 Penalties
• 31 USC Secs. 3729 to 3733 The Federal False Claims
  Act
  • 31
    USC Sec. 3729 False Claims.
  • 31 USC Sec.
    3730 Civil Actions for False Claims.
  • 31 USC Sec.
    3731 False Claims Procedures.
  • 31 USC Sec.
    3732 False Claims Jurisdiction.
• 42 USC Sec.
  1320a-7 Exclusion of certain individuals and entities from
  participation in Medicare
• 42 USC Sec.
  1320a-7a Civil monetary penalties
• 42 USC Sec.
  1320a-7b Criminal penalties for acts involving federal health care
  program (the Anti-Kickback law)
• 42 USC Sec.
  1395nn Limitation on certain physician referrals (the Stark law)

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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
    • Sec. 1000.10
      General definitions.
    • Sec. 1000.20
      Definitions specific to Medicare.
    • Sec. 1000.30
      Definitions specific to Medicaid.
  • 
    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)

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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)

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Reports

• DOJ:
  Health Care Fraud Press releases related to criminal and civil
  health care fraud enforcement actions collected by the HHS OIG.

• FBI: Health Care Fraud Recent cases show that medical
  professionals are more willing to risk patient harm in their schemes.
  The FBI is the primary agency for exposing and investigating health care
  fraud, with jurisdiction over both federal and private insurance
  programs.

• IRS: Healthcare Fraud – Criminal Investigation Criminal tax
  investigations are initiated when income generated from healthcare fraud
  is not correctly reported on tax returns, or when there is an
  overstatement of expenses on tax returns.
  • Examples of Healthcare Fraud Investigations The
    following examples of healthcare fraud investigations are written from
    public record documents on file in the courts within the judicial
    district where the cases were prosecuted.
  • 
    Statistical Data Healthcare Fraud enforcement statistics on
    investigations initiated, prosecutions recommended, indictments,
    sentenced investigations and months to serve in prison.
• HHS OIG: Provider Compliance
  Training Comparison of the anti-kickback statute and Stark law.

• Most Wanted Health
  Care Fugitives HHS is seeking fugitives on charges related to health
  care fraud and abuse.

• Exclusions Database List
  of Excluded Individuals and Entities (LEIE). Anyone who hires an
  individual or entity on the LEIE may be subject to civil monetary
  penalties.

• CMS Could Take
  Additional Actions to Help Improve Provider and Beneficiary Fraud
  Controls (GAO 2015) Federal laws require both federal and state
  entities to protect the Medicaid program from fraud, waste, and abuse.
  In February 2015, we reported that Medicaid remains at high risk because
  of concerns about the adequacy of fiscal oversight of the program,
  including improper payments to Medicaid providers.

• A Framework for
  Managing Fraud Risks in Federal Programs (GAO 2015) The Framework
  encompasses control activities to prevent, detect, and respond to fraud,
  with an emphasis on prevention, as well as structures and environmental
  factors that influence or help managers achieve their objective to
  mitigate fraud risks.

• HHS Met
  Many Requirements of the Improper Payments Information Act But Did Not
  Fully Comply for Fiscal Year 2013 (OIG 2014) OIG objectives were to
  (1) determine whether the Department of Health and Human Services
  (Department) complied with the IPIA for fiscal year (FY) 2013 in
  accordance with related Office of Management and Budget (OMB) guidance,
  (2) evaluate the accuracy and completeness of the Department’s
  reporting, and (3) evaluate the Department’s performance in reducing and
  recapturing improper payments.

• Special Fraud Alert:
  Laboratory Payments to Referring Physicians (OIG 2014) Addresses
  compensation paid by laboratories to referring physicians and physician
  group practices for blood specimen collection, processing, and
  packaging, and for submitting patient data to a registry or database.

• Special
  Advisory Bulletin: Effect of Exclusion from Participation in Federal
  Health Care Programs (OIG 2013) This updated HHS OIG Special
  Advisory Bulletin describes the scope and effect of the legal
  prohibition on payment by Federal health care programs for items or
  services furnished (1) by an excluded person or (2) at the medical
  direction or on the prescription of an excluded person.

• Special Fraud Alert: Physician-Owned
  Entities (OIG 2013) OIG addresses physician-owned entities that
  derive revenue from selling, or arranging for the sale of, implantable
  medical devices ordered by their physician-owners for use in procedures
  the physician-owners perform on their own patients at hospitals or
  ambulatory surgical centers.

• 
  Physicians May Be Liable for False Claims Submitted by Entities
  Receiving Reassigned Medicare Payments (OIG 2012) Physicians who
  reassign their right to bill the Medicare program and receive Medicare
  payments by executing the CMS-855R application may be liable for false
  claims submitted by entities to which they reassigned their Medicare
  benefits.

• Medicare Fraud &
  Abuse: Prevention, Detection, and Reporting Although no precise
  measure of health care fraud exists, those intent on abusing the system
  can cost taxpayers billions of dollars while putting beneficiaries’
  health and welfare at risk.

• Medicare
  Identity Theft and Fraud Deter, detect, defend!

• List of Largest
  Pharmaceutical Settlements List of the 20 largest settlements
  reached between the United States Department of Justice and
  pharmaceutical companies, ordered by the size of the total settlement.

• Health Care Fraud
  And Abuse Control Program: Indicators Provide Information on Program
  Accomplishments, but Assessing Program Effectiveness is Difficult
  (GAO 2013) The amount of money returned to the government as a result of
  HCFAC activities compared with the funding appropriated to conduct those
  activities–has increased from $4.90 returned for every $1.00 invested
  for fiscal years 2006-2008 to $7.90 returned for every $1.00 invested
  for fiscal years 2010-2012.

• Montana State
  Medicaid Fraud Control Unit: 2012 Onsite Review (OIG 2013) We
  recommend that the Montana Unit (1) ensure that supervisory approval to
  close cases and periodic supervisory reviews are documented in Unit case
  files, (2) ensure that it refers providers for exclusion to OIG within
  the appropriate timeframe, (3) revise its MOU with DPHHS, and (4) adhere
  to the MOU provisions. The Unit concurred with all four of our
  recommendations.

• MEDIC
  Benefit Integrity Activities in Medicare Parts C and D (OIG 2013)
  Although the MEDIC has benefit integrity responsibility for both
  Medicare Parts C and D, its Part C investigations and case referrals
  represented a small percentage of its benefit integrity activities. In
  addition, a small percentage of the MEDIC’s investigations and case
  referrals resulted from proactive methods. Moreover, barriers exist
  regarding data availability, access to information, and the recovery of
  inappropriate payments.

• The
  Medicare-Medicaid (Medi-Medi) Data Match Program (OIG 2012) The
  Medi-Medi program produced limited results and few fraud referrals.
  During 2007 and 2008, the program—in which 10 States had chosen to
  participate—received $60 million in appropriations and it avoided and
  recouped $57.8 million. The program produced 66 referrals to law
  enforcement, and law enforcement accepted 27 of these.

• Types of Providers
  Involved in Medicare Cases, and CMS Efforts to Reduce Fraud (GAO
  2012) Medical facilities (such as medical centers, clinics, and
  practices) and durable medical equipment suppliers were the most
  frequent subjects of criminal fraud cases in Medicare, Medicaid, and
  CHIP in 2010.

• Medicare
  Advantage Organizations’ Identification of Potential Fraud and Abuse
  (OIG 2012) MA organizations efforts to identify and address potential
  fraud and abuse are crucial to protecting the integrity of the MA
  program. Prior to this report, no study had examined potential fraud and
  abuse identified by MA organizations. CMS requires MA organizations to
  have compliance plans that include measures to detect, correct, and
  prevent fraud, waste, and abuse. However, CMS does not require MA
  organizations to report the results of their efforts to identify and
  address potential fraud and abuse incidents.

• Medicaid
  Managed Care: Fraud and Abuse Concerns Remain Despite Safeguards
  (OIG 2011) CMS stated that it will advise States to work with their MCEs
  to determine and implement effective strategies for verifying that
  services billed by network providers are received. CMS also stated that
  it has been developing a strategy to effectively address managed care
  program integrity and will revise its guidelines once that strategy is
  complete.

• Telemarketing by Durable Medical Equipment
  Suppliers (OIG 2010) Section 1834(a)(17)(B) specifically prohibits
  payment to a supplier that knowingly submits a claim generated pursuant
  to a prohibited telephone solicitation. Accordingly, such claims for
  payment are false and violators are potentially subject to criminal,
  civil, and administrative penalties, including exclusion from Federal
  health care programs.

• Guidance for Implementing
  Permissive Exclusion Authority Under Section 1128(b)(15) of the Social
  Security Act (OIG 2010) Sets forth nonbinding factors the Office of
  Inspector General (OIG) will consider in deciding whether to impose
  permissive exclusion.

• Policy Regarding
  Providers, Practitioners, and Suppliers That Waive Beneficiary
  Cost-Sharing Amounts Attributable to Retroactive Increases in Payment
  Rates (OIG 2010) OIG statement to assure providers, practitioners,
  and suppliers affected by retroactive increases in payment rates
  resulting from the operation of new Federal statutes or regulations that
  they will not be subject to Office of Inspector General (OIG)
  administrative sanctions if they waive Retroactive Beneficiary
  Liability.

• Schemes to Defraud
  Medicare, Medicaid, and Private Health Care Insurers (GAO 2000) GAO
  discussed various schemes used to defraud the Medicare and Medicaid
  programs.

• 
  Physician Liability for Certifications in the Provision of Medical
  Equipment and Supplies and Home Health Services (OIG 1999) While the
  OIG believes that the actual incidence of physicians’ intentionally
  submitting false or misleading certifications of medical necessity for
  durable medical equipment or home health care is relatively infrequent,
  physician laxity in reviewing and completing these certifications
  contributes to fraudulent and abusive practices by unscrupulous
  suppliers and home health providers.

• 
  Fraud and Abuse In Nursing Home Arrangements with Hospices (OIG
  1998) OIG focuses on the interrelationship between the hospice and
  nursing home industries and describes some potentially illegal practices
  the OIG has identified in arrangements between these providers.

• Medicare Home Health Benefit: Congressional and
  HCFA Actions Begin to Address Chronic Oversight Weaknesses (GAO
  1998) Discusses new tools that Congress has provided to strengthen
  oversight of the home health benefit.

• Medicare: Improper Activities by Mid-Delta Home
  Health. (GAO 1998) GAO discussed the results of its investigation
  into allegations of improper Medicare billings by a home health care
  agency.

• Fiscal
  Intermediary Fraud Units (OIG 1998) The HCFA requires that fiscal
  intermediaries and carriers have distinct units to detect and deter
  fraud and abuse. These units are part of HCFA’s overall Medicare
  integrity program and are monitored by HCFA regional offices. The HCFA
  is currently planning to separate future anti- fraud functions from
  other intermediary and carrier operations.

• Medicaid Fraud and Abuse: Stronger Action Needed to
  Remove Excluded Providers From Federal Health Programs (GAO 1997)
  Pursuant to a congressional request, GAO reviewed the Department of
  Health and Human Services (HHS) Inspector General’s (OIG) process for
  excluding providers from federal health care programs.

• Medicare Home Health Agencies: Certification
  Process Ineffective in Excluding Problem Agencies (GAO 1997)
  Examines how Medicare: (1) controls the entry of home health agencies
  (HHA) into the program; (2) ensures that certified HHAs continue to
  comply with conditions of participation and associated standards; and
  (3) decertifies HHAs that are not complying with requirements.

• Carrier Fraud
  Units (OIG 1996) The Health Care Financing Administration (HCFA) has
  charged their contractors with the responsibility of detecting and
  deterring program fraud, waste and abuse. Both carriers and
  intermediaries have set up fraud and abuse units as one element of
  HCFA’s overall benefit integrity program. To help defray the cost of
  investigating complaints, HCFA provided the carriers with nearly $23
  million to fund their fraud units.

• Fraud and Abuse in the Provision of Services
  in Nursing Facilities (OIG 1996) Nursing facilities and their
  residents have become common targets for fraudulent schemes. Nursing
  facilities represent convenient resident “pools” and make it lucrative
  for unscrupulous persons to carry out fraudulent schemes.

• Health Care Fraud: Information-Sharing Proposals to
  Improve Enforcement Efforts (GAO 1996) GAO discussed: (1) the extent
  of federal and state immunity laws protecting persons who report health
  care fraud; and (2) evidence for and against establishing a centralized
  health care fraud database.

• Fraud and Abuse: Providers Target Medicare Patients
  in Nursing Facilities (GAO 1996) GAO reviewed allegations of fraud
  and abuse related to services and supplies provided to nursing facility
  patients.

• Fraud and Abuse: Medicare Continues to Be
  Vulnerable to Exploitation by Unscrupulous Providers (GAO 1995). GAO
  discussed challenges Medicare faces in battling fraud and abuse in the
  health care system.

• Medicare Claims: Commercial Technology Could Save
  Billions (GAO 1995) Pursuant to a congressional request, GAO
  reviewed the Health Care Financing Administration’s (HCFA) potential use
  of commercial technology to detect Medicare billing errors.

• Medicare: Antifraud Technology Offers Significant
  Opportunity to Reduce Health Care Fraud (GAO 1995) Pursuant to a
  congressional request, GAO provided information on how the Medicare
  program detects and prevents fraud.

• Health Care Fraud: Information-Sharing Proposals to
  Improve Enforcement Efforts (GAO 1996) Pursuant to a congressional
  request, GAO discussed: (1) the extent of federal and state immunity
  laws protecting persons who report health care fraud; and (2) evidence
  for and against establishing a centralized health care fraud database.

• Medicare: New Claims Processing System Benefits and
  Acquisition Risks (GAO 1994). A new system for processing Medicare
  claims offers considerable opportunities to improve Medicare operations
  and safeguard program dollars.

• Medicare Transaction System: Success Depends Upon
  Correcting Critical Managerial and Technical Weaknesses (GAO 1997)
  Pursuant to a congressional request, GAO reviewed the Health Care
  Financing Administration’s (HCFA) acquisition of its Medicare
  Transaction System.

• Medicare: Referrals to Physician-Owned Imaging
  Facilities Warrant HCFA’s Scrutiny (GAO 1994). Because Florida had
  the only statewide information then available on doctors with a
  financial stake in imaging center joint ventures, GAO analyzed 1990
  Medicare claims for imaging services ordered by physicians in that
  state.

• Medicare: Greater Investment in Claims Review Would
  Save Millions (GAO 1994) Given soaring U.S. health care costs and
  shrinking budgets for many government programs, Congress is concerned
  that Medicare pay only for appropriate medical services without
  compromising the quality of care provided to beneficiaries.

• Medicare: Inadequate Review of Claims Payments
  Limits Ability to Control Spending (GAO 1994) Medicare overpayments
  of millions of dollars are being made because of inadequate safeguards
  by contractors who process Medicare claims and inattention by the
  federal Health Care Financing Administration.

• Medicare: Tighter Rules Needed to Curtail
  Overcharges for Therapy in Nursing Homes (GAO 1995) Nursing homes
  and rehabilitation centers are taking advantage of ambiguous payment
  rules and lack of guidelines to bill Medicare at inflated rates for
  therapy services.

• Medicare: Excessive Payments for Medical Supplies
  Continue Despite Improvements (GAO 1995) In fiscal year 1994 alone,
  Medicare was billed over $6.8 billion for medical supplies.

• Medicare Spending: Modern Management Strategies
  Needed to Curb Billions in Unnecessary Payments (GAO 1995) Pursuant
  to a congressional request, GAO examined Medicare’s vulnerability to
  provider exploitation and ways to remedy Medicare fraud and abuse.

• Medicare: Home Health Utilization Expands While
  Program Controls Deteriorate (GAO 1996) Pursuant to a congressional
  request, GAO examined the growth in the use of Medicare home health
  benefits.

• Fraud and Abuse: Providers Target Medicare Patients
  in Nursing Facilities (GAO 1996) Pursuant to a congressional
  request, GAO reviewed allegations of fraud and abuse related to services
  and supplies provided to nursing facility patients.

• Medicare: Millions Can Be Saved by Screening Claims
  for Overused Services (GAO 1996) GAO provided information on
  Medicare payments for unnecessary medical services.

• Medicare: Private Payer Strategies Suggest Options
  to Reduce Rapid Spending Growth (GAO 1996) GAO discussed strategies
  to curb Medicare spending, which has grown by over 10 percent a year
  since 1989, twice the rate of the national economy.

• Medicare: Early Resolution of Overcharges for
  Therapy in Nursing Homes is Unlikely (GAO 1996) Pursuant to a
  congressional request, GAO reviewed the Health Care Financing
  Administration’s (HCFA) progress in curbing overbilling for occupational
  speech and physical therapy services.

• Fraud and Abuse: Providers Excluded From Medicaid
  Continue to Participate in Federal Health Programs (GAO 1996) GAO
  discussed whether the Department of Health and Human Services’ (HHS)
  Office of Inspector General’s (OIG) process for removing fraudulent
  health care providers from all federal health programs.

• Medicare HMOs: HCFA Can Promptly Eliminate Hundreds
  of Millions in Excess Payments (GAO 1997) Pursuant to a
  congressional request, GAO provided information on Medicare’s
  rate-setting method for paying risk contract health maintenance
  organizations.

• Medicaid Fraud and Abuse: Stronger Action Needed to
  Remove Excluded Providers From Federal Health Programs (GAO 1997)
  Pursuant to a congressional request, GAO reviewed the Department of
  Health and Human Services (HHS) Inspector General’s (OIG) process for
  excluding providers from federal health care programs.

• Medicare: Need to Hold Home Health Agencies More
  Accountable for Inappropriate Billings (GAO 1997) Pursuant to a
  congressional request, GAO reviewed Medicare’s ability to detect and
  prevent inappropriate payments to home health agencies.

• Nursing Homes: Too Early to Assess New Efforts to
  Control Fraud and Abuse (GAO 1997) GAO discussed the challenges that
  exist in combating fraud and abuse in the nursing facility environment.

• Medicare: Allegations Against ABC Home Health
  Care (GAO 1997) In response to a congressional request, GAO
  investigated allegations against ABC Home Health Care, a home health
  agency (HHA), and its participation in the Medicare home health care
  program.

• Fraud and Abuse: Providers Excluded From Medicaid
  Continue to Participate in Federal Health Programs (GAO 1996) GAO
  discussed whether the Department of Health and Human Services’ (HHS)
  Office of Inspector General’s (OIG) process for removing fraudulent
  health care providers from all federal health programs.

• Fraud and Abuse: Providers Target Medicare Patients
  in Nursing Facilities (GAO 1996) Pursuant to a congressional
  request, GAO reviewed allegations of fraud and abuse related to services
  and supplies provided to nursing facility patients.

• Electronic Benefits Transfer: Use of Biometrics to
  Deter Fraud in the Nationwide EBT Program (GAO 1995) The National
  Performance Review recommended in 1993 that the federal government
  consider paying individuals by using electronic rather than paper means.

• Investigators’ Guide to Sources of Information
  (GAO 1997) GAO presented an investigative tool for identifying sources
  of information about people, property, business, and finance.

• Medicare: Antifraud Technology Offers Significant
  Opportunity to Reduce Health Care Fraud (GAO 1995) Pursuant to a
  congressional request, GAO provided information on how the Medicare
  program detects and prevents fraud.

• Medicare Claims: Commercial Technology Could Save
  Billions (GAO 1995) Pursuant to a congressional request, GAO
  reviewed the Health Care Financing Administration’s (HCFA) potential use
  of commercial technology to detect Medicare billing errors.

• Medicare Claims
  Billing Abuse: Commercial Software Could Save Hundreds of Millions
  Annually (GAO 1995) With an investment of only $20 million in
  off-the-shelf commercial software, Medicare could save nearly $4 billion
  over five years by detecting fraudulent claims by physicians–primarily
  manipulation of billing codes.

• Medicare: Modern
  Management Strategies Could Curb Fraud, Waste, and Abuse (GAO 1995)
  Medicare’s vulnerability to waste, fraud, and abuse stems from several
  factors: (1) higher-than-market rates; 2) inadequate checks for
  detecting fraud and abuse; 3) superficial criteria for confirming
  authenticity of providers, and; (4) weak enforcement. 

• Medicare:
  Excessive Payments for Medical Supplies Continue Despite
  Improvements (GAO 1995) (1) Medicare’s payment rates for surgical
  dressings are generally excessive, compared to wholesale and retail
  prices; (2) Medicare contractors that process claims for hospitals and
  nursing homes are unable to identify specific items being billed, which
  makes it difficult to determine whether the total charges are
  reasonable; (3) Medicare contractors that process claims for providers
  have paid for some surgical dressings without first reviewing the claims
  before payment; (4) claims processing contractors cannot cross-reference
  payment records to identify possible duplicate payments; and (5) the
  fee-schedule approach provides a good starting point for setting
  appropriate Medicare prices, but the Health Care Financing
  Administration needs greater flexibility to adjust fee schedule prices
  when market conditions warrant such changes

• Financial
  Arrangements Between Physicians and Health Care Businesses: Report to
  Congress (OIG 1989) Section 203(c)(3) of the Medicare Catastrophic
  Coverage Act (MCCA) of 1988 directed the GIG to report to Congress by
  May 1, 1989 on: physician ownership of, or compensation from, an entity
  providing items or services to which the physician makes referrals and
  for which payment may be made under the Medicare program; the range of
  such arrangements and the means by which they are marketed to
  physicians; the potential of such ownership or compensation to influence
  the decision of a physician regarding referrals and to lead to
  inappropriate utilization of such items and services; and the practical
  difficulties involved in enforcement actions against such ownership and
  compensation arrangements that violate current anti-kickback provisions.

• Financial
  Arrangements Between Physicians and Health Care Businesses: Perspectives
  of Health Care Professionals (OIG 1989) In 1980, an influential
  article in The New England Journal of Medicine by the journal’s editor,
  Dr. Arnold Relman, elicited strong debate in the medical community
  concerning the appropriateness of such arrangements and the impact that
  they might have on medical judgments made by physicians in determining
  what services their patient’s require. Since then, public scrutiny of
  those financial arrangements has increased.

• Financial
  Arrangements Between Physicians and Health Care Businesses: State Laws
  and Regulations (OIG 1989) No respondents indicated that their
  states have an outricrht ban on phvsicians owning a health care entitv.
  However. respondents in Michiqan cited a law in their state which
  forbids physicians from referring patients to an entity in which they
  have financial interests.

• Medicare
  Carriers’ Performance of Program Integrity Functions (OIG 1988) It
  is estimated that the Medicare carriers processed over 333 million
  claims in Fiscal Year 1987. In the processing of these claims carriers
  must ensure that payments are made only for services covered under the
  Medicare program, medically necessary under recognized standards of
  medical care, and actually rendered to eligible beneficiaries.

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