An introduction to healthcare fraud and abuse for compliance staff, consultants and managers: the legal framework, the major federal laws and their exceptions, common schemes, enforcement agencies and processes, compliance program elements, auditing and monitoring, investigations and self-disclosure, penalties, whistleblowers and building a career in compliance. Eighteen lessons.
Modules
The Fraud and Abuse Framework
Lessons
Exceptions and Common Schemes
Lessons
Compliance Programs
Lessons
Auditing Monitoring and Investigations
Lessons
Penalties and Enforcement Outcomes
Lessons
Specialized Areas and Career
Lessons
Other Lessons
Module 4 Review
Module review: key terms, activity and quiz.
Lesson 1.1: Why Healthcare Fraud and Abuse Law Exists
Healthcare is unusual among industries in how often the person receiving a service (the patient) is not the one deciding what service to provide or paying most of its cost; a physician typically decides what care is medi
Lesson 5.1: Mandatory and Permissive Exclusions
HHS OIG has the authority to exclude individuals and entities from participation in all federal healthcare programs, meaning an excluded individual or entity cannot bill Medicare, Medicaid, or other federal healthcare pr
Lesson 1.2: Fraud, Abuse, and Waste: Related but Distinct Concepts
Healthcare fraud generally refers to knowingly and willfully submitting, or causing the submission of, false or fraudulent claims for payment, such as billing for services never rendered, billing for a higher level of se
Lesson 5.2: The List of Excluded Individuals and Entities (LEIE)
OIG maintains the List of Excluded Individuals and Entities (LEIE), a searchable public database of all individuals and entities currently excluded from federal healthcare program participation, updated regularly. Health
Lesson 1.3: Who Enforces These Laws
Several federal agencies share enforcement responsibility for healthcare fraud and abuse law, often working together on the same matters. The Department of Justice (DOJ), through its Civil Division and U.S. Attorneys’ Of
Lesson 5.3: Building an Exclusion Screening Process
An effective exclusion screening process starts with checking the LEIE and the applicable state Medicaid exclusion list(s) before any hire, credentialing, or contracting decision, and documenting the results of that chec
Module 1 Review
Module review: key terms, activity and quiz.
Module 5 Review
Module review: key terms, activity and quiz.
Lesson 2.1: What the Anti-Kickback Statute Prohibits
The federal Anti-Kickback Statute (AKS) makes it a criminal offense to knowingly and willfully offer, pay, solicit, or receive any remuneration to induce or reward referrals of items or services reimbursable by a federal
Lesson 6.1: The Seven Elements of an Effective Compliance Program
OIG has long described a set of core elements that characterize an effective healthcare compliance program, elements that appear consistently across OIG’s compliance program guidance documents for different provider type
Lesson 2.2: Safe Harbors
Because the AKS is written broadly enough to potentially capture many ordinary and legitimate healthcare business arrangements, HHS OIG has established regulatory safe harbors: specific sets of conditions that, if fully
Lesson 6.2: Risk Assessment and Red Flag Identification
A functioning compliance program conducts a periodic risk assessment identifying the organization’s specific fraud and abuse risk areas based on its actual services, business arrangements, and payer mix, since a complian
Lesson 2.3: Penalties and Common Risk Areas
AKS violations carry both criminal and civil consequences: criminal penalties can include fines and imprisonment, and civil consequences can include civil monetary penalties and exclusion from federal healthcare programs
Lesson 6.3: Bringing the Laws Together: A Worked Compliance Scenario
Consider a hospital that pays a cardiologist a monthly stipend for serving as medical director of its cardiac catheterization lab, and that same cardiologist regularly refers patients to that hospital for both designated
Module 2 Review
Module review: key terms, activity and quiz.
Module 6 Review
Module review: key terms, activity and quiz.
Lesson 3.1: What the Stark Law Prohibits
The Stark Law (the physician self-referral law) generally prohibits a physician from referring Medicare or Medicaid patients for certain designated health services (DHS) to an entity with which the physician (or an immed
Lesson 3.2: Strict Liability: Why Stark Doesn’t Require Intent
The single most important distinction between Stark and the Anti-Kickback Statute is that Stark is a strict liability statute: unlike AKS, which requires proving the parties acted knowingly and willfully, Stark can be vi
Lesson 3.3: Stark Exceptions and Compliance Consequences
Stark exceptions function similarly in concept to AKS safe harbors, specific sets of conditions that, if met, permit an otherwise prohibited financial relationship, but Stark exceptions operate differently in a critical
Module 3 Review
Module review: key terms, activity and quiz.
Lesson 4.1: What the False Claims Act Prohibits
The federal False Claims Act (FCA) imposes civil liability on anyone who knowingly presents, or causes to be presented, a false or fraudulent claim for payment to the federal government, or who knowingly makes, uses, or
Lesson 4.2: Qui Tam Provisions and Whistleblowers
One of the FCA’s most consequential features is its qui tam provision, which allows a private individual (called a relator, often a current or former employee with inside knowledge of the alleged fraud) to file a lawsuit
Lesson 4.3: The Civil Monetary Penalties Law
The Civil Monetary Penalties Law (CMP Law) gives HHS OIG independent authority to impose civil monetary penalties, assessments, and program exclusion for a range of prohibited conduct, some of which overlaps with conduct