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Health Law & Policy. Center For Health Law and Policy Innovation. (2023, October 3). https://chlpi.org/health-law-and-policy/

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The Big Five Federal Fraud and Abuse Laws

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The Big Five Federal Fraud and Abuse Laws

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The federal government has laws which apply to physicians in regard to fraud and abuse. The five laws False Claims Act (FCA), the Anti-Kickback Statute (AKS), the Physician Self-Referral Law (Stark law), the Exclusion Authorities, and the Civil Monetary Penalties Law (CMPL) (Fraud & abuse laws, 2021). The federal government has assigned several agencies to oversee these laws. The agencies include Department of Justice, the Department of Health & Human Services Office of Inspector General (OIG), and the Centers for Medicare & Medicaid Services (Fraud & abuse laws, 2021). The laws presented today are the best tools each agency has against crime committed against healthcare.

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Stark Law is designed to prohibit physicians from referring patients to special interest or family members for financial benefit. The law is one of many which protects patients from financial physician abuse. Office of Inspector General Defines Stark Law (2021) as,

"The Physician Self-Referral Law, commonly referred to as the Stark law, prohibits physicians from referring patients to receive "designated health services" payable by Medicare or Medicaid from entities with which the physician or an immediate family member has a financial relationship."

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The Exclusion Statute disbars individual committed crimes such as healthcare fraud from working with federal health care programs. In Florida, AHCA works with healthcare organizations to run background checks on new employee hires. Office of Inspector General states (2021),

"OIG is legally required to exclude from participation in all Federal health care programs individuals and entities convicted of the following types of criminal offenses: (1) Medicare or Medicaid fraud, as well as any other offenses related to the delivery of items or services under Medicare or Medicaid; (2) patient abuse or neglect; (3) felony convictions for other health-care-related fraud, theft, or other financial misconduct; and (4) felony convictions for unlawful manufacture, distribution, prescription, or dispensing of controlled substances."

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The Civil Monetary Penalties Law gives Secretary of Health and Human Services the authority to impose fines on individuals who defraud the government health programs. Two programs found most abused are Medicare and Medicaid. The Office of Inspector General (2021) defines the law as,

"OIG may seek civil monetary penalties and sometimes exclusion for a wide variety of conduct and is authorized to seek different amounts of penalties and assessments based on the type of violation at issue. Penalties range from $10,000 to $50,000 per violation. Some examples of CMPL violations include:"

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Anti-Kickback Statue discourages healthcare providers from receiving additional money for referring patients. Good example is drug treatment centers providing money to individuals who refer patients to their centers. The Office of Inspector General Defines Anti-Kickback statue as (2021),

"The AKS is a criminal law that prohibits the knowing and willful payment of "remuneration" to induce or reward patient referrals or the generation of business involving any item or service payable by the Federal health care program."

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Patients are protect by the False Claims Act which ensures patients are overcharges for health services. The False Claims Act is one of most powerful tools our Federal Government has against healthcare fraud. According to the Office of Inspector General (2021),

"The civil FCA protects the Government from being overcharged or sold shoddy goods or services. It is illegal to submit claims for payment to Medicare or Medicaid that you know or should know are false or fraudulent."

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Professionalism in medicine: Exploring the code of conduct. Avant. (n.d.). https://www.avant.org.au/Professionalism_in_medicine__exploring_the_code_of_conduct/

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What are the fraud and abuse laws? What are their differences?

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Fraud & abuse laws. Office of Inspector General | Government Oversight | U.S. Department of Health and Human Services. (2021, October 5). https://oig.hhs.gov/compliance/physician-education/fraud-abuse-laws/

Health Law & Policy. Center For Health Law and Policy Innovation. (2023, October 3). https://chlpi.org/health-law-and-policy/

Professionalism in medicine: Exploring the code of conduct. Avant. (n.d.). https://www.avant.org.au/Professionalism_in_medicine__exploring_the_code_of_conduct/