Health Care Fraud and Abuse Compliance Manual


Health Care Fraud and Abuse Compliance Manual


Publication Date



An immensely practical resource, Health Care Fraud and Abuse Compliance Manual provides a comprehensive overview of legislative and regulatory restrictions that affect the way health care providers conduct business and how they structure relationships among themselves. This treatise helps providers determine the boundaries of permissible conduct under the myriad statutes and regulations that relate to health care fraud and abuse at both the federal and state levels.



Table of Contents

Overview of Health Care Fraud and Abuse Summary of Health Fraud Offenses and Sanctions Government Enforcement Programs and Trends False Claims and Fraudulent Billing Criminal Penalties for False Statements, False Claims, and Other Fraudulent Billing Activities Civil Penalties for False Statements, False Claims, and Other Fraudulent Activities Risks of Potential Civil and Criminal Liability Exclusion from Federal and State Health Care Programs Double Jeopardy and Excessive Fines Fraud and Abuse Prohibitions under the Antikickback Statute The Antikickback Statute Provider Risks under the Antikickback Statute Safe Harbor Regulations Sanctions Attorney Involvement in Antikickback Arrangements Federal Physician Self-Referral Prohibitions: The Stark Law History of the Law and Regulations Self-Referral Provisions Sanctions and Enforcement Reporting Requirements Distinction Between Antikickback and Self-Referral Legislation Advisory Opinions under the Stark Law Provider Risk Areas and Risk Avoidance Administrative Action and Judicial Interpretations Corporate Compliance Programs Liability for Corporate Offenses The Guidelines and Corporate Compliance Programs Developing a Compliance Program Benefits of a Compliance Program Anatomy of an Investigation Investigators of Health Care Fraud Investigative Tools Investigatory Strategies Origins of an Investigation Strategies for Responding to a Subpoena How to Deal with Investigators Attorney-Client Privileges and Others Specific Defenses to Investigative Methods Used in Health Care Fraud Internal Investigations Managing Documents Medical Records Anticipating Health Care Fraud Investigations Provider Disclosures The Settlement Process Report on State Antifraud Enforcement State Medicaid Fraud Control Units Fraud and Abuse in Medicaid Managed Care State Medicaid Agency Fraud and Abuse Plan State False Claims Acts State Health Care False Claims Statutes State Self-Referral and Antikickback Laws Future Trends in Fraud Enforcement

Health Care Fraud and Abuse Compliance Manual