Health care fraud and abuse laws

Archives of Pathology and Laboratory Medicine

Volumn 130, Issue 8, 2006, Pages 1169-1177

  Klein, Roger D ^a,b   Campbell, Sheldon ^a  

^a YALE UNIVERSITY SCHOOL OF MEDICINE   (United States)

^b YALE NEW HAVEN HOSPITAL   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

FORGERY; HEALTH CARE FRAUD; HEALTH CARE PLANNING; HUMAN; LABORATORY DIAGNOSIS; LAW; LAW ENFORCEMENT; LEGAL ASPECT; PATHOLOGIST; PATHOLOGY; PROFESSIONAL MISCONDUCT; PROFESSIONAL PRACTICE; PUNISHMENT; REVIEW;

FRAUD; GOVERNMENT REGULATION; HEALTH CARE COSTS; HEALTH SERVICES MISUSE; HUMANS; LAW ENFORCEMENT; UNITED STATES;

EID: 33746713725     PISSN: 00039985     EISSN: None     Source Type: Journal    
DOI: None     Document Type: Review

References (62)

1. Department of Health and Human Services/Office of Inspector General. Fiscal Year 2005 Work Plan, Centers for Medicare and Medicaid Services, 11. Available at: http://oig.hhs.gov/publications/workplan.html. Accessed April 10, 2005.
2. The Health Insurance Portability and Accountability Act of 1996, 42 USC §1320a-7(c)(1996).
3. Health Care Fraud and Abuse Control Program Annual Report for FY2003. Available at: http://www.usdoj.gov/dag/pubdoc/hcfacreport2003.htm. Accessed April 10, 2005.
4. Krause J. Regulating, guiding, and enforcing health care fraud. NYU Annual Survey of American Law. 2004;60:241-282.
5. 42 USC §1320a-7b.
6. United States v Graber, 760 F2d 68 (3rd Cir 1985); United States v McClatchey, 217 F3d 823 (10th Cir 2000).
7. Office of Inspector General Advisory Opinion No. 99-13, November 30, 1999; OIG Special Fraud Alert, December 19, 1994.
8. See also an October 2, 1997, letter from Kevin C. McAnaney, Chief of the OIG Industry Guidance Branch, to an unnamed party. Available at: http:// oig.hhs.gov/. Accessed April 10, 2005. This letter described as "highly suspect" the failure of a laboratory to charge a nursing home for the provision of a variety of clinical pathology-related services, including "reviewing doctors' orders and establishing, changing, or discontinuing 'standing orders' for certain tests based on that review; determining whether doctors' orders for laboratory tests have been carried out and recorded, along with the results, in patients' charts; reviewing patients' drug regimens and determining whether there is a need for laboratory monitoring or tests; and providing infection control services, including testing and reporting areas where acceptable limits are exceeded. The OIG stated that "a strong inference is that the clinical laboratories are being asked to provide the free chart review and infection control services in exchange for referrals of the nursing homes' laboratory business, including services payable in whole or in part by a federal program."
9. United States v Liss, 265 F3d 1220 (11th Cir 2001);
10. BNA Health Care Fraud Report. 1999;3(13):57;
11. BNA Health Care Fraud Report. 2000;4(8):279;
12. BNA Health Care Fraud Report. 2000;4(9):311.
13. AMNews. November 19, 2001;
14. AMNews. October 28, 2002.
15. Office of Inspector General Advisory Opinion No. 04-17, December 17, 2004.
16. Financial Arrangements Between Hospitals and Hospital Based Physicians, Office of Inspector General, Department of Health and Human Services. OEI-09-89-00330, January 31, 1991. See also, OIG Supplemental Compliance Program Guidance for Hospitals, 11(B)(2)(b), 70 Federal Register 4867 (2005). "Accordingly, arrangements that require physicians to provide Medicare Part A supervision and management services for token or no payment in exchange for the ability to provide physician-billable Medicare Part B services at the hospital potentially violate the anti-kickback statute and should be closely scrutinized."
17. 42 CFR §1001.952.
18. 42 USC §§1395nn.
19. 42 CFR §§411.351-361.
20. 66 Federal Register. 859-860 (2001).
21. Fabrikant R, Kalb PE, Hopson MD, Bucy PH. Health care fraud: enforcement and compliance. New York, NY: Law Journal Press. 1996:§4.05[5].
22. 42 USC §1395nn(g).
23. 42 USC §1320a-7a(a)(7).
24. 42 CFR §411.355; 42 CFR §410.20.
25. 66 Federal Register. 874 (2001).
26. Fabrikant R, Kalb PE, Hopson MD, Bucy PH. Health care fraud: enforcement and compliance. New York, NY: Law Journal Press. 1996:§4.05[2](c).
27. Direct compensation arrangements involve remuneration directly between a physician or immediate family member and a DHS provider. Indirect compensation arrangements involve remuneration between a referring physician or immediate family member and an entity that is part of an unbroken chain between DHS and the referring physician or immediate family member such that each link in the chain has an ownership or investment interest or a compensation arrangement with the preceding link. Under the regulations, indirect financial relationships by definition require knowledge of the relationship on the part of the DHS entity.
28. 31 USC §§3729; 3730(a)-(b).
29. United States ex rel Pogue v American Healthcorp, Inc, 914 FSupp 1507 (MD Tenn 1966).
30. Taxpayers Against Fraud Website, Qui Tam Statistics (citing figures provided by the United States Department of Justice). Available at: http://www.taf.org/ statistics.htm. Accessed March 25, 2005.
31. United States ex rel Merena v SmithKline Beecham Corp, 114 FSupp 2d 352 (ED Pa Aug 3, 2000).
32. Raspanti MS, Laigaie DM. A case study: Department of Justice v. Qui Tam Relators. BNA Health Care Fraud Report. 2(11) June 3, 1998.
33. BNA Health Care Fraud Report. 1(3) February 12, 1997.
34. BNA Health Care Fraud Report. 2(14) July 15, 1998.
35. BNA Health Care Fraud Report. 1(14) July 16, 1997.
36. Health Care Fraud and Abuse Control Program Annual Report for FY2003. Available at: http://www.usdoj.gov/dag/pubdoc/hcfacreport2003.htm. Accessed April 10, 2005.
37. U.S. v. Worner v. Dianon Systems, Inc., No. 3:99CV407 (D. Conn.). TAF Quarterly Review. 2003;29:54-55.
38. BNA Health Care Fraud Report. 2003;7:34.
39. 42 USC §1320a-7a;42 CFR §§1101.100-.135.
40. 18 USC §1347.
41. 18 USC §1956. Fabrikant R, Kalb PE, Hopson MD, Bucy PH. Healthcare fraud: enforcement and compliance. New York, NY: Law Journal Press. 1996: §3.02[12](3-100).
42. 18 USC §982(a)(6).
43. 42 USC §1320a-7d.
44. 42 CFR §§1008, et seq.
45. Fabrikant R, Kalb PE, Hopson MD, Bucy PH. Health care fraud: enforcement and compliance. New York, NY: Law Journal Press. 1996:§3.01[3-5].
46. 18 USC §669.
47. 18 USC §1035.
48. 18 USC §1347.
49. 18 USC §1518.
50. 42 USC §1320a-7b.
51. 42 USC §1320a-7b(a)(1).
52. 42 USC §1320a-7b(a)(5).
53. 42 USC §1320a-7b(a)(3).
54. 42 USC §1320a-7a; 42 CFR §§1101.101-.3005.
55. 18 USC §§1035, 3571.
56. 18 USC §§1961 et seq.
57. 18 USC §§1341, 1343.
58. 18 USC §§1956, 1957.
59. 18 USC §§286, 371.
60. 18 USC §641.
61. 18 USC §§286, 287, 1001.
62. 18 USC §§1503, 1505, 1512, 1518, 1622.