As the health care industry becomes more complex, so does compliance regarding the False Claims Act, Medicare Fraud, Medicare Abuse, Anti-Kickback Statute (AKS), Stark Law, and Criminal Health Care Fraud Statute.
Below is a brief summary as to how the criminal health care fraud statute may be defined and/or interpreted.
The Criminal Health Care Fraud Statute, 18 U.S.C. Section 1347 prohibits knowingly and willfully executing, or attempting to execute, a scheme or lie in connection with the delivery of, or payment for, health care benefits, items, or services to either:
- Defraud any health care benefit program
- Obtain (by means of false or fraudulent pretenses, representations, or promises) any of the money or property owned by, or under the control of, any health care benefit program
Example: Several doctors and medical clinics conspire in a coordinated scheme to defraud the Medicare Program by submitting medically unnecessary claims.
Penalties: Penalties for violating the Criminal Health Care Fraud Statute may include fines, imprisonment, or both.
Exclusion Statute
The Exclusion Statute, 42 U.S.C. Section 1320a-7, requires the OIG to exclude individuals and entities convicted of any of the following offenses from participation in Federal health care programs:
- Medicare or Medicaid fraud, as well as any other offenses related to the delivery of items or services under Medicare or Medicaid;
- Patient abuse or neglect;
- Felony convictions for other health care-related fraud, theft, or other financial misconduct; and/or
- Felony convictions for unlawful manufacture, distribution, prescription, or dispensing controlled substances.
The OIG also may impose permissive exclusions on other grounds, including:
- Misdemeanor convictions related to health care fraud other than Medicare or Medicaid fraud, or misdemeanor convictions for unlawfully manufacturing, distributing, prescribing, or dispensing controlled substances;
- Suspension, revocation, or surrender of a license to provide health care for reasons bearing on professional competence, professional performance, or financial integrity;
- Providing unnecessary or substandard services;
- Submitting false or fraudulent claims to a Federal health care program;
- Engaging in unlawful kickback arrangements; and/or
- Defaulting on health education loan or scholarship obligations.
Excluded providers may not participate in the Federal health care programs for a designated period. If the physician is excluded by OIG, then Federal health care programs, including Medicare and Medicaid, will not pay for items or services that the physician furnishes, orders, or prescribes. Excluded providers may not bill directly for treating Medicare and Medicaid patients, and an employer or a group practice may not bill for an excluded provider’s services. At the end of an exclusion period, an excluded provider must seek reinstatement; as reinstatement is not automatic.
The OIG maintains a list of excluded parties called the List of Excluded Individuals/Entities (LEIE).
Courtesy of CMS (2/19)
