Fraud Specifically Health Insurance Fraud Term Paper


¶ … Medicare and Medicaid Services (CMS), previously the Health Care Financing Administration (HCFA), that by the time 2011, health care expenditure will arrive at $2.8 trillion, as well as it will bill for 17% of the Gross Domestic Product. As a result, it is no revelation that white-collar offenders observe health care deception as a rewarding effort. Certainly, the General Accounting Office ("GAO") quotes that such deception accounts for up to 10% of entire health care expense (3). As health care deception outlays taxpayers almost $100 billion a year, federal, as well as state agencies have given health care fraud tribunal a key center of attention. All through her term, Attorney General Janet Reno made impeaching health care fraud a top precedence at the Department of Justice ("DOJ"), subsequent only to brutal offenses (3).

The government focuses its pains to perceive, as well as take legal action against health care fraud in the federal health care insurance programs, Medicare and Medicaid. Statutes passed to deal with fraud in these precise programs have turned out to be requirements for the reason that the government's second largest community program, Medicare, carries on to be an eye-catching target for fraud, as well as abuse (7).

Individuals and organizations licensed by Department of Health and Human Services ("HHS") to accept imbursement under the Social Security Act may focus on Medicare and Medicaid fraud examinations (7). Persons, as well as organizations comprise nursing and rehabilitation centers, hospitals, Health Maintenance Organizations ("HMOs"), intermediate carriers for example private and public clinics, private insurance companies, durable medical equipment ("DME") providers, medical laboratories, physician practice groups, physicians, as well as other certified health care organizations (7).

Quite a few government agencies are in the process of lessening health care fraud. The DOJ, as well as HHS give screening and enforcement of health care fraud regulations. Inside HHS, the Office of the Inspector General ("OIG"), as well as CMS, assisted by the individual states, start and chase investigations of Medicare and Medicaid fraud (3).

Additionally, the OIG utilizes its tolerant prohibition power as an inducement for suppliers to assist in the attempt through a charitable disclosure program. In trials of fraud, DOJ uses the funds of its personal criminal and civil divisions, as well as those of the United States Attorney offices and the Federal Bureau of Investigation ("FBI") (3).

This paper critically evaluates the statutes purposely passed to tackle Medicare and Medicaid insurance fraud, evaluates the fundamentals, penalties, defenses, and safe harbor provisions for each and every statute, as well as concludes with a discussion of accessible legal safe harbor provisions (3).

This paper also discusses the wide-ranging federal statutes employed to impeach health care fraud, together with the False Claims, False Statements, as well as Mail and Wire Fraud Acts, and explains the basics of the offenses, accessible defenses, and penalties valid under each statute. The paper also gives an indication of federal and state government agencies' pains to examine and take legal action against health care fraud (3).

Statutes and provisions specifically enacted to address Medicare and Medicaid fraud

Congress' reply to the mushrooming augmentation in Medicare and Medicaid fraud and mistreatment has been to make stronger existing statutes and to go by new laws that considerably augment the government's aptitude to notice and battle health care fraud and abuse. The effect is a legislative and regulatory scheme that makes civil and criminal restrictions for any person or legal entity that gives health care goods or services in a deceitful or offensive manner. Criminal prosecution might, in addition, be brought under the False Claims Act, as well as other criminal fraud statutes (3).

A. Medicaid False Claims Statute

The Medicaid False Claims Statute criminalizes the constructing of fake statements or representation regarding any requests for claim of benefits or payment, or removal of assets underneath a federal health care program. At the same time as the Medicaid False Claims Statute was passed to aim fake statements or representations specially concerning health care, the preponderance of trials concerning health care fraud and abuse continue to be produced under other statutes (5).

I. Elements of the Offense

The government has got to establish four elements to maintain a conviction under the statute: (i) the defendant made, or caused to be made, a statement of material fact in an application for payment or benefits under a federal health care program; (ii) the statement or representation was false; (iii) the defendant knowingly and willfully made the statement; and (iv) the defendant knew the statement to be false (5).

a. Statement of Material Fact



Materiality subsists where the fake statement has a usual propensity to power, or is competent of disturbing or manipulating, a task executed by a government agency. Only the aptitude of a statement to persuade must be revealed, not the subsistence of actual dependence on a statement (5).
b. Representation Made Was False

The fake statement has got to essentially be presented. This comprises, but is not restricted to, billing Medicaid for measures or tests not executed; falsely maintaining that a series of measures were considered necessary, owing to "accidents;" submitting demands for patients never seen; as well as submitting claims for services not in-person provided (5).

c. Knowingly and Willfully

The Medicaid False Claims Statute is relevant to whoever knowingly and willfully makes or causes to make any false statement or representations (5).

d. Defendant Knew the Statement to be False

At the same time as several Circuits have not yet measured whether a showing of knowledge of fallacy is necessary under the Medicaid False Claims Statute, both the Ninth, as well as Tenth Circuits have affirmed that knowledge of fallacy is an indispensable component of Medicaid fraud (5).

In United States v. Laughlin, the Tenth Circuit upturned defendant's Medicaid fraud sentences on the ground that the trial judge committed damaging error by failing to explain the adjudicators that the defendant has got to know that the statement was fake when the claim was put forward. As such, in these circuits, the defendant must not simply have made a false statement, however, the defendant must also have recognized the statement to be fake at the time of its creation (5).

2. Penalties

Conviction under the Medicaid False Claims Statute is a criminal act that is carrying a punishment by a fine not to go beyond $25,000, custody for not more than five years, or both. Until lately, a person who advised or helped an individual to relocate assets to turn out to be qualified for medical assistance was responsible of an offense and confronted a fine not more than $10,000, custody for not more than one year, or both. On the other hand, the soundness of this stipulation, [section] 1320a-7b (a)(6)(ii), has lately been called into question. In 1998, the Northern District of New York instructed the Department of Justice from implementing the provision on First Amendment basis. Depending on the New York case, a Florida state Court of Appeals confirmed this provision unlawful. The Supreme Court, on the other hand, has not ruled on the constitutionality of this stipulation (5).

In addition, the bureaucrat of such programs might bound, limit or postpone a person found culpable under [section] 1320a-7b from contributing in Medicaid and Medicare programs for an age not to go beyond one year. Courts have held that this postponement is not disciplinary and, consequently, does not infringe the Double Jeopardy Clause of the Fifth Amendment (5).

B. Medicaid Anti-Kickback Statute

The Medicaid anti-kickback statute forbids knowingly and willfully paying or getting any compensation directly or in a roundabout way, openly or secretly, in hard cash or kind, in swap for prescribing, buying or advocating any service, treatment or item for which expense will be made by Medicare, Medicaid or any additional federally financed health care program (19).

The statute is fairly wide in range and applies in almost all sectors of the health care business. Section 1320a-7b (b) forbids not only deliberate unlawful actions, for example bribes and kickbacks, but in addition, a selection of economic associations considerably more multifaceted than simple direct payments for services (19).

Consequently, the statute applies to a lot of practices that were beforehand commonly acknowledged in business, together with reduction arrangements, enticements given to pharmacists, expenses for services, as well as the practices of manufacturers providing gifts and business courtesies (19).

1. Elements of the Offense

So as to convict a defendant for infringing the anti-kickback statute, the government has got to show that the defendant: knowingly and willfully, asked for or received payments, in return for transfer of program-related business (19).

a. Knowingly and Willfully

Understanding of the "knowingly and willfully" obligation and the definition of payment has generated diverse results. The stipulations "knowingly and willfully" are not definite in the statute. As such, the circuits have been divided on the essential level of intent required to please the mens rea obligation (19).

A number of circuits have interpreted "knowingly and willfully" to require that the Government have to establish that the defendants identified their behavior was illegal. For instance, in Hanlester Network v. Shalala, the Ninth Circuit stated "knowingly and willfully"…

Sources Used in Documents:


(1) Adelaide Few & Jay Trezevant, Fighting the Battle Against Health Care Fraud & Federal Enforcement Actions, 72 FLA. B.J. 34, 34-6 (1998)

(2) Alice A. Love, Leniency Offered Health Care Providers that Admit Federal Fraud, S.D. Union Trib., Oct. 22, 1998

(3) Andy Bunds, The results of the Health Insurance Regulations on Health Care Fraud and Abuse, 72 Mont L. Rev. 63, 72 (2001)

(4) Brian A. Kaset, Sailing Without Safe Harbors: Physician Recruitment and the Law of Fraud and Abuse, 9 Healths Span. 9, 9 (1992)

Cite this Document:

"Fraud Specifically Health Insurance Fraud" (2003, November 26) Retrieved June 13, 2024, from

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