Health Insurance Fraud

Paper Summary:

This paper critically evaluates the statutes purposely passed to tackle medicare and medicaid insurance fraud. It also examines 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. It discusses the wide-ranging federal statutes employed to impeach health care fraud, together with the False Claims, False Statements, and the Mail and Wire Fraud Acts, and explains the basics of the offenses, accessible defenses, and penalties valid under each statute. It also gives an indication of federal and state government agencies' pains to examine and take legal action against health care fraud.

Outline
Introduction
Statutes and Provisions Specifically Enacted to Address Medicare and Medicaid Fraud
Medicaid False Claims Statute
Penalties
Medicaid Anti-Kickback Statute
Sale of Physician Practices, Practitioner Recruitment and Obstetrical Malpractice Insurance Subsidies
Contracts for Space, Equipment, Personal Services and Employment
Advertisements and Promotions
Referral Services
Relationships Between Providers
Arrangements Between Providers and Health Plans
Relationships Between Providers and Suppliers
Prosecuting Health Care Fraud With General Federal Statutes
False Claims Act
False Statements
Mail and Wire Fraud
Conclusion

From the Paper:

"An added safe harbor permits health plans with accords with CMS or a state health care program to give care for beneficiaries to augment coverage, decrease cost sharing amounts, or decrease premium amounts for enrollees under particular conditions. If the proposal is a competitive medical plan, health maintenance organization plan, prepaid health plan or any other plan with a contract with CMS or a state health care program, it has got to offer identical augmented coverage or reduced cost-sharing or payments to all Medicare or state health program enrollees unless CMS or the state endorses otherwise."

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