* Legal and Ethical Considerations in Healthcare Fraud Investigation
Expert-defined terms from the Professional Certificate in Healthcare Fraud Investigation course at Stanmore School of Business. Free to read, free to share, paired with a globally recognised certification pathway.
Anti #
kickback Statute (AKS): A federal law that prohibits the exchange of anything of value in return for referrals of federal healthcare program business, such as Medicare or Medicaid. Violations of the AKS can result in criminal penalties, including fines and imprisonment.
False Claims Act (FCA) #
A federal law that allows private citizens to bring lawsuits on behalf of the government against individuals or entities that have submitted false or fraudulent claims to the government. Whistleblowers, also known as relators, can receive a portion of any recovery obtained by the government.
Stark Law #
A federal law that prohibits physicians from making referrals for certain designated health services payable by Medicare to entities with which they have a financial relationship, unless an exception applies. Violations of the Stark Law can result in significant monetary penalties.
Healthcare Fraud #
The intentional submission of false or misleading claims to healthcare programs, such as Medicare or Medicaid, for the purpose of obtaining unauthorized payments. Healthcare fraud can take many forms, including billing for services not provided, upcoding, and unbundling.
Billing Fraud #
A type of healthcare fraud that involves the submission of false or misleading claims for healthcare services or equipment. Billing fraud can take many forms, including upcoding, unbundling, and billing for services not provided.
Upcoding #
A type of billing fraud that involves billing for a more expensive service or procedure than was actually provided. Upcoding can occur when a healthcare provider uses a billing code that corresponds to a more expensive service than the one that was actually provided.
Unbundling #
A type of billing fraud that involves billing for individual components of a procedure or service separately, rather than billing for the procedure or service as a whole. Unbundling can result in higher payments than would be allowed for the bundled procedure or service.
Medically Unnecessary Services #
Services or procedures that are not reasonable and necessary for the diagnosis or treatment of a medical condition. Billing for medically unnecessary services is a form of healthcare fraud.
Kickbacks #
The exchange of anything of value in return for referrals of healthcare program business. Kickbacks are prohibited by the Anti-kickback Statute and can result in criminal penalties.
Safe Harbors #
Exceptions to the Anti-kickback Statute that permit certain arrangements that would otherwise violate the statute. Safe harbors include arrangements such as discounts for early payment and personal services and management contracts.
Whistleblower #
A person who reports suspected illegal activity, such as healthcare fraud, to the government. Whistleblowers are protected by laws such as the False Claims Act, which allow them to bring lawsuits on behalf of the government and receive a portion of any recovery obtained.
Qui Tam #
A provision of the False Claims Act that allows private citizens to bring lawsuits on behalf of the government against individuals or entities that have submitted false or fraudulent claims. Qui tam relators, also known as whistleblowers, can receive a portion of any recovery obtained by the government.
Civil Monetary Penalties Law (CMPL) #
A federal law that imposes civil monetary penalties on individuals and entities that violate certain healthcare program requirements, such as the Anti-kickback Statute and the Stark Law.
Exclusion #
The removal of an individual or entity from participation in federal healthcare programs, such as Medicare or Medicaid. Exclusions can be mandatory or permissive and can result from a variety of violations, including healthcare fraud.
Corporate Integrity Agreement (CIA) #
A settlement agreement between the Department of Health and Human Services Office of Inspector General (OIG) and a healthcare organization that has been found to have committed healthcare fraud. CIAs typically include requirements for the organization to implement compliance programs and undergo regular monitoring.
Compliance Program #
A set of policies, procedures, and practices designed to prevent and detect healthcare fraud and ensure compliance with applicable laws and regulations. Compliance programs are required for certain healthcare organizations and are recommended for all organizations that participate in federal healthcare programs.
Healthcare Fraud Investigation #
The process of investigating suspected healthcare fraud, which can include reviewing medical records, conducting interviews, and analyzing data. Healthcare fraud investigations can be conducted by a variety of agencies, including the Department of Justice, the Department of Health and Human Services Office of Inspector General, and state Medicaid Fraud Control Units.
Data Analytics #
The use of statistical analysis and data mining techniques to identify patterns and anomalies in healthcare data that may indicate healthcare fraud. Data analytics can be used to identify potential fraud schemes, such as billing for services not provided or upcoding.
Predicate Offenses #
Criminal offenses that serve as the basis for a Racketeer Influenced and Corrupt Organizations (RICO) lawsuit. Predicate offenses can include healthcare fraud, mail fraud, and wire fraud.
Racketeer Influenced and Corrupt Organizations (RICO) #
A federal law that allows for the prosecution of organized crime. RICO allows for the prosecution of individuals and entities that engage in a pattern of racketeering activity, which can include healthcare fraud.
Civil Investigative Demand (CID) #
A request for documents or information issued by the Department of Justice in connection with a healthcare fraud investigation. CIDs are used to gather evidence and can be issued to individuals, healthcare organizations, or other entities.
Search Warrant #
A court order authorizing law enforcement officers to search a specific location for evidence of a crime. Search warrants are used in healthcare fraud investigations to seize documents, electronic records, and other evidence.
Grand Jury #
A group of citizens who are convened to consider evidence presented by prosecutors and determine whether there is sufficient evidence to bring criminal charges. Grand juries are used in healthcare fraud investigations to consider evidence of healthcare fraud and return indictments against individuals or entities.
Plea Agreement #
A negotiated agreement between a defendant and prosecutors in which the defendant agrees to plead guilty to certain charges in exchange for a lesser sentence or other concessions. Plea agreements are often used in healthcare fraud cases to resolve cases without the need for a trial.
Trial #
A formal legal proceeding in which a judge or jury considers evidence presented by prosecutors and defense attorneys and determines whether an individual or entity is guilty of healthcare fraud.
Sentencing #
The imposition of a criminal penalty, such as a fine or imprisonment, on an individual or entity that has been found guilty of healthcare fraud. Sentencing is typically conducted by a judge and takes into account the seriousness of the offense, the defendant's criminal history, and other factors.
Parallel Proceedings #
The simultaneous investigation and prosecution of healthcare fraud by both criminal and civil authorities. Parallel proceedings can result in both criminal and civil penalties for the same conduct.
Deferred Prosecution Agreement (DPA) #
A settlement agreement between prosecutors and an individual or entity that is facing criminal charges. Under a DPA, the individual or entity agrees to comply with certain conditions, such as implementing a compliance program, in exchange for the dismissal of the criminal charges.
Non #
Prosecution Agreement (NPA): A settlement agreement between prosecutors and an individual or entity that is facing criminal charges. Under an NPA, the individual or entity agrees to pay a fine and comply with certain conditions, such as implementing a compliance program, in exchange for the dismissal of the criminal charges.
Statute of Limitations #
The time period within which criminal or civil charges must be brought. The statute of limitations for healthcare fraud can vary depending on the specific circumstances of the case.
Qui Tam Action #
A lawsuit brought by a whistleblower, also known as a relator, on behalf of the government against an individual or entity that has committed healthcare fraud. Qui tam actions are governed by the False Claims Act.
Relator #
A person who brings a qui tam action on behalf of the government against an individual or entity that has committed healthcare fraud. Relators are also known as whistleblowers.
Intervention #
The government's decision to join a