In recent years, health care fraud and abuse have become major issues,
in part because of the rising cost of health care, industry consolidation,
the emergence of private "whistle-blowers," and a change in the concept of
fraud to include an emerging concern about quality of care. The 3 types of
conduct that are generally prohibited by health care fraud laws are false
claims, kickbacks, and self-referrals. False claims are subject to several
criminal, civil, and administrative prohibitions, notably the federal civil
False Claims Act. Kickbacks, or inducements with the intent to influence the
purchase or sale of health care–related goods or services, are prohibited
under the federal Anti-Kickback statute as well as by state laws. Finally,
self-referrals—the referral of patients to an entity with which the
referring physician has a financial relationship—are outlawed by the
Ethics in Patient Referral Act as well as numerous state statutes. Consequences
of violations of these laws can include, in addition to imprisonment and fines,
civil monetary penalties, loss of licensure, loss of staff privileges, and
exclusion from participation in federal health care programs. Federal criminal
and civil statutes are enforced by the US Department of Justice; administrative
actions are pursued by the Department of Health and Human Services' Office
of Inspector General; and all state actions are pursued by the individual
states. In addition, private whistle-blowers may, acting in the name of the
United States, file suit against an entity under the False Claims Act. Enforcement
of health care fraud and abuse laws has become increasingly commonplace and
now affects many mainstream providers. This trend is likely to continue.
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