White Collar Crime: Federal and Ohio: Health Care Fraud

Health care fraud

Theft of medical products

Theft or embezzlement in connection with health care.

The Civil False Claims Act protects the Government from being overcharged or sold shoddy goods or services. It is illegal to submit claims for payment to Medicare or Medicaid that a provider knows or should know are false or fraudulent.

OIG is legally required to exclude from participation in all Federal health care programs doctors and entities convicted of the following types of criminal offenses: (1) Medicare or Medicaid fraud, as well as any other offenses related to the delivery of items or services under Medicare or Medicaid; (2) patient abuse or neglect; (3) felony convictions for other health-care-related fraud, theft, or other financial misconduct; and (4) felony convictions for unlawful manufacture, distribution, prescription, or dispensing of controlled substances.

The Anti-kickback statute s a criminal law that prohibits the knowing and willful payment of "remuneration" to induce or reward patient referrals or the generation of business involving any item or service payable by the Federal health care programs (e.g., drugs, supplies, or health care services for Medicare or Medicaid patients).

The Health Care Fraud and Abuse Control Program is under the joint control of the Attorney General and the Office of Inspector General of Health and Human Services Department.

HHS secretary enters into agreements with state agencies to conduct investigations, called surveys, and to certify to the secretary that a provider meets the conditions of participation in federal health insurance program.

Recovery Audit Contractors review and correct improper payments in the Medicare Part A-D and in the Medicare-Medicaid Data Match Program.

The Physician Self-Referral Law, commonly referred to as the Stark law, prohibits physicians from referring patients to receive "designated health services" payable by Medicare or Medicaid from entities with which the physician or an immediate family member has a financial relationship, unless an exception applies.

Premium and cost-sharing subsidies for low-income individuals. State Medicaid agencies determine eligibility of Medicare beneficiaries for the low-income subsidy.

McKnight's Long Term Care News 8/26/26

US DOJ 2/17/23

ProPublica 12/30/22

Propublica 11/28/22

Ohio Capital Journal 9/6/22

Ohio Capitol Journal 6/14/21

ProPublica 7/19/19

NPR 7/23/19. Federal audits estimate such plans nationwide have overcharged.

Dubin was convicted of Medicaid fraud. When the dispute came to the Supreme Court, Dubin challenged his conviction under a federal law that makes it a crime to use another person’s identity in the process of committing another crime. Federal prosecutors contended that Dubin’s use of his patient’s name on a false Medicaid claim violated the statute, adding an extra two years to his one-year sentence for fraud. The US Supreme Court said that was not identity theft.

Medicaid fraud

Medicaid eligibility fraud

Medicaid eligibility fraud - new version effective 9/30/25.

Rewards for information relating to Medicare fraud and abuse

PROGRAM INTEGRITY - MEDICARE AND STATE HEALTH CARE PROGRAMS

CIVIL MONEY PENALTIES, ASSESSMENTS AND EXCLUSIONS

From the HHS, Office for Civil Rights. The health records privacy rules.

Stat : Reporting from the frontiers of health and medicine. July 2, 2018

2024

2024

Created by the Affordable Care Act to test systems of provider payment and delivery of services in order to cut costs while preserving or enhancing quality of care.

HHS and DOJ Joint Report

CBO Report April 2024

Private organizations that process and pay Medicare Part A and B claims.

DOJ chart explaining where to report various fraud crimes dealing with the COVID crisis.

Confidential clearinghouse for fraud and abuse information.

Charged with auditing and investigating fraud and abuse in the Medicare and Medicaid programs.

A Quality Improvement Organization (QIO) is a group of health quality experts, clinicians, and consumers organized to improve the quality of care delivered to people with Medicare.

Office of Inspector General, US Dept. of Health & Human Services