skip navigation

PUBLICATIONS

Register for Latest Research

Stay Informed
Register with NCJRS to receive NCJRS's biweekly e-newsletter JUSTINFO and additional periodic emails from NCJRS and the NCJRS federal sponsors that highlight the latest research published or sponsored by the Office of Justice Programs.

NCJRS Abstract

The document referenced below is part of the NCJRS Virtual Library collection. To conduct further searches of the collection, visit the Virtual Library. See the Obtain Documents page for direction on how to access resources online, via mail, through interlibrary loans, or in a local library.

 

NCJ Number: 64610 Find in a Library
Title: FRAUD AND ABUSE IN MEDICARE AND MEDICAID
Journal: ADMINISTRATIVE LAW REVIEW  Volume:30  Issue:1  Dated:(WINTER 1978)  Pages:1-43
Author(s): B G LEE
Corporate Author: American Bar Assoc
Administrative Law Section
United States of America
Date Published: 1978
Page Count: 43
Sponsoring Agency: American Bar Assoc
Chicago, IL 60637
Format: Article
Language: English
Country: United States of America
Annotation: MEDICAID FRAUD CASES INDICATE THAT ONLY A FEW DISHONEST PROVIDERS ARE CAUGHT AND PUNISHED.
Abstract: CONGRESSIONAL INTEREST IN MEDICARE AND MEDICAID HAS RESULTED IN HARSHER PENALTIES, ALTHOUGH SEVERE SANCTIONS ARE PRESENT IN EXISTING STATUTES. OVERUTILIZATION OF SERVICES IS THE MOST COMMON ABUSE, PARTICULARLY BY HEALTH CARE ENTITIES SHARING THE SAME BUILDING. ABUSE CASES ARE OFTEN SETTLED OUTSIDE THE FORMAL REGULATION PROCESS AND SANCTIONED BY EXCLUSION FROM THE PROGRAM OR CESSATION OF PAYMENTS. ALTHOUGH SOME POTENTIAL FRAUD SITUATIONS ARE IDENTIFIED IN REGULATIONS, THEY ARE AS VARIED AS HUMAN IMAGINATION. EXISTING PENALTIES INCLUDE HEAVY FINES, IMPRISONMENT, LOSS OF ASSETS, AND REVOKING PROFESSIONAL LICENSES. BECAUSE MEDICAID FRAUD CAN BE INVESTIGATED CONCURRENTLY BY FEDERAL AND STATE AGENCIES, IT IS DIFFICULT TO DETERMINE THE EXACT PENALTIES THAT COULD BE IMPOSED. STATES HAVE THEIR OWN LAWS FOR MEDICAID FRAUD, BUT FEW CASES HAVE BEEN PROSECUTED. THE ALLEGATION OF FRAUD CAN SEVER PAYMENTS TO A HEALTH CARE FACILITY, ENDANGERING ITS FINANCIAL POSITION, AND THIS HAS RAISED LEGAL QUESTIONS INVOLVING DUE PROCESS. THE SOLUTION TO THE PROBLEM IS NOT MORE PENALTIES, BUT COORDINATION AND UPGRADING OF INVESTIGATIONS. THE ARTICLE WAS PREPARED BEFORE NEW FEDERAL STATUTES WERE ENACTED AND CONTAINS ONLY A BRIEF SUMMARY OF THESE AMENDMENTS. THE APPENDIXES CONTAIN A CHART OF APPEAL PROCEDURES FOR A HEALTH CARE FACILITY AND A LIST OF STATUTES UNDER WHICH MEDICARE/MEDICAID FRAUD AND ABUSE CAN BE PROSECUTED. (MJM)
Index Term(s): Fraud; Insurance fraud; Medicaid/Medicare fraud; US Department of Health, Education, and Welfare; US Department of Justice; White collar crime
To cite this abstract, use the following link:
http://www.ncjrs.gov/App/publications/abstract.aspx?ID=64610

*A link to the full-text document is provided whenever possible. For documents not available online, a link to the publisher's website is provided. Tell us how you use the NCJRS Library and Abstracts Database - send us your feedback.