MEDICARE FRAUD & ABUSE

www.cms.gov/MLNProducts/downloads/Fraud_and_Abuse.pdf


MEDICARE FRAUD & ABUSE RESOURCE REFERENCE
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A free e-mail “listserv” that informs subscribers of new additions to the OIG’s website. For more information visit http://www.oig.hhs.gov/mailinglist.asp on the Internet.
CMS Website
CMS’ website (http://www.cms.hhs.gov) offers a vast amount of information pertaining to Medicare Program rules and requirements, including:
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The “Medicare Learning Network” (MLN), which includes informative articles and training modules. For more information visit http://www.cms.hhs.gov/MLNGenInfo on the CMS website.
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Part D prescription drug benefit
compliance guidance;
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Information on the physician
self-referral prohibition;
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Medicare coverage information and policies;
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Information and guidance on billing and
coding issues;
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Provider enrollment and
certification information;
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Information regarding CMS forms;
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Information about coordination of benefits and Medicare as secondary payer; and
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Subscription to an electronic mailing list service for those interested in receiving news from CMS. To subscribe, go to http://www.cms.hhs.gov/aboutwebsite/emailupdates on the CMS website.
Stop Medicare Fraud Website
The Department of Justice and HHS partnered to set up the Health Care Fraud Prevention and Enforcement Action Team (HEAT) to encourage the public to get involved in their efforts to combat Medicare fraud. This team created the Stop Medicare Fraud website which has valuable information on how to identify and protect against Medicare fraud and how to report it. For more information go to http://www.stopmedicarefraud.gov on the Internet.
Kickbacks and Self-Referrals
The anti-kickback statute and the physician self-referral law are two important fraud and abuse authorities. Violations of these laws can result in nonpayment of claims, civil monetary penalties, exclusion from the Medicare Program, and liability for the submission of false claims to the government. Violation of the anti-kickback statute may additionally result in imprisonment and criminal fines.
The Anti-Kickback Statute set forth at § 1128B of the Social Security Act, (42 U.S.C. § 1320a-7b), makes it a criminal offense to knowingly and willfully offer, pay, solicit, or receive any remuneration to induce or reward referrals of items or services reimbursable by a Federal health care program. Where remuneration is paid purposefully to induce or reward referrals of items or services payable by a Federal health care program, the anti-kickback statute is violated. By its terms, the statute ascribes criminal liability to parties on both sides of an impermissible “kickback” transaction. For purposes of the anti-kickback statute, “remuneration” includes the transfer of anything of value, directly or indirectly, overtly or covertly, in cash or in kind. For more information go to http://www.oig.hhs.gov/fraud/safeharborregulations.asp onthe Internet.
The Physician Self-Referral Prohibition Statute, commonly referred to as the “Stark Law,” is set forth at § 1877 of the Social Security Act, (42 U.S.C. § 1395nn). This statute prohibits physicians from referring Medicare patients for certain designated health services to an entity with which the physician or a member of the physician’s immediate family has a financial relationship—unless an exception applies. It also prohibits an entity from presenting or causing to be presented a bill or claim to anyone for a designated health service furnished as a result of a prohibited referral. For more information go to http://www.cms.hhs.gov/PhysicianSelfReferral on the CMS website.
February 2010
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