Title XI of the Social Security Act includes Medicare and Medicaid program-related anti-fraud laws, which not only punish violators with civil and criminal penalties, but also possible exclusion from federal health care programs. The laws address Medicare fraud, which occurs when providers bill Medicare for services or supplies Medicare patients don’t receive. They also tackle the illegal activities associated with Medicare abuse–when doctors, suppliers and others don’t follow good medical practices, resulting in unnecessary costs to Medicare, improper payments, or services that aren’t medically necessary.
Having Medicare fraud laws in place is especially important given the financial toll of this type of fraud. The Medicare program makes about $500 billion in payments each year. Each year, approximately 10% of the Medicare payments are improper and the result of fraud.
Some of the more commonly used laws to fight heathcare fraud and abuse were amended in March 2010, with passage of legislation aimed at improving health care fraud and abuse enforcement, called the Patient Protection and Affordable Care Act (PPACA).
- Federal Civil Monetary Penalties (Section 1128A of the Social Security Act/42 USC 1320a-7aa)
- Anti-Kickback” law/Criminal Penalties for Acts Involving Federal Health Care Programs (Section 1128B of the Social Security Act/42 USC 1320a-7b)
- “Stark I, II”/Physician Self-Referral Law (Section 1877 of the Social Security Act/42 USC 1395nn)
- Federal Civil False Claims Act (31 USC 3829-3733)
- Exclusion from Federal Health Care Programs (Section 1128(a),(b) and (c) of the Social Security Act/42 USC 1320a-7a)
- Safe Harbors; Advisory Opinions; Fraud Alerts (Section 1128D of the Social Security Act/42 USC 1320a-7d)
- Health Care Fraud and Scheme (18 USC 1347) 18_USC_1518
- Theft or Embezzlement in Connection with Health Care Benefit Program (18 USC 669)
- Obstruction of Criminal Investigations of Health Care Offenses (18 USC 1518)
- False Statements Relating to Health Care Matters (18 USC 1035)