Avoiding Medicare and Medicaid Fraud and Abuse – Roadmap for New Physicians

PUBLISHED: Apr 16, 2018
Relevant to: All Healthcare Organizations

The U.S. Department of Health & Human Services Office of Inspector General's (OIG) booklet, A Roadmap for New Physicians: Avoiding Medicare and Medicaid Fraud and Abuse, is designed to assist in teaching physicians about the Federal laws designed to protect the Medicare and Medicaid programs and program beneficiaries from fraud, waste, and abuse.

The booklet summarizes the five main Federal fraud and abuse laws:

  • False Claims Act (31 U.S.C. §§ 3729–3733)
  • Anti-Kickback Statute (42 U.S.C. § 1320a-7b(b))
  • Physician Self-Referral Law (Stark law) (42 U.S.C. § 1395nn)
  • Exclusion Statute (42 U.S.C. § 1320a-7)
  • Civil Monetary Penalties Law (42 U.S.C. § 1320a-7a)

This self-study guide, available at no cost, provides tips on how physicians should comply with these laws in their relationships with payers (e.g., the Medicare and Medicaid programs), vendors (e.g., drug, biologic, and medical device companies), and fellow providers (e.g., hospitals, nursing homes, and physician colleagues).

It is imperative for all new physicians to understand their obligations under these laws. Not only is following them the right thing to do, the consequences of violating these laws can include criminal penalties, civil fines, exclusion from the Federal health care programs, or loss of medical license from the State medical board.

Resources such as this guide are a great complement to an organization’s comprehensive compliance plan, which should include training and education for physicians on Federal fraud and abuse laws. A link to OIG’s booklet, as well an example policy addressing compliance training and education is provided below.

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