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Health Law and Ethics
September 22/29, 1999

Health Care Fraud and Abuse

Author Affiliations

Author Affiliation: Dr Kalb is a partner at the law firm of Sidley & Austin in Washington, DC.


Health Law and Ethics Section Editors: Lawrence O. Gostin, JD, the Georgetown/Johns Hopkins University Program in Law and Public Health, Washington, DC, and Baltimore, Md; Helene M. Cole, MD, Contributing Editor, JAMA.

JAMA. 1999;282(12):1163-1168. doi:10.1001/jama.282.12.1163

In recent years, health care fraud and abuse have become major issues, in part because of the rising cost of health care, industry consolidation, the emergence of private "whistle-blowers," and a change in the concept of fraud to include an emerging concern about quality of care. The 3 types of conduct that are generally prohibited by health care fraud laws are false claims, kickbacks, and self-referrals. False claims are subject to several criminal, civil, and administrative prohibitions, notably the federal civil False Claims Act. Kickbacks, or inducements with the intent to influence the purchase or sale of health care–related goods or services, are prohibited under the federal Anti-Kickback statute as well as by state laws. Finally, self-referrals—the referral of patients to an entity with which the referring physician has a financial relationship—are outlawed by the Ethics in Patient Referral Act as well as numerous state statutes. Consequences of violations of these laws can include, in addition to imprisonment and fines, civil monetary penalties, loss of licensure, loss of staff privileges, and exclusion from participation in federal health care programs. Federal criminal and civil statutes are enforced by the US Department of Justice; administrative actions are pursued by the Department of Health and Human Services' Office of Inspector General; and all state actions are pursued by the individual states. In addition, private whistle-blowers may, acting in the name of the United States, file suit against an entity under the False Claims Act. Enforcement of health care fraud and abuse laws has become increasingly commonplace and now affects many mainstream providers. This trend is likely to continue.

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