Unit 2: Legal and Ethical Considerations in Healthcare Fraud Investigation
Expert-defined terms from the Advanced Certificate in Healthcare Fraud Investigation Best Practices course at London School of Business and Administration. Free to read, free to share, paired with a globally recognised certification pathway.
Advanced Certificate in Healthcare Fraud Investigation Best Practices #
a professional certification program that provides investigators with the knowledge and skills necessary to detect, investigate, and prevent healthcare fraud.
Anti #
kickback Statute (AKS): a federal law that prohibits the exchange of anything of value in return for referrals for services or items paid for by federal healthcare programs.
Clinical Laboratory Improvement Amendments (CLIA) #
federal regulations that establish standards for laboratory testing and require laboratories to be certified by the Centers for Medicare and Medicaid Services.
Compliance program #
a set of internal policies, procedures, and controls designed to prevent and detect violations of laws and regulations governing healthcare.
False Claims Act (FCA) #
a federal law that imposes civil and criminal penalties on individuals and entities that submit false or fraudulent claims to the federal government.
Fraud #
the intentional deception or misrepresentation made by a person or entity for the purpose of receiving something of value to which they are not entitled.
Healthcare Fraud Prevention and Enforcement Action Team (HEAT) #
a joint initiative between the Department of Justice and the Department of Health and Human Services to combat healthcare fraud.
Identity theft #
the unauthorized use of another person's personal information, such as their name, social security number, or credit card information, for the purpose of committing fraud.
Kickback #
the offering, giving, soliciting, or receiving anything of value in exchange for referrals for services or items paid for by federal healthcare programs.
Medicare Fraud Strike Force #
a team of federal, state, and local law enforcement officials who investigate and prosecute healthcare fraud cases.
Mental Health Parity and Addiction Equity Act (MHPAEA) #
a federal law that requires health insurance plans to provide the same level of coverage for mental health and substance use disorder benefits as they do for medical and surgical benefits.
Qui tam #
a legal provision that allows private citizens to file lawsuits on behalf of the government and receive a portion of any recovered damages.
Stark Law #
a federal law that prohibits physician self-referral, or the referral of a patient for certain designated health services to an entity in which the physician has a financial interest.
Whistleblower #
an individual who exposes illegal or unethical practices within an organization.
Example #
A healthcare provider who reports a colleague for submitting false claims to Medicare is considered a whistleblower.
Practical Application #
Compliance programs are an important tool for preventing and detecting healthcare fraud. Investigators should be familiar with the key components of an effective compliance program, including policies and procedures, training, and internal monitoring and auditing.
Challenge #
Healthcare fraud investigators must stay up-to-date on the constantly evolving laws and regulations governing healthcare. This requires a commitment to ongoing education and training. Additionally, investigators must be able to effectively communicate complex legal and technical concepts to a variety of stakeholders, including healthcare providers, patients, and attorneys.