Program exclusions and civil money penalties: the administrative process

Area of Science:

• Health Law
• Healthcare Policy
• Regulatory Compliance

Background:

• The authority to combat healthcare fraud and abuse has significantly expanded over the last decade.
• Government experience has led to refined statutory and regulatory enforcement powers.
• The Medicare and Medicaid Patient and Program Protection Act of 1987 marked a key development.

Purpose of the Study:

• To address expanded bases for exclusion from federal healthcare programs.
• To examine new authorities for imposing civil money penalties.
• To analyze recently proposed regulations stemming from the 1987 Act.

Main Methods:

• Review of the Medicare and Medicaid Patient and Program Protection Act of 1987.
• Analysis of proposed regulations concerning fraud and abuse enforcement.
• Examination of expanded grounds for provider exclusion and civil monetary penalties.

Main Results:

• The 1987 Act broadened the government's ability to exclude providers and levy civil penalties.
• Proposed regulations detail the implementation of these expanded enforcement authorities.
• Increased scrutiny on fraud and abuse in Medicare and state health programs.

Conclusions:

• The legislative and regulatory landscape for combating healthcare fraud and abuse has evolved significantly.
• Providers face new grounds for exclusion and financial penalties.
• Ongoing regulatory proposals aim to strengthen enforcement against program integrity risks.