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Practitioner fraud and abuse: a public policy status report
Journal of Health and Human Resources Administration
|January 5, 1988
Summary
New public policy combats healthcare fraud and abuse, enacted through laws like the Medicare-Medicaid Anti-Fraud and Abuse Amendments. Success hinges on analyzing fraud extent and avoiding disruption to care for vulnerable populations.
Area of Science:
- Public Health Policy
- Healthcare Law
- Medical Economics
Background:
- Growing public concern over social and health service program spending fueled policy changes.
- Legislative action led to new laws targeting practitioner fraud and abuse.
Purpose of the Study:
- To outline the established public policy aimed at eliminating healthcare practitioner fraud and abuse.
- To assess the factors influencing the success of this policy.
Main Methods:
- Review of legislative enactments, including the Medicare-Medicaid Anti-Fraud and Abuse Amendments of 1977 and the Civil Money Penalties Law of 1981.
- Analysis of prosecution efforts utilizing laws such as the False Claims Act of 1963.
- Identification of key areas for future research, including quantifying fraud and defining "Medical Mills".
Main Results:
- Implementation of a public policy framework to address healthcare fraud and abuse through legal prosecution.
- Enactment of specific legislation to penalize fraudulent practices within Medicare and Medicaid programs.
- Recognition of the need for objective analysis to gauge the true extent of fraud and abuse.
Conclusions:
- The effectiveness of the anti-fraud policy depends on accurate assessment of fraud levels and understanding "Medical Mills".
- Future policy development must balance fraud prevention with ensuring uninterrupted healthcare access for the elderly and poor.
- Avoiding excessive regulation is crucial for the maturation of healthcare fraud and abuse policy.