E. Bart Daniel
Joseph P. Griffith, Jr
J. Brady Hair
Derk Van Raalte
Marshall T. “Matt” Austin
Sloan P. Ellis
Aggressive fraud enforcement in the health care arena was almost unheard of prior to the passage of HIPAA in 1996, which forever changed the enforcement landscape. In addition to creating a specific health care fraud offense, it funded new prosecutor, auditor and agent positions to ferret out and prosecute health care offenders. The 2010 Affordable Care Act (ACA) built on HIPAA, providing additional tools for more aggressive enforcement. In the field, talented and creative Assistant U. S. Attorneys opened an entirely new frontier with the advent of “data mining” where potential health care fraud could be identified in real time.
This publication discusses the impact of these additional weapons of enforcement and the wide-ranging case law which has followed. Whether it's big Pharma, large scale hospital systems or the day-to-day operations of a small town pharmacy or a behavioral service provider, submission of claims for payment to the Medicare/Medicaid/Tricare programs has become a minefield for the unwary.  Civil False Claims Act exposure, criminal prosecution and exclusion from health care programs is a real concern for providers today. Moreover, the providers risk the loss of their professional licenses and the ability to earn a living. Health care counsel must become familiar with civil and criminal enforcement enough to recognize the early warning signs of an investigation and understand the action that should be taken.
Summary of Contents
I.         Introduction
II.        Types of Health Care Fraud 
III.       Investigative Agencies and Their Roles
IV.       How an Investigation Begins
V.        Federal Enforcement
VI.       State Enforcement: Health Care Fraud Prosecutions in the State Arena
VII.      Defending Health Care Cases
VIII.     Federal Sentencing Guidelines
IX.       Collateral Consequences and Proceedings
X.        Internet Resources
XI.       Scorecard of Acronyms