Time Line: Federal Laws to Identify and Prosecute Fraud
1986 — False Claims Act (FCA)• Providers subject to $5,000 to $10,000 fine for each false claim or statement, plus triple the amount lost by the government to fraudulent claims from that provider.
• Violators of the Medicare/Medicaid Act may be precluded from being a beneficiary of those programs in addition to facing felony convictions.
• "Whistle blower" provisions allow qui tam action that encourage reporting of fraud.
• The act has resulted in an increase in the number of private actions filed, from 33 in 1986 to 360 in 1996.
1989 — Omnibus Budget Reconciliation Act (OBRA)
• Known also as Stark I (initially lab testing).
• Prevents physician self-referral of patients to entities where the physician has a financial interest.
• Expanded to 10 other entities with Stark II in 1995.
1992 — United States Sentencing Commission (USSC) "Guidelines for Organizations"
• Created the seven requirements for the Corporate Compliance Plan (CCP), which serves two purposes: deterrence and detection.
• Allowed the government to impose a CCP more onerous than the voluntary, proactive compliance programs facilities should be establishing following convictions on fraud charges.
1995 — Operation Restore Trust
• Two-year initiative (1995-1997) to reduce Medicare fraud and abuse.
• Joint project of Office of Inspector General, Department of Justice, Health Care Financing Administration, and Administration on Aging.
• Initial focus was on five states that account for 40% of Medicare/Medicaid beneficiaries (CA, FL, IL, NY, TX). More states will be added.
1996 — Health Insurance Portability and Accountability Act (HIPAA)
• Established a fraud and abuse control program between Department of Health and Human Services and U.S. District Attorney.
• Imposes criminal penalties for "knowingly and willfully" defrauding any health care benefit program.
• Imposes civil penalties for improper coding and medically unnecessary services.
• Established whistle-blower payments of at least $100 for those who report fraud.
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