The Government views health care fraud as a growing problem across the United States. In response to this growing problem, in 1993, the Attorney General made health care fraud one of the Department’s top priorities. Through increased resources, focused investigative strategies and better coordination among law enforcement, the Department continues to upgrade its efforts in combatting the full array of fraud perpetrated by health care providers. Health care fraud can be prosecuted both civilly and criminally under a variety of statutes and regulations including Fraud Against the Government, Mail and Wire Fraud, and Program Fraud and Bribery. Although health care fraud is typically investigated by federal authorities, states also prosecute such offenses.
The Health Insurance Portability and Accountability Act (HIPPA) established and funds a Health Care Fraud and Abuse Program to combat fraud and abuse committed against all health plans, both public and private. HIPPA empowers the Attorney General to issue investigative demands to obtain records for investigations relating to Federal criminal health care fraud offenses; these records are not subject to the constraints applicable to grand jury matters set forth in Fed. R. Crim. P. 6(e). The Department’s health care fraud efforts are centered in the United States Attorneys’ Offices, the Criminal Division and the Civil Division. Yet, each public program has its own rules for the provision of services, reimbursement for the costs of services, and the investigation of fraud.
Allegations of health care fraud put at risk one’s liberty, professional licenses, and financial well-being. Those involved can face criminal prosecution, administrative sanctions, and civil litigation. In cases involving the submission of inflated or false financial claims against Medicaid, Medicare, or other government programs, the law affords a “whistleblower” the opportunity to bring a civil claim against the alleged perpetrator. This is called a qui tam action.