"Corporate Accountability and Compliance in Health Care - Will Health Care Be the Next Enron." Mondaq Business Briefing (July 26, 2004): pp. na Notes: Available full-text on Infotrac
Abstract: This paper will address the myriad of federal and state statutes regulating health care fraud and abuse, delineating certain risk behaviors targeted by theses statutes, and analyzing the penalties associated with unlawful conduct. The second part discusses the importance of implementing a comprehensive and effective compliance program for hospital organizations and the pharmaceutical manufacturing industry. Finally, this paper will address the overall impact of the heightened scrutiny of the health care industry, including recommended reform measures.

"Healthcare Fraud and Abuse Remains a Costly Challenge." Managed Healthcare Executive (October 2004): pp. 38, 40. Notes: Available full-text on Wilsonweb
Abstract: Although the immediate targets of fraudulent billing practices in health care are private health payers and government-funded health plans, the reality is that payers, employers, and patients ultimately carry the burden in terms of higher-premiums, lower benefits, higher taxes, and higher co-payments. According to a 1999 Health Insurance Association of America report, fraud is a contributing factor to the increasing cost of health benefits, which rose by 48 percent between 1998 and 2003. Moreover, aside from cost, the quality of care can be compromised with false or inflated claims.

Anderson, Todd D. and Jr. John W. Sadoff. "Home Health, Long-Term Care, and Other Compliance Activities." Healthcare Financial Management (April 1999): pp. 48-51.
Notes: Available full-text on Wilsonweb
Abstract: The federal government continues to crack down on fraud and abuse in the healthcare industry with such initiatives and tools as Operation Restore Trust and Intermediate tax sections. Home health and long-term care organizations are the latest entities under study by the Office of Inspector General, and the result of these studies likely will be more antifraud and abuse measures being taken against these entities. Healthcare organizations that put effective compliance programs in place should be able to reduce overall risk of challenges to their financial practices.

Bourjolly, Lissa and Erin Moak. "Health Care Fraud." American Criminal Law Review (Spring 2004): pp. 751-817.
Abstract: The laws covering federal health care fraud and its enforcement are examined, with emphasis on the general federal laws used to prosecute health care fraud, the laws specifically enacted to address Medicare and Medicaid fraud, federal and state enforcement efforts, and recent developments.

Cozort, Larry A. "The Bribery Statute: A New Weapon Against Medicare Fraud." Healthcare Financial Management (March 2001): pp. 44-48. Notes: Available full-text on Wilsonweb
Abstract: A May 2000 U.S. Supreme Court decision determining when a federal bribery statute can be used to fight Medicare fraud has ramifications for healthcare providers. In Fisher v. United States, the Court concluded that healthcare providers that participate in Medicare are considered to receive benefits as set forth in the bribery statute and thus can be prosecuted for fraudulent activities against the government under the statute. Provider organizations and business associates of such organizations should be aware that the government may step up its use of the bribery law in prosecuting fraudulent activity. In addition, although the case pertained specifically to healthcare providers that participate in Medicare, providers that do not participate in Medicare may wish to evaluate the advisability of accepting other federal funding because of the possible reach of the bribery statute.

Eremia, Alexander D. "When Self-Regulation, Market Forces, and Private Legal Actions Fail: Appropriate Government Regulation and Oversight Is Necessary to Ensure Minimum Standards of Quality in Long-Term Health Care." Annals of Health Law 11(2002): pp.93-124.
Notes: Available full-text on Wilsonweb
Abstract: Despite having the most technologically advanced and costly healthcare system in the world, both physicians and American healthcare consumers have increasingly perceived a decline in the quality of services provided by the medical community. While no nationally accepted and uniform standards exist which succinctly define "quality of care," consumers expect and deserve at least the minimally prescribed or professionally accepted standards for the treatment of their ailments. Historically, consumers have relied on self-regulation and the professionalism of their physicians and health care providers to ensure appropriate quality care. Under the fee-for-service regime, it is alleged that over-utilization led to excessive services and "quality." Today, some financial incentives which encourage under-utilization, and a number of prominent failure of care incidents suggest a need to focus on quality and make it clear that self-regulation alone cannot be the sole mechanism for ensuring quality care.

Federal Bureau of Investigation. "About the Health Care Fraud Unit." [http://www.fbi.gov/hq/cid/fc/hcf/hcf.htm]. February 2005.
Abstract: Established in 1992 as a separate unit within the Financial Crimes Section of the Criminal Investigative Division, one of the primary missions of the Health Care Fraud Unit is to ensure the success of investigations, which have a national impact on the health care fraud crime problem. This is accomplished by concentrating investigative resources on multi-district investigations of large health corporations suspected of committing fraud against both public and private payers of health care benefits, and by coordinating these investigations with other law enforcement and regulatory agencies. This site offers current statistics and case summaries.

Frieden, Joyce. "Health Care Fraud Is 'Alive and Well,' but Payers Fight Back." Internal Medicine News (September 15, 2004): pp. 59+. Notes: Available full-text on Infotrac
Abstract: Health care fraud continues to grow, fueled by rising health care expenditures. The federal government is working hard to stop health care fraud, and Blue Cross/Blue Shield has
launched an antifraud "strike force" to improve coordination of antifraud activities among its various plans.

Geier, Peter. "Seeking a Cure for Health Care Fraud." Daily Record (Baltimore, MD) (July 2004): NA. Notes: Available full-text on Infotrac
Abstract: Health care fraud units assess the potential for civil recovery as well as criminal conviction.

Hausfeld, Michael D. and Margaret G. Farrell. "Class Actions Challenging Managed Care Abuses: Fraudulent Misrepresentation and Breach of Fiduciary Duty." Sedona Conference Journal (July 2000): pp. 191-206. Notes: Available full-text on Wilsonweb
Abstract: Not surprisingly, businesses immune from legal restraints - statutory and common law - sometimes use their market power to engage in deceptive and unfair practices. So it has been with managed health care. Because of anomalous voids in state and federal regulatory authority, managed care organizations have been unaccountable to policyholders, patients, regulators, doctors and the public for important aspects of their operations. Now, however, following the lead of two recent Supreme Court decisions that removed barriers to suit, litigants are seeking to redress abusive practices by managed health care organizations under federal statutes.

Huntington, Susan. "Fraud Probes Raise New Healthcare Risks." National Underwriter (January 8, 2001): pp. 13-14. Notes: Available full-text on Wilsonweb
Abstract: The government reports that fraudulent activities in the healthcare system account for an alarming 10 percent, about $1 billion of healthcare spending. As a result, healthcare fraud and abuse has become the number two law enforcement priority for the federal government, just behind prosecution of violent crimes.

Krause, John H. "Regulating, Guiding, and Enforcing Health Care Fraud." New York University Annual Survey of American Law (2004): pp. 242-73. Notes: Available full-text on Westlaw
Abstract: Analyzes the current regulation-guidance-enforcement approach to health care fraud. After summarizing the major fraud laws, the article identifies both practical and theoretical problems with each conceptual prong. In short, the combination of cumbersome rulemaking procedures, the proliferation of unofficial forms of guidance, and the growing use of litigation as a regulatory strategy has created an increasingly untenable situation for the health care industry. Alleviating these problems will require us to focus on regulatory clarity as a necessary precondition for a legitimate enforcement framework--in other words, demanding clear rules to govern the conduct of health care providers, backed by substantial penalties for clear violations.

Maas, Angela. "Pharmaceutical Fraud: RX For Trouble." Employee Benefit News (October 1, 2004): pp. na. Notes: Available full-text on Infotrac
Abstract: A troubling and quickly increasing aspect to medical fraud is pharmaceutical fraud. Americans spend about $170 billion each year on prescriptions with an annual increase of 11% to 16%. Of the $170 billion, it is estimated that between 5% and 15% is fraudulent.

Miller, Sharon. "Arizona's Medicaid Eligibility Fraud Prevention." Spectrum (Summer 2001): pp. 28-29. Notes: Available full-text on Wilsonweb
Abstract: Arizona became aware of fraud in Medicaid and state medical benefits applications through the eligibility quality control process. Through the subsequent formation of a pre-approval fraud investigation process, taxpayer dollars have been saved before they were spent on ineligible persons.

Negri, Pam, et al [eds.]. Medicare Medicaid Fraud Buster. Washington, DC: U.S. Department of Health and Human Services, 1997. Call Number: HE 1.2:F 86/3
Abstract: Health care fraud hurts all of us and it will take all of us working together to stop fraud artists from stealing our health care dollars. Statewide ombudsman staff, volunteer networks and others serving the elderly and disabled populations are in a unique position to participate in this effort because of their daily contact with beneficiaries and their families.

Payne, Brian K. Crime in the Home Health Care Field. Springfield, IL: Charles C. Thomas, 2003.
Call Number: HV 6250.4.A34P39 2003
Abstract: This book is one of the first to fully address abuses occurring in the home health care industry. Its intent is not to suggest that home health care is a dangerous field for workers and consumers; rather, the intent is to shed some light on the types of misconduct found in home health care.

Payne, Brian K. and Charles Gray. "Fraud by Home Health Care Workers and the Criminal Justice Response." Criminal Justice Review (Autumn 2001): pp. 209-32.
Abstract: Although criminologist have examined health care fraud by physicians, virtually no criminological research has assessed crime within the home health care industry. This article attempts to fill that void by considering the kinds of home health care offenses that are investigated by fraud control units throughout the United States. Findings indicate that home health care professionals commit offenses that are similar to, yet different from, those that are committed by doctors.

Proenca, E. Jose. "Ethics Orientation As a Mediator of Organizational Integrity in Health Services Organizations." Health Care Management Review (January/March 2004): pp. 40-50.
Notes: Available full-text on Infotrac
Abstract: Increasing scrutiny of ethical misconduct by federal and state agencies has prompted health services organizations to adopt codes of ethics and institute legal compliance programs. This study examined the effect of five ethics program elements on organizational integrity and the mediating role played by ethics orientation in this relationship. It found that program elements influence organizational integrity by engendering among employees a values orientation, a compliance orientation, or both. These findings have important implications for health services managers involved in designing and implementing an ethics program.

Rocke, Sid. "Health Care Fraud Prosecution." Prosecutor (January/February 2004): pp. 30-32.
Notes: Available full-text on Westlaw
Abstract: Health care fraud has proven to be a pressing problem nationwide, with many authorities estimating that up to 10 percent of the over $1 trillion spent per year on health care costs is lost to fraud. As a result, since the mid-1990s, health care fraud has been the focus of considerable federal law enforcement efforts. However, state and local prosecutors can and should also pay an important role in the fight against health care fraud. Their participation is particularly appropriate in the many cases in which these fraud schemes have a direct impact on state and local governments.

Sparrow, Malcolm K. Fraud Control in the Health Care Industry: Assessing the State of the Art. Washington, DC: U.S. Department of Justice, 1998. Call Number: J2824: F 86
Abstract: Discussed in this brief: The health care industry's traditional approach to fraud control, the weaknesses of the approach, and the essential elements of more effective fraud control systems.

________. License to Steal: How Fraud Bleeds America's Health Care System. Boulder, CO: Westview Press, 2000. Call Number: RA 395.A3S764 2000
Abstract: Health care fraud remains uncontrolled, and mostly invisible. For Americans, this problem represents one of the most massive and persistent fiscal failures in their history. Many who, work the system, or feed off it, like it so. For those who profit from it, health care fraud is not seen as a problem, but as an enormously lucrative enterprise, worth defending vigorously.

Taylor, Mark. "Policing Quality." Modern Healthcare (June 30, 2003): pp. 24 +.
Notes: Available full-text on Wilsonweb
Abstract: Allegations of negligent care, unnecessary care, and the repeated harming of patients are attracting the attention of federal fraud enforcement agencies and the unwelcome intrusion of government investigators. The U.S Justice Department is increasingly focusing its enforcement efforts on issues pertaining to the quality of care provided by U.S. hospitals. Recent high-profile raids and investigations show that regulators have started to throw the full weight of their administrative, civil, and criminal powers at providers that fail to deliver a minimal standard of health care.

________. "Storm Warning." Modern Healthcare (November 17, 2003): pp. 26, 28-9, 34.
Notes: Available full-text on Wilsonweb
Abstract: Although "rainmaker" doctors can bring in major revenues for hospitals, they can also bring a deluge of legal problems. Fraud investigators and prosecutors are scrutinizing Medicare billing data and investigating quality related complaints against high-volume and high-billing physicians. However, officials say that it can be hard to stop rainmakers performing medically unnecessary procedures. The failure of utilization review and peer-review programs to monitor quality of care and eliminate unnecessary treatments is discussed.

Weld, Leonard G., et al. "Anatomy of a Financial Fraud: A Forensic Examination of HealthSouth." CPA Journal (October 2004): pp. 44-49. Notes: Available full-text on Infotrac
Abstract: Contemporary corporate fraud in the United States has affected market values, disseminated private 401(k) plans, and devalued public pension funds. Tyco, Dynegy, WorldCom, and others joined Enron's fraudulent accounting ranks in 2002. Birmingham, Alabama-based HealthSouth became a member of that disreputable group a year later.

White, Amy G. "Paying for Patients: Choice of Law, Conflicting Interests, and Evolving Standards of Health Care Remuneration." Texas International Law Journal (Winter 2004): pp. 327-45.
Notes: Available full-text on Wilsonweb
Abstract: This paper will address the application of domestic federal laws involving Medicare and Medicaid kickbacks and referrals, the anti-bribery and books and records provisions of the Foreign Corrupt Practices Act (FCPA), and the laws of selected other countries regarding these types of transactions. State-level regulations will not be discussed here, since various states approach this issue differently, practitioners should consult their local state regulations before entering into a transaction of this nature.

Wild, Robert, et al. "Government Audits Probe Potential Fraud and Abuse by Physicians and Health Facilities." New York State Bar Journal (July/August 2002): pp.8-25.
Notes: Available full-text on Westlaw
Abstract: This article addresses the government's weapon of choice in combating fraud and abuse--the False Claims Act--as well as other laws in the government's arsenal, including anti-kickback statutes and physician self-referral laws. It also provides information on disclosing overpayments received from the government and private insurers and discusses the benefits of implementing a compliance program to avoid and detect fraudulent behavior.