Fraud and Abuse Law in the United States

Abstract

This chapter focuses on healthcare fraud, which remains a significant problem in the United States despite years of increased fraud enforcement. It describes the US federal government's anti–fraud activities, which include expanding the range and severity of laws targeting healthcare fraud. It also points out the role played by the United States' lack of a centralized, universal program of health insurance, which causes healthcare to be paid for by a variety of public, private, and hybrid sources. This chapter mentions the strategy of capitation as the strictest mechanism for managing care, in which a primary care physician receives a fixed per–patient payment in return for meeting the patient's healthcare needs during a set period of time. It also looks at changes made to Medicare reimbursement under the Patient Protection and Affordable Care Act (ACA) that reward providers for the “value” rather than the volume of services provided.