Aspen Health Law Center. Health Care Fraud and Abuse Compliance Manual. Gaithersburg, MD: Aspen Publishers, Inc., 1997.Call Number: KF 3608 .A4H443Abstract: This manual explains fraud and abuse laws in simple language, using examples to illustrate the principles. It has an overview chapter that presents a general introduction to the subject areas that are explored in greater detail in subsequent chapters. The main areas addressed are false claims and fraudulent billing, fraud and abuse prohibitions under the Antikickback Statute, Federal physician self-referral prohibitions, the Stark Law, corporate compliance programs, anatomy of an investigation, and state fraud and abuse investigations and enforcement.

Bureau of National Affairs. BNA's Health Care Fraud Report. Washington, DC: Bureau of National Affairs.Abstract: A biweekly report that covers the latest health care fraud and abuse issues in the private insurance industry, managed care organizations, and Federal and state health care programs.

Burstein, Rachel. "Is There An Imposter In The House?" Mother Jones 23, no. 3(May-June 1998): p. 20.Notes: Available full-text on WilsonWebAbstract: Authorities are unlikely to catch many of the perpetrators of a new type of private health insurance fraud that occurs in the home. An example of this fraud was allegedly committed by Tony and Dianne Cannon, who are said to have posed as physical therapists throughout Maryland, defrauding Medicare and private insurers of hundreds of thousands of dollars. Unfortunately, Maryland is the only state that has introduced legislation to maintain the type of fraud units that tracked down the Cannons.

Darken, Kevin J. "Understanding the New Health Care Fraud Legislation." Criminal Justice 12, no. 3(Fall 1997): pp. 30-59.Notes: Available full-text on WestlawAbstract: This is a guide to understanding new criminal statutes regarding health care fraud. It summarizes key sections of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law No. 104-191. Subtitle E of HIPAA created five new criminal statutes which prohibit: (1) defrauding a health care program; (2) embezzling, stealing or misapplying funds from a health care program; (3) making false statements or concealing material facts in connection with delivery of or payment for health care benefits; (4) obstructing the communication to a criminal investigator of information regarding Federal health care offense or violation; and (5) disposing of assets in order for an individual to become Medicaid eligible. HIPAA also expanded existing money laundering, asset forfeiture and fraud injunction statutes to cover Federal health care offenses.

This bibliography is a representative selection of materials either owned or on order by the FBI Academy Library. Inclusion of an item does not represent an endorsement by the FBI of the material or its author.

Federal Bureau of Investigation. "About the Health Care Fraud Unit." [http://www.fbi.gov/programs]. 20 July 2000.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 insure 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 care 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 website offers current statistics and case summaries.

Gibeaut, John. "Painful Treatment: Providers Feel Sting of Two-Prong Government Attack on Health Care Fraud." ABA Journal 84(April 1998): p. 87.Abstract: The Federal Government is ready to impose new laws into criminal prosecutions of health care fraud and civil lawsuits. A primary source of the Government's larger arsenal is the 1996 Health Insurance Portability and Accountability Act.

Health Insurance Association of America. Fraud: The Hidden Cost of Health Care. Washington, DC: Health Insurance Association of America, 1996.Call Number: RA 395 .A3F696 1996Abstract: This book examines the problem of fraud in the health insurance industry and its investigation and prevention. Topics include insurers' anti-fraud activities, criminal investigations and government anti-fraud efforts, investigative techniques and case preparation, automated tools for detection and investigation, fraud in managed care arrangements, fraud and electronic data interchange, legal issues, and disability income fraud. Comes with a companion study manual.

Kleiner, Shari, et al. "Health Care Fraud." American Criminal Law Review 36, no. 3(Summer 1999): pp. 773-807.Notes: Available full-text on Criminal Justice Periodical IndexAbstract: 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.

Longman, Phillip. "Who Is The Victim?" Home Health Care Fraud 123(August 1997): pp. 18-20.Notes: Available full-text on WilsonWebAbstract: Fraud is a huge problem for Medicare, but an extensive pattern of small-scale cheating by millions of ordinary Americans and their health care providers is the main reason that the cost of home care has skyrocketed.

Office of Inspector General, US Department of Health and Human Services. "Special Fraud Alerts, Medicare Advisory Bulletins and Special Advisory Bulletins." [http://www.oig.hhs.gov]. 20 July 2000.Abstract: The Office of Inspector General (OIG) issues Special Fraud Alerts based on information it obtains concerning particular fraudulent and abusive practices within the health care industry. These Special Fraud Alerts provide the OIG with a means of notifying the industry that it has become aware of certain abusive practices which it plans to pursue and prosecute, or bring civil and administrative action, as appropriate. The alerts also serve as a powerful tool to encourage industry compliance by giving providers an opportunity to examine their own practices.

Samborn, Hope Viner. "Relying on RICO." ABA Journal 84(May 1998): p. 30.Abstract: Using civil racketeering laws, insurers are collecting big damages from attorneys and others who aid fraud. The work by casualty and health care insurers to curb billions in fraud is discussed.

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: J 28.24:F 86Abstract: The incidence of health care fraud remains at alarmingly high levels despite unprecedented attention in recent years from policymakers and law enforcement. Major scams appear to be artfully designed to circumvent routine controls and may remain invisible for long periods. When they are discovered, it seems often to be more by luck than judgment. This document discusses the health care industry's traditional approach to fraud control, the weaknesses of that 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, 2nd Ed., 2000.Call Number: RA 395 .A3S764 2000Abstract: Who steals? An extraordinary range of folk--from low-life hoods who sign on as Medicare or Medicaid providers equipped with nothing more than beepers and mailboxes, to drug trafficking organizations, organized crime syndicates, and even major hospital chains. This book shows how the industry's defenses, which focus mostly on finding and correcting billing errors, are no match for such well orchestrated attacks. The maxim for thieves simply becomes "bill your lies correctly." Provided they do that, fraud perpetrators with any degree of sophistication can steal millions of dollars with impunity, testing payment systems carefully, and then spreading fraudulent billings widely enough across patient and provider accounts to escape detection. The kinds of highly automated, quality controlled claims processing systems that pervade the industry present fraud perpetrators with their favorite kind of target: rich, fast paying, transparent, utterly predictable check printing systems, with little threat of human intervention, and with the US Treasury on the end of the electronic line.

________. License to Steal: Why Fraud Plagues America's Health Care System. Boulder, CO: Westview Press, Inc., 1996.Call Number: RA 395 .A3S764 1996Abstract: This volume examines the components and layers of existing systems for detecting and controlling criminal fraud in the health care industry, questions the adequacy of these efforts, and offers recommendations for making fraud controls more effective.

Tillman, Robert. Controlling Fraud in the Small Business Health Insurance Industry: Executive Summary. Washington, DC: U.S. Department of Justice, 1998.Call Number: *In catalogingAbstract: Fraud in the small business health insurance industry was studied, with a focus on entities that market health insurance under the guise of being employee welfare benefit plans as defined by the Employment Retirement Security Act and that ultimately fail to pay medical claims to large numbers of their participants.

_______ . Broken Promises: Fraud by Small Business Health Insurers. Boston: Northeastern University Press, 1998.
Call Number: HV 6769 .T55 1998Abstract: This critical examination of fraudulent health insurance providers, draws on court documents, congressional hearings and actual cases to provide examples of the three most prevalent forms of fraud: scams involving multiple employer welfare arrangements, employee leasing schemes, and fictitious labor unions. Two structural changes have created an environment wherein white-collar criminals are able to thrive by creating what is essentially a black market in health insurance. First, most large insurance companies have left the market as many large corporations have set up their own insurance plans, and maintenance organizations and other managed care networks have made significant inroads into the health care market. Small business owners have seen their health insurance costs rise dramatically and many are unable to find insurance for their employees at any cost. Second, the Federal Employee Retirement Income Security Act, which was intended to make it easier for employers, labor unions and other organizations to provide health benefits to employees, contains legal loopholes that facilitate massive fraud.

US Department of Health and Human Services. "A Comprehensive Strategy to Fight Health Care Waste, Fraud and Abuse." HHS Fact Sheet (March 2000).Notes: Available full-text at http://www.hhs.govAbstract: Since 1993, the Clinton Administration has focused unprecedented attention on the fight against fraud, abuse and waste in the Medicare and Medicaid programs. This fact sheet outlines the result, which is a series of investigations, indictments and convictions, as well as new management tools to identify wasteful mispayments to health care providers.

US Department of Health and Human Services. "State Medicaid Fraud Control Units (SMFCU)." [http://www.hhs.gov/progorg/oi/mfcu/index.htm]. 20 July 2000.Abstract: The enactment of the Medicare and Medicaid Anti-Fraud and Abuse Amendments of 1977 authorized the establishment of, and Federal funding for, the State Medicaid Fraud Control Units (SMFCUs). Currently 47 states and the District of Columbia have units in operation. The mission of the Medicaid fraud units is to investigate and prosecute Medicaid provider fraud and incidences of patient abuse and neglect. Since the inception of the Medicaid fraud control program, the SMFCUs have successfully convicted thousands of Medicaid providers and have recovered hundreds of millions of program dollars. An annual report and SMFCU performance certification standards are available at this website.

US Department of Health and Human Services and US Department of Justice. "Health Care Fraud and Abuse Control Program Annual Report for FY 1999." January 2000. [http://www.usdoj.gov/dag/pubdoc/hipaa99ar21.htm]. 20 July 2000.Abstract: The detection and elimination of health care fraud and abuse is a top priority of Federal law enforcement. Efforts to combat fraud were consolidated and strengthened considerably by the Health Insurance Portability and Accountability Act of 1996, which established a national Health Care Fraud and Abuse Control Program under the joint direction of the Attorney General and the Secretary of the Department of Health and Human Services, acting through the Department's Inspector General. The program is designed to coordinate Federal, state and local law enforcement activities with respect to health care fraud and abuse. The Act brought much needed and powerful new criminal and civil enforcement tools and financial resources that permitted the government to expand and intensify the fight against health care fraud. This report, which covers the third year of operation under the program, saw a continuation of the collaborative efforts of Federal and state enforcement and oversight agencies to identify and prosecute the most egregious instances of health care fraud, to prevent future fraud or abuse, and to protect program beneficiaries.

US General Accounting Office. Medicaid Fraud and Abuse: Stronger Action Needed to Remove Excluded Providers From Federal Health Programs. Gaithersburg, MD: US General Accounting Office, 1997.Call Number: GA 1.13:HEHS-97-63 Notes: Available in microfiche Abstract: The process used by the Office of the Inspector General of the Department of Health and Human Services to ensure the exclusion of health care providers that commit fraud or abuse or those that are incompetent was studied to determine its effectiveness in overcoming weaknesses revealed in a 1996 review by the General Accounting Office. This report addresses the remaining weaknesses.

Compiled by Jean Caddy, 8/00