AHFI LEGAL
# Term Definition
1 ERISA Employee Retirement Income Security Act
Preempts state law to establish and preserve
uniform and exclusive federal regulations of
covered employee benefit plans Primary source
of regulation for self funded plans but also
applies to insured health benefit plans
2 HIPAA Health Insurance Portability and Accountability
Act Title 1: Health Care Access, Portability, and
renewability Title 2: Preventing health care fraud
and abuse, administrative simplification, medical
liability reform
3 HIPAA - Healthcare Fraud and Far reaching program to combat fraud and
Abuse Control Program abuse in both public and private health plans
Appropriates money from the Healthcare Fraud
and Abuse Control Account, approved by
Secretary and Attorney General support HHS and
DOJ enforcement
4 DOJ Department of Justice Civil division, Criminal
division, US Attorneys office, Civil Rights Division,
and FBI FBI has investigatory jurisdiction for
commercial healthcare with state LE
5 HHS Health and Human Services OIG, Office of
General Counsel, CMS, FDA OIG and FBI
responsible for investigating fraud in Medicare
and in Medicaid (along with MFCUs)
6 Anti-Kickback Statute Knowingly or willfully solicits, receives, offers, or
pays any remuneration directly or indirectly in
return for referrals or for any good, facility or
service any federal health care program may pay
*ACA amended that person does not have to
have knowledge of the law to violate -Felony
-Applies only to federal health care programs,
most states have enacted their own version of
Anti-Kickback law -up to $25,000, imprisonment
up to 5 years, or both -Under Civil Monetary
Penalties law, violators also subject to exclusion
from federal health care programs and civil
monetary penalties up to $50,000 for each
violation and triple the amount of remuneration
offered, paid, solicited or received
, AHFI LEGAL
# Term Definition
7 STARK Anti-referral Statute Prohibits physicians with direct or indirect
financial interests in an entity from making
referrals to that entity for designated health
services -Applies to Medicare and Medicaid, 12
designated health services, many states have
own version -Applies without regard to violators
knowledge -Civil Statute -Penalties include
non-payment of services, CMS, exclusion from
Medicare/Medicaid and a penalty of up to
$100,000 for a circumvention scheme
8 Civil False Claims Act Presenting or causing to be presented a false or
fraudulent claim to the federal government. Most
states has version of false claims act - $5,000 to
$10,000 per false claim plus triple the amount to
federal government. Standard of proof is
preponderance of evidence
9 Qui Tam "Whistleblower" Initially files claim on behalf of
the government and can recover 15 to 25% of
government's recovery if the government
intervenes, 25 to 30% if the government does not
intervene
10 Civil Monetary Penalties Statute Provides civil monetary penalties and exclusion
from federal health care programs for conduct
that encompasses the concept of improperly filed
claims Range of monetary penalties depending
on conduct, penalties are in addition to other
penalties prescribed by law
11 Health Care Fraud Statute Prohibits executing or attempting to execute a
scheme or artifice to defraud or to fraudulently
obtain money or property from any health
benefit program -Fines and imprisonment not
more than 10 years, if serious bodily injury
occurs, then imprisonment for not more than 20
years, if death occurs life in prison is available
12 Health Care Benefit Program False Prohibits falsifying or concealing a material fact
Statements Statute or making false statements in connection with
the delivery of health care benefits Penalty
includes fines and up to 5 years in prison
# Term Definition
1 ERISA Employee Retirement Income Security Act
Preempts state law to establish and preserve
uniform and exclusive federal regulations of
covered employee benefit plans Primary source
of regulation for self funded plans but also
applies to insured health benefit plans
2 HIPAA Health Insurance Portability and Accountability
Act Title 1: Health Care Access, Portability, and
renewability Title 2: Preventing health care fraud
and abuse, administrative simplification, medical
liability reform
3 HIPAA - Healthcare Fraud and Far reaching program to combat fraud and
Abuse Control Program abuse in both public and private health plans
Appropriates money from the Healthcare Fraud
and Abuse Control Account, approved by
Secretary and Attorney General support HHS and
DOJ enforcement
4 DOJ Department of Justice Civil division, Criminal
division, US Attorneys office, Civil Rights Division,
and FBI FBI has investigatory jurisdiction for
commercial healthcare with state LE
5 HHS Health and Human Services OIG, Office of
General Counsel, CMS, FDA OIG and FBI
responsible for investigating fraud in Medicare
and in Medicaid (along with MFCUs)
6 Anti-Kickback Statute Knowingly or willfully solicits, receives, offers, or
pays any remuneration directly or indirectly in
return for referrals or for any good, facility or
service any federal health care program may pay
*ACA amended that person does not have to
have knowledge of the law to violate -Felony
-Applies only to federal health care programs,
most states have enacted their own version of
Anti-Kickback law -up to $25,000, imprisonment
up to 5 years, or both -Under Civil Monetary
Penalties law, violators also subject to exclusion
from federal health care programs and civil
monetary penalties up to $50,000 for each
violation and triple the amount of remuneration
offered, paid, solicited or received
, AHFI LEGAL
# Term Definition
7 STARK Anti-referral Statute Prohibits physicians with direct or indirect
financial interests in an entity from making
referrals to that entity for designated health
services -Applies to Medicare and Medicaid, 12
designated health services, many states have
own version -Applies without regard to violators
knowledge -Civil Statute -Penalties include
non-payment of services, CMS, exclusion from
Medicare/Medicaid and a penalty of up to
$100,000 for a circumvention scheme
8 Civil False Claims Act Presenting or causing to be presented a false or
fraudulent claim to the federal government. Most
states has version of false claims act - $5,000 to
$10,000 per false claim plus triple the amount to
federal government. Standard of proof is
preponderance of evidence
9 Qui Tam "Whistleblower" Initially files claim on behalf of
the government and can recover 15 to 25% of
government's recovery if the government
intervenes, 25 to 30% if the government does not
intervene
10 Civil Monetary Penalties Statute Provides civil monetary penalties and exclusion
from federal health care programs for conduct
that encompasses the concept of improperly filed
claims Range of monetary penalties depending
on conduct, penalties are in addition to other
penalties prescribed by law
11 Health Care Fraud Statute Prohibits executing or attempting to execute a
scheme or artifice to defraud or to fraudulently
obtain money or property from any health
benefit program -Fines and imprisonment not
more than 10 years, if serious bodily injury
occurs, then imprisonment for not more than 20
years, if death occurs life in prison is available
12 Health Care Benefit Program False Prohibits falsifying or concealing a material fact
Statements Statute or making false statements in connection with
the delivery of health care benefits Penalty
includes fines and up to 5 years in prison
