Federal fraud guidelines issued

The Department of Health and Human Services Office of the Inspector General recently issued guidelines for the Health Care Fraud and Abuse Control Program. The creation of an anti-fraud program was mandated in the language of the Health Insurance Portability and Accountability Act of 1996.

The anti-fraud program is a joint effort between the Attorney General’s office and the Secretary of Health and Human Services’ office. Both public and private health plans are targeted to combat fraud. Funding will come from the Medicare Hospital Insurance Trust Fund. The Fraud and Abuse Control Program was developed based on results of the Health Care Financing Administration’s anti-fraud demonstration project called Operation Restore Trust.

Goals for the anti-fraud program include:

• coordinating federal, state, and local law enforcement programs to control fraud and abuse in health plans;

• conducting investigations, audits, evaluations, and inspections of the delivery and payment for health care;

• facilitating the enforcement of civil, criminal, and administrative statutes applicable to health care;

• providing industry guidance, including advisory opinions, safe harbors, and special fraud alerts.