Medicare and Medicaid Fraud and Abuse introduces fundamental concepts as well as detailed analysis of the aspects of Medicare and Medicaid fraud and abuse, including regulation, caselaw, advisory opinions, and more. It is updated annually to reflect the dynamism in this area of the law.
Alice Gosfield has been the author since 2003 and has been assisted by Daniel Shay since 2010. It is written specifically for practicing lawyers, regardless of whether they represent plaintiffs, defendants, or those who merely want to avoid problems.
- Chapter 1 – Introduction to basic concepts, the activities of the Office of the Inspector General and the Department of Justice in the previous year, how each sector of the industry is impacted by these laws, and a discussion of the multiple compliance guidances issued by the OIG.
- Chapter 2 – The Antikickback Laws covering their development over the years, including analysis of all the safe harbor regulations, significant caselaw, special fraud alerts and bulletins, the voluntary disclosure protocol, and advisory opinions.
- Chapter 3 – The Stark Statute and Regulations: Distinctions between this law and the antikickback statute as well as the antimarkup rules, all of the Stark regulatory exceptions, the disclosure protocol for Stark issues, advisory opinions, major settlements, and caselaw.
- Chapter 4 – Administrative Penalties and Exclusions: When they apply, how permissive and mandatory exclusions differ, civil money penalty authorities, the Sunshine Act, quality relevant penalties, administrative penalties for false claims, and other remedies and sanctions.
- Chapter 5 – False claims: Criminal, Civil, and Qui Tam Actions. Criminal false claims statutes, civil false claims, qui tam actions, and legal issues under all of those including extensive discussion of caselaw regarding procedural and substantive issues.
- Chapter 6 – Investigations, coauthored by Kevin Raphael and James W. Kraus, coming from both the prosecutorial and defense bars, in active practice in this arena. This chapter addresses the key players, grand jury investigations, DOJ or HIPAA subpoenas, search warrants, administrative searches, defenses, and challenges to common investigative techniques, privilege claims, conducting internal investigations, and more.