Medicare Fraud and Abuse Course Overview
It is estimated that annual healthcare costs surpassed $3.35 trillion in 2018, and losses from fraud and abuse reached $300 billion—a loss of about $820 million every day. Whether covered by employer-sponsored health insurance or individual policies, healthcare fraud and abuse inevitably translates into higher premiums and out-of-pocket expenses for consumers, as well as reduced benefits or coverage. For employers—private and government alike—healthcare fraud and abuse increases the cost of providing insurance benefits to employees and, in turn, increases the overall cost of doing business. The financial and legal consequences for organizations can be severe, including hefty fines, exclusion from federal healthcare programs, and criminal prosecution.
This Medicare Fraud and Abuse course provides a comprehensive overview of the principal laws used to combat fraud against government healthcare programs including the False Claims Act, Anti-Kickback Statute, and Stark Law, along with communication mandates from the Deficit Reduction Act. The training details employer responsibilities in preventing fraud through establishment of compliance programs and employees’ responsibilities in identifying and preventing fraud and abuse in the workplace, including whistleblower activities and protections. Developed for all employees and management working in healthcare organizations, this course ensures your team understands the fundamental rules regarding healthcare fraud and abuse.
Medicare Fraud and Abuse Course Content
Lesson 1: Introduction & Objectives
Course overview and learning objectives, magnitude of healthcare fraud problem ($300 billion annually), impact on healthcare costs and insurance premiums, importance of compliance for all healthcare workers
Lesson 2: Defining Fraud and Abuse
Distinguishing fraud from abuse, intentional vs. unintentional violations, examples of common fraud schemes, examples of waste and abuse, consequences of fraud and abuse violations
Lesson 3: Laws Combating Healthcare Fraud
- False Claims Act (31 USC § 3729)
- Anti-Kickback Statute (42 USC § 1320a-7b(b))
- Physician Self-Referral “Stark” Law (42 USC § 1395nn)
- Fraud Enforcement and Recovery Act of 2009 (FERA)
- Patient Protection and Affordable Care Act
- Deficit Reduction Act of 2005 (DRA)
Lesson 4: Compliance Plans and Preventing False Claims Act Violations
Seven elements of effective compliance programs, code of conduct, designated compliance officer, effective training and education, effective lines of communication, internal monitoring and auditing, enforcing standards through disciplinary guidelines, responding to detected offenses, employee responsibilities in preventing violations
Lesson 5: Role of Whistleblowers in False Claims Act Suits
Qui tam lawsuits under False Claims Act, whistleblower eligibility and rewards (15-30% of recovery), protection from retaliation, reporting procedures, confidentiality protections, examples of successful whistleblower cases
