California Advanced Thinking About Medicare Fraud & Abuse

This course provides an in-depth analysis of Medicare-related fraud and abuse within the context of the healthcare and insurance industries. The course meticulously examines the intricacies of Medicare's regulatory framework, including laws like the False Claims Act and the Stark Law, and explores case studies such as U.S. v. Jain and Columbia/HCA. These examples illustrate real-world applications of anti-fraud statutes and the ongoing challenges of jurisdiction, prosecution, and enforcement. By highlighting scenarios of compliance failures, financial misconduct, and jurisdictional disputes, the course equips professionals with the knowledge to navigate the complex legal environment of Medicare fraud prevention and the regulatory obligations imposed on providers.

For insurance professionals, this course is highly relevant to understanding the financial and legal implications of fraud and abuse within Medicare and related healthcare insurance products. It emphasizes the professional competence needed to assess risk, enforce compliance, and implement safeguards against fraudulent activities. The detailed exploration of fraud prevention and compliance strategies contributes to the technical acumen required for effectively managing healthcare claims, fostering ethical practices, and ensuring adherence to Medicare regulations, thereby enhancing the practitioner's capacity to operate within their licensed roles responsibly and effectively.

The topics include:

• Prosecutions and Jurisdictions
• Related Entities
• The Stark Law
• The False Claims Act
• Whistleblower or Qui Tam Lawsuits
• Intentional Miscoding
• Property: Forfeitures and "Safe Harbors"
• Pharmaceuticals, Durable Medical Equipment and Other Medicare Supplies
• Kickbacks and Other Medicare-related Bribes
• Physical Therapy, Ambulance Services and Abuse of Fiscal Intermediaries
• In-Home Health Care Fraud and Abuse
• Medicare HMOs and Fraudulent Denials
• Medicare Fraud and Money Laundering
• Sentencing Issues
• Tips from CMS for Avoiding Medicare Frauds and Scams