Legal Issues in Healthcare Fraud and Abuse: Navigating the Uncertainties, Fourth Edition with 2013 Cumulative Supplement is a guidebook for healthcare providers, consultants, and attorneys, and describes the broad spectrum of laws and legal theories, as well as the principles used by the government to enforce its drive against fraud in the healthcare arena.

The book begins with a thorough review of governmental enforcement entities, including the Department of Justice, the Department of Health and Human Services(and its affiliated subgroups like the Office of Inspector General, and Centers for Medicare & Medicaid Services), as well as other federal agencies, state governments, and private payers.

The authors review all of the major laws and activities that are the subject of healthcare fraud investigations, and spend considerable time addressing the major statutory elements in each. These include the anti-kickback statute, the federal physician self-referral prohibitions (as well as the applicable safe harbors), the false claims act, and the administrative sanctions that are available to the enforcers. They also provide an overview of state counterparts to the federal laws addressing self-referrals, anti-kickback issues, false claims, other statutory authorities, and private initiatives.

In addition, the authors address two important areas in healthcare fraud: corporate compliance efforts and managed care. They note the tremendous growth in the managed care segment of the industry and the challenge in enforcement efforts due to the subtle and complicated nature of fraud in this setting. They identify some of the differences between fraud in the fee-for-service and managed care settings, such as denial of appropriate care, inadequate treatment, and inflation of reporting numbers of patients treated. Finally, the authors discuss some of the important issues that confront attorneys practicing in the subspecialty of healthcare fraud, and take a look into the crystal ball for potential legislative activities and anticipated enforcement efforts in the remainder of the 21st century.

Highlights of the Fourth Edition include: