Federal Fraud and Abuse Enforcement and Compliance Plans

  • Ronald L. Eisenberg


According to a report of the Office of the Inspector General (OIG) of the Department of Health and Human Services (HHS), in 1996 Medicare disbursed about $23 billion in overpayments for inappropriate and possibly fraudulent services; more than 20% of these improper payments went to physicians. The OIG estimated that spending attributable to waste, fraud, and abuse ranges from 3% to 10% of national health care expenditures. In an effort to recoup some of this huge sum, the authority of the federal government to combat health care fraud was clarified and its enforcement ability was significantly expanded with the enactment of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Among its provisions, “This law doubled the number of OIG auditors and investigators in addition to expanding the power of the Federal Bureau of Investigation to investigate health care fraud; created the Medicare Integrity Program whereby HHS may enter into contracts with private entities to review and audit activities where Medicare provides coverage; and established a reward program to encourage Medicare beneficiaries to report questionable behavior.” Consequently, physicians submitting a claim for payment must be aware that the federal government has the authority to investigate its propriety. An inappropriate claim for payment, ranging from an inadvertent mistake to outright fraud, may lead to liability to both criminal and civil sanctions (monetary fines).


Internal Investigation Compliance Officer Compliance Plan Monetary Fine Baseline Audit 
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  1. 1.
    American Medical Association at:
  2. 2.
    Smith JJ, Berlin B. Medicare fraud and abuse. AJR 2003; 180: 591–595.PubMedGoogle Scholar

Copyright information

© Springer-Verlag New York, Inc. 2004

Authors and Affiliations

  • Ronald L. Eisenberg
    • 1
    • 2
  1. 1.Department of RadiologyAlameda County Medical CenterOaklandUSA
  2. 2.University of California School of Medicine at San Francisco and DavisUSA

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