A Conceptual Model of Health Care Fraud Enforcement

Abstract

This article posits that recent federal efforts to eradicate health care fraud can best be explained through a tripartite conceptual model consisting of regulation, information, and litigation. Despite the fact that only regulations promulgated through notice-and-comment procedures are legally binding, health care fraud enforcement efforts increasingly rely on informal expressions of agency views, as well as the use of public and private litigation to address ambiguities in substantive regulation. While these developments provide increased guidance to the health care industry as to the scope of permissible activities, they simultaneously raise troubling concerns about subjecting health care providers to unofficial - and at times inconsistent - legal interpretations. This article explores the implications of the tripartite model, concluding that these problems can only be remedied by a focus on regulatory clarity.

Keywords: health care fraud, enforcement, false claims, kickbacks, regulation, information, litigation