Enforcement

FederalStateLocalPrivate Sector

All levels of government and the private sector should adequately fund and support antifraud and anti-abuse efforts. A balanced approach to enforcement should be taken. It should ensure that antifraud and anti-abuse activities do not have unintended negative effects on patient health care. For example, if they decrease access to care or result in the withholding of medically necessary treatment. 

Restrictions on physician self-referral and provider-kickback schemes must be strengthened and enforced. 

The Department of Health and Human Services (HHS) and the Department of Justice should continue their enforcement activities, including research to determine the extent of fraud and abuse. They should also assess the effects of initiatives to combat them. Both agencies must continue investigations, operations, and prosecutions to reduce the impact of fraud and abuse on federal health care programs and beneficiaries. Congress should continue to oversee the effectiveness of these enforcement activities to ensure that they are appropriate and do not adversely affect access to care. HHS should expand and intensify its efforts to educate health care providers about compliance with Medicare billing rules. And HHS should assist them in preventing and correcting billing errors. 

Fines and penalties recovered as the result of enforcement efforts should be spent for the benefit of Medicare and Medicaid. This includes continued enforcement activities to reduce fraud and abuse in these programs. These funds should not be redirected to unrelated programs.