Volume 7, Issue 1

Jamie R. Welton

Reports of widespread criminal abuse of the Medicare system have resulted in the creation of new legislation and regulations interpreted as broad mandates to clean up the financially unstable Medicare system. The federal government’s recent investigation and prosecution of Columbia/HCA for Medicare fraud served as a wake-up call to health-care providers participating in the Medicare system. As a result, in order to avoid a similar fate as Columbia/HCA, health-care providers are now more energetically guarding against noncompliance with Medicare requirements.

In this note, Mr. Welton analyzes Medicare reimbursement requirements, Medicare procedures for reviewing reimbursement requests, specific areas of reimbursement often investigated, and the effects of such investigations. Mr. Welton also examines the statutes used by the government to punish noncompliance, exemptions to the statutes, and the elements required for establishing a good-faith defense to a charge of noncompliance. Lastly, Mr. Welton recommends several strategies on how health-care providers may avoid the initiation of an investigation and discusses various means of recourse if the government initiates an investigation.