The federal body of law applying to Medicare and Medicaid providers which prohibits three things: (1) the filing of false claims, (2) paying or receiving bribes or kickbacks for referrals, and (3) self-referral schemes. The practical effect of this legislation is greater con¬ centration in the health care delivery system because it encourages physicians to form groups or become employees of a health care system. Violations of these laws can result in both civil penalties and criminal punishment. The Inspector General (IG) of the Department of Health and Human Services (DHHS) enforces the civil penalties. The Department of Justice (DOJ) enforces the criminal penalties. Also known as the “Medicare and Medicaid fraud and abuse law”.
A statute that regulates the appropriateness of health care provider behavior in billing practices, receipt of payments, and provision of medically necessary services.