CHAPTER 5

Coding for Dollars

Healthcare Fraud and Abuse

As funding and reimbursement for health care cover less and less of the cost of providing care, the temptation to find “loopholes” in the reimbursement systems grows.

The U.S. Department of Health and Human Services (HHS) established a Fraud and Abuse Control Program, effective January 1, 1997. The Office of Inspector General (OIG) carries out nationwide audits, investigations, and inspections in order to protect the integrity of HHS programs. Included as subjects of the investigatory efforts would be any healthcare program that receives and distributes federal funds. The OIG also has the authority to investigate hospitals, pharmaceutical manufacturers, third-party medical billing companies, ...

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