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Background Information
Over the years numerous fraudulent claims have cost Medicare enormous amounts of money.
The Department of Health and Human Services (HHS) Office of Inspector General (OIG)
Semiannual Report to Congress reported total fiscal year (FY) 2005 savings and expected
recoveries of nearly $35.4 billion, more than doubling savings and recoveries since FY 2000.
Also for this reporting period, OIG reported exclusions of 3,806 individuals and entities
for fraud or abuse of Federal health care programs and/or their beneficiaries.
As a result, the Office of the Inspector General (OIG) issued to solo and group physician practices –
which are responsible for making sure claims are valid and honest – a voluntary compliance standard.
If, in fact, fraudulent claims are submitted, the penalties are serious: criminal prosecution, huge monetary fines, and exclusion of the physician from Medicare and Medicaid participation. In addition, physicians may be held responsible even if they were unaware of the fraud or if the infractions were caused by a billing company. It is noteworthy, too, that the OIG often views violations of the law less rigidly if the physician/group has instituted an active compliance program that includes documented training and auditing.
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