The criminal regulatory framework

Greg Kelminson (Gregory.Kelminson@amgh.us) is Legal Director of Compliance at Air Medical Group Holdings, Inc. in Lewisville, TX.

Jeff Ansley (jansley@bellnunnally.com) is Partner in the Dallas offices of Bell Nunnally LLP and head of the firm’s white collar defense and internal investigations practice.

The United States government has a plethora of agencies at its disposal to coordinate and enforce healthcare legislation. One agency, above all others, possesses the sole power to indict not only individuals, but companies that it views as having committed healthcare fraud. The Department of Justice (DOJ) is tasked with enforcing the law and defending the interests of the United States according to the law. The DOJ has recently estimated that healthcare fraud costs the United States more than $100 billion per year and growing. To that end, among the most frequently abused laws are the healthcare regulations.

To combat this fraud, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) established a national Health Care Fraud and Abuse Control Program (HCFAC) under the joint direction of the Attorney General and the Secretary of the Department of Health and Human Services (HHS). And, in 2009, the DOJ and investigative agencies established the Health Care Fraud Prevention & Enforcement Action Team (HEAT).

HEAT was designed to: (1) aggregate significant resources across government to prevent fraud, waste, and abuse in the Medicare and Medicaid programs; (2) reduce skyrocketing healthcare costs and improve the quality of care by ridding the system of those preying on Medicare and Medicaid beneficiaries; (3) highlight best practices by providers and public sector employees; and (4) build upon existing partnerships between DOJ, HHS and their client agencies to reduce fraud and recover taxpayer dollars.

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