What medical residents need to know about fraud-and-abuse laws

Marc Zarefsky , Contributing News Writer

It is easy for medical residents to be intimidated by the specter of fraud-and-abuse laws. After all, filing false insurance claims to Medicare, Medicaid or other federally funded health care programs—even unintentionally—could cripple or destroy a physician’s practice.

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It is important to remember that these laws were implemented as safeguards to prevent people from misusing programs like Medicare, says an AMA educational module, "Fraud and Abuse." It is one of the AMA GME Competency Education Program offerings, which include nearly 30 courses that residents can access online through their institution’s subscription, on their own schedule.

Among the program’s experts are several who contributed to the AMA’s Health Systems Sciencetextbook, which draws insights from faculty at medical schools that are part of the Association’s Accelerating Change in Medical Education consortium. 

Modules cover five of the six topics—patient care, practice-based learning and improvement, interpersonal and communication skills, professionalism, and system-based practice—within the Accreditation Council for Graduate Medical Education’s core competency requirements. The sixth requirement, medical knowledge, is one that is typically addressed during clinical education.

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Violations and ramifications

The module offers residents with a brief overview of fraud-and-abuse laws and reviews proactive steps physicians can take to identify and comply with them.

The False Claims Act, for example, addresses false medical claims made to the government such as claims for services that are not medically necessary or claims for services not provided. It is important to recognize that individuals can be found liable when they know about fraudulent claims, even if they were not aware of the fraudulent aspects or did not intend to fraud.

The module also covers:

  • Civil monetary penalties law.
  • Physician self-referral law (aka, the Stark law).
  • Anti-kickback statute.

Residents who take this module are guided through the key components necessary to develop a strong compliance plan and will hear suggestions of the best people within a hospital or practice to talk with to learn more about fraud and abuse prevention.

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They also learn about the potential ramifications for violating fraud and abuse laws—in some cases, prohibiting some from practicing medicine. Residents are not expected to be lawyers, but it is important for them to know where to go with questions or concerns. Those who take this course will be armed with tips on how to proactively take steps to avoid fraud and abuse.

Visit the AMA GME Competency Education Program for more information on this and other offerings or to request a demo.