Guide · Healthcare

Health Care Fraud and Abuse: A Comprehensive Guide to the Anti-Kickback Statute, Stark Law, and Overpayments

42 U.S.C. § 1320

Type
Guide
Jurisdiction
National
Date
2024-10-21
Topic
Healthcare

This guide states the law governing health care fraud and abuse. Part 1 covers the Anti-Kickback Statute, its elements, the one-purpose test, its voluntary safe harbors, and the advisory opinion process. Part 2 covers the Stark Law, its strict liability structure, the designated health services it reaches, and the mandatory exceptions that distinguish it from the kickback regime. Parts 3 and 4 cover the False Claims Act — including materiality and scienter after Escobar and SuperValu, the qui tam procedure, and the retaliation provision — together with the sixty-day overpayment rule that converts retained overpayments into false claims. Parts 5 and 6 cover exclusion, civil monetary penalties, and the criminal statutes, including the scienter holding of Ruan. Parts 7 and 8 cover the self-disclosure protocols, corporate integrity agreements, compliance program elements, and investigation response. Later parts address value-based arrangements, the enforcement patterns that recur in each sector, and the state statutes that frequently reach further than federal law.

Health Care Fraud and Abuse: A Comprehensive Guide to the Anti-Kickback Statute, Stark Law, and Overpayments

Healthcare > Fraud, Abuse, and Compliance | Published 21 October 2024 - Updated 21 February 2026 | UpLaw - uplaw.us

Part 1 — The Anti-Kickback Statute

1.1 Elements

42 U.S.C. § 1320a-7b(b) prohibits knowingly and willfully soliciting or receiving, or offering or paying, any remuneration directly or indirectly, overtly or covertly, in cash or in kind, in return for referring an individual for, or for purchasing, leasing, ordering, arranging for, or recommending, any item or service for which payment may be made in whole or in part under a federal health care program.

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