Health and policy 5-1 Discussion: Fraud and Abuse Regulation

Healthcare—particularly government-funded healthcare—is heavily regulated. Providers who agree to participate in these programs and accept payment for services must comply with numerous confusing (and expensive) regulations.

Consider the following hypothetical:

You are head of risk management for a medical group that is employed by a hospital. You have just learned that Dr. Stevens, an orthopedic surgeon, has sent Christmas gifts for the past three years to every primary care provider who has referred patients to Dr. Stevens. What legal risks are raised by Dr. Stevens' actions? Should this behavior be legal or illegal? What questions will you ask Dr. Stevens and what additional information do you need to gather?

Set out a stepwise plan to address this situation. Based on the conclusions you draw, recommend policy changes by the hospital and medical group.