미국의 의료비 부정청구 방지법제에 관한 고찰

다국어 초록 (Multilingual Abstract)

Since its inception in 1863, the federal False Claims Act(the “Act”) has included provisions whereby citizens can assist in the detection and enforcement of frauds against the government. To increase fraud recoveries, the Act authorizes private citizens(“relators”) to sue on behalf of the government(“qui tam” lawsuits) when they detect a fraud that is not already the subject of a federal enforcement action.
Periodically, Congress has adjusted the Act’s qui tam provisions in order to balance its dual goals of creating, on the one hand, sufficient incentives for private parties to detect and pursue frauds, but to discourage, on the other hand, qui tam actions where the federal government already has the ability to discover and prosecute the fraud on its own. Over the years, Congress aimed to attain the “golden mean”--an equitable balance between encouraging private fraud detection that increases federal fraud recoveries but discouraging “parasitic” qui tam actions where the relator merely asserts fraud claims that have already been made public.
The most recent adjustments to the qui tam provisions of the Act occurred with the enactment of health reform, the Patient Protection and Affordable Care Act. Amidst a national recession that ballooned the ranks of the uninsured and reports of rampant health care frauds that were robbing millions of dollars from federal health care programs, Congress sought to expand incentives for private citizens to detect and report health care frauds.
And for two of its almost three decades, the Medicare antikickback law(now applicable to nearly all federal health care programs) served as an allegory concerning the punishment of truly corrupt behavior, such as naked bribes or kickbacks in exchange for patient referrals. Other part saw the Department of Health and Human Services’s(DHHS’s) Office of Inspector General(OIG) boldly staking out new territory in a series of “safe harbor” regulations, special fraud alerts, indictments, and enforcement proceedings.
This Article will examine the purposes and history of the antikickback law and describes its evolution into a potent weapon against the corruption of medical decision making in the procurement of prescription drugs and medical devices. The article also details these recent amendments to the qui tam provisions of the False Claims Act, focusing on the enormous expansion of relators’ ability to commence qui tam actions, and changes to the qui tam bar that are likely to result. While the purposes of the law are laudable, its current broad interpretation may impede not only corruption, but also benign forms of customer relations and innovative approaches to cost-effective medical care.

참고문헌 (Reference)

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