Dissertation Abstract

Healthcare Fraud and Abuse: The Conundrum of Voluntary Disclosure and Self-Reporting.

Eliminating healthcare fraud and abuse has become an urgent priority of the federal government, and hospital healthcare fraud investigations increasingly commonplace. The investigations can result in staggering fines and criminal convictions, with healthcare executives facing the possibility of sentencing and prison terms.

This project reviews the issue of healthcare fraud and abuse: its definition, quantification, public perception, the law, government funding, manpower and areas targeted for investigation by the federal government.

Hospitals are engaged in efforts to develop compliance programs. Compliance programs are an essential response to the federal government fraud and abuse efforts and offer advantages to hospitals involved in an investigative action. An effective program can lead to the discovery of over billings, mistakes, and errors, leaving a hospital with the decision of how to respond. The Office of Inspector General, U.S. Department of Health and Human Services, in October of 1998 issued a Protocol for Voluntary Disclosure, a formal program having advantages, disadvantages and consequences. The decision whether to voluntarily disclose and self-report or not is a conundrum for hospitals, healthcare executives and the attorneys who represent them.

This project includes a case study on one of the first hospital voluntary disclosure settlements. Interviews with health attorneys about the process are analyzed and discussed. Recommendations are made to improve the Voluntary Disclosure Program, along with suggestions for continued and additional research in this area.

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