S. Health Care Fraud

Fraud, waste and abuse in health care is a growing crisis. National health care spending exceeded $4 trillion in 2020, representing 18% of GDP. By one estimate, up to 10% of the health care spending is due to fraud, waste, and abuse, which results in significant financial losses to consumers, government and private plans and risks serious harm to patients.

This course will review health care fraud schemes and federal and state criminal, civil and administrative tools to detect, investigate, prosecute and prevent fraud. We will address health care specific issues as well as matters relevant to white collar crime generally such as whistleblower qui tam suits, compliance, and the effect of changing federal administrations on enforcement practices. In addition to traditional tools, the course will review other efforts to redress wrongdoing in health care such as the Food and Drug Administration's response to consumer fraud, state agencies' oversight of licensing and professional misconduct, and private parties bringing medical malpractice actions. We will also examine the impact of health care fraud and responses on quality of care and inequity. Over the semester, we will consider fraud in public and private health plans, fee-for-service and managed care, and other health care financing schemes at home and abroad. Students will have discretion to focus on particular health care providers such as nursing homes, substance abuse and mental health programs, and hospitals. Finally, we will conclude the seminar by exploring how traditional fraud detection and enforcement may be altered by recent developments such as the growth in telemedicine, the response to COVID-19, and the expanded use of technology in health care such as artificial intelligence, online providers and apps.

Readings primarily consist of statutes, regulations, cases, articles, and pleadings. Class discussion is encouraged. Over the semester, students will participate in simulations applying the course material to different practical scenarios such as interviewing a whistleblower, counseling physicians affiliated with academic medical centers or practicing telemedicine, and advising a public health agency responding to COVID-19.