Department of Health and Human Services
OFFICE OF 
   
INSPECTOR GENERAL 
 
 
 
 
 
 
 
 
MED ICARE AND MEDICAID  
 
F A T  
RAUD AND  BUSE  RAINING 
 
 
M E  
IN  EDICAL  DUCATION
 
 
 
 
 
 
Daniel R. Levinson  
Inspector General 
 
October 2010 
OEI-01-10-00140   
   
 E X E C U T I V E   S U M M A R Y  
OBJECTIVES
 
To determine the extent to which:  
1.  medical schools provide instruction on compliance with Medicare 
and Medicaid laws aimed at preventing fraud and abuse, 
2.  institutions offering physician residency and fellowship programs 
provide instruction on compliance with these laws, and  
3.  medical schools and institutions offering physician residency and 
fellowship programs would like the Office of Inspector General (OIG) 
to provide educational resources addressing compliance with these 
laws.  
BACKGROUND 
Medicare and Medicaid fraud and abuse cost U.S. taxpayers billions of 
dollars each year and put the programs beneficiaries health and 
welfare at risk.  No current law requires medical schools and 
institutions offering physician residency or fellowship programs to 
provide instruction on compliance with Medicare and Medicaid laws 
aimed at preventing fraud and abuse.  OIG has dedicated significant 
resources to promoting the adoption of compliance programs and 
encouraging health care providers to incorporate integrity safeguards 
into their organizations as an essential component of a comprehensive 
antifraud strategy. 
Among the Federal statutes addressing fraud and abuse are the civil 
False Claims Act, the anti-kickback statute, and the physician           
self-referral statute.   
For this report, we conducted a survey of all accredited medical schools 
and accredited osteopathic schools and institutions offering physician 
residency and fellowship programs. 
FINDINGS 
Despite lack of a Federal requirement, 44 percent of medical schools 
reported providing instruction to students on Medicare and 
Medicaid fraud and abuse laws in 2010.  Of the 131 deans who 
responded, 57 (44 percent) indicated that they provided instruction on 
Medicare and Medicaid fraud and abuse laws.  Of those 57 deans,        
53 indicated that the instruction took place in the classroom.        
  OEI-01-10-00140  MEDICARE AND MEDICAID FRAUD AND ABUSE TRAINING IN MEDICAL EDUCATION  i   
   
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Thirty-eight respondents reported that the instruction covered the False 
Claims Act and the physician self-referral law, while 35 reported 
covering the anti-kickback statute.  
More than two-thirds of institutions offering residency and 
fellowship programs reported instructing participants on 
compliance with Medicare and Medicaid fraud and abuse in 2010.  Of 
the 387 designated institution officials (DIO) who responded to our 
survey, 263 (68 percent) reported providing instruction on fraud and 
abuse laws.  Of those 263 DIOs, 212 (81 percent) reported using 
conferences and lectures. 
Almost all medical schools and institutions offering residency and 
fellowship programs are interested in OIG-provided instructional 
materials relating to Medicare and Medicaid fraud and abuse.       
One hundred twenty-one deans (92 percent) reported that they would be 
interested in receiving instructional materials covering fraud and abuse 
laws.  Among institutions offering residency and fellowship programs,              
347 (90 percent) reported that they would be interested in such 
materials.  Most deans and DIOs stated that they were interested 
specifically in more information on the False Claims Act, the anti-
kickback statute, and the physician self-referral law. 
CONCLUSION 
We recognize that medical schools and institutions offering residency 
and fellowship programs face enormous challenges in providing a 
comprehensive medical education to their students and physicians-in-
training.  Despite these challenges, many reported providing fraud and 
abuse training in 2010.   
These efforts notwithstanding, opportunities exist for OIG to provide 
additional educational materials addressing these topics.  Such 
materials could provide medical schools and hospitals with a consistent 
starting point on which to build their training programs and would 
support OIGs efforts to promote voluntary compliance.  Toward that 
end, OIG plans to take the following steps:  
  Prepare educational materials appropriate for medical schools and 
institutions offering residency and fellowship programs.   
  Distribute the materials to medical schools and institutions that 
sponsor residency and fellowship programs.    
  OEI-01-10-00140  MEDICARE AND MEDICAID FRAUD AND ABUSE TRAINING IN MEDICAL EDUCATION  ii   
   
E X E C U T I V E   S U M M A R Y  
  Seek feedback from the medical schools and institutions offering 
residency and fellowship programs on ways to improve the 
materials.  Such feedback could include emerging compliance 
challenges that physicians, hospitals, and other providers face.   
 
 
  OEI-01-10-00140  MEDICARE AND MEDICAID FRAUD AND ABUSE TRAINING IN MEDICAL EDUCATION  iii    
 
 
 T A B L E   O F   C O N T E N T S  
EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i
 
 
I N T RO DUC T IO N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 
 
 
F I N D IN G S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 
Despite lack of a Federal requirement, 44 percent of medical schools 
reported providing instruction to students on compliance with 
Medicare and Medicaid fraud and abuse laws in 2010 . . . . . . . . . . 5 
More than two-thirds of institutions offering residency and fellowship 
programs reported instructing participants on compliance with 
Medicare and Medicaid fraud and abuse laws in 2010 . . . . . . . . . . 5 
Almost all medical schools and institutions offering residency  
and fellowship programs are interested in OIG-provided  
instructional materials relating to Medicare and Medicaid  
fraud and abuse laws . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   6  
   
CONC LUSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7  
 
 
A C K NO WL E D G M E N T S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   8   
   
 I N T R O D U C T I O N  
OBJECTIVES 
To determine the extent to which:  
1.  medical schools provide instruction on compliance with Medicare 
and Medicaid laws aimed at preventing fraud and abuse, 
2.  institutions offering physician residency and fellowship programs 
provide instruction on compliance with these laws, and  
3.  medical schools and institutions offering physician residency and 
fellowship programs would like the Office of Inspector General (OIG) 
to provide educational resources addressing compliance with these 
laws.  
BACKGROUND 
Medicare and Medicaid fraud and abuse cost U.S. taxpayers billions of 
dollars each year and put the programs beneficiaries health and 
welfare at risk.1  No current law requires medical schools or institutions 
such as hospitals or universities offering physician residency and 
fellowship programs to provide instruction on compliance with Medicare 
and Medicaid laws aimed at preventing fraud and abuse. 
OIG Efforts to Combat Fraud and Abuse 
OIG considers partnering with health care providers, such as hospitals, 
as an important component of a comprehensive effort to promote 
program integrity.  Toward that end, OIG has traditionally assisted 
health care providers in adopting practices that promote compliance 
with program requirements.   
OIG uses a variety of tools in this effort.  It issues compliance program 
guidance that provide health care providers, suppliers, and 
organizations comprehensive and specific frameworks, standards, and 
principles to establish and maintain effective internal compliance 
programs.  OIG also is required to provide advisory legal opinions on 
whether specific business arrangements violate fraud and abuse laws 
and make these opinions available to the public.2   On a periodic basis, 
 
1 Health Care Reform:  Opportunities to Address Waste, Fraud and Abuse:  Hearing 
before the House Energy and Commerce Committee Subcommittee of Health U.S. House of 
Representatives, 111th Cong. (2009) (Statement of Daniel R. Levinson, Inspector General, 
Department of Health and Human Services). 
2 Relevant law and regulation may be found at 42 U..S.C.  1320a-7d(b). and 42 CFR  
1008.47.   
  OEI-01-10-00140  MEDICARE AND MEDICAID FRAUD AND ABUSE TRAINING IN MEDICAL EDUCATION  1   
   
I N T R O D U C T I O N  
OIG also develops and issues guidance, including special advisory 
bulletins, fraud alerts, and open letters, to alert and inform the health 
care industry about potential problems or areas of special interest.3    
Civil and Administrative Statutes Addressing Fraud and Abuse 
Among the Federal statutes addressing fraud and abuse are the civil 
False Claims Act, the anti-kickback statute, and the physician           
self-referral statute.  We asked medical school deans and designated 
institution officials (DIO) at institutions offering physician residency 
and fellowship programs about each of these laws in this evaluation.  
The civil False Claims Act.  The civil False Claims Act addresses 
fraudulent billing of the Federal Government.  This Act assigns liability 
to any person who knowingly submits a fraudulent claim for payment to 
the Federal Government.  It also addresses the creation and submission 
of false records relating to false claims, among other provisions.  
Violations generally are punishable by a civil penalty up to $10,000 (as 
adjusted by the Federal Civil Penalties Inflation Adjustment Act of 
1990) and three times the amount of damages suffered by the 
Government as a result of the fraudulent claims.4  
Anti-kickback statute.  The Federal anti-kickback statute states that 
anyone who knowingly and willfully receives or pays anything of value 
to influence the referral of Federal health care program business, 
including Medicare and Medicaid, can be charged with a felony.  
Violations of the law are punishable by up to 5 years in prison and 
criminal fines up to $25,000.  Violators also are potentially subject to 
administrative civil monetary penalties up to $50,000 under                 
42 U.S.C. 1230a-7a and exclusion from participating in Federal health 
care programs under 42 U.S.C. 1230a-7. 
Physician self-referral statute.  The physician self-referral statute 
prohibits, with certain exceptions, the practice of physicians referring 
patients to facilities in which they have ownership or other financial 
interests.  Violations of the law are punishable by a civil penalty up to 
$15,000 per improper claim, denial of payment, and refunds for certain 
past claims.5 
 
3 Additional information regarding these tools may be found on OIGs website at 
http://www.oig.hhs.gov/fraud.asp.   
4 31 U.S.C.  3729 et seq. 
5 42 U.S.C.  1395nn. 
  OEI-01-10-00140  MEDICARE AND MEDICAID FRAUD AND ABUSE TRAINING IN MEDICAL EDUCATION  2   
   
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Other Federal statutes addressing fraud and abuse include the Civil 
Monetary Penalties Law and the Exclusion Statute.  The Civil 
Monetary Penalties law covers an array of fraudulent and abusive 
activities and is similar to the False Claims Act.  Violations of the law 
may result in penalties between $10,000 and $50,000 and up to three 
times the amount unlawfully claimed.6  The Exclusion Statute excludes 
individuals or entities from participating in the Medicare or Medicaid 
program from a minimum of 3 to 5 years, depending on the offense, to 
possible lifetime exclusion. 
We will refer to these civil and administrative laws collectively as 
Medicare and Medicaid fraud and abuse laws. 
Medical Education in the United States 
Physicians begin their medical education in either an allopathic or 
osteopathic medical school.  Students generally attend for 4 years and 
attend traditional lecture courses as well as receiving clinical 
instruction in hospitals and other clinical settings.   
Upon completing medical school, students enter residency programs, 
where their training focuses on a medical specialty.  Residency 
programs generally operate within a hospital setting and last between  
3 and 8 years, depending on the specialty.  For some subspecialties, 
residents may train for an additional 1 to 3 years as fellows.   
In addition to providing advanced clinical training, hospitals or 
individual specialty programs may provide their residents and fellows 
with training in subjects such as ethics or compliance with Federal laws 
and regulations.         
METHODOLOGY 
Scope 
This study assessed the extent to which, in 2010, U.S. medical schools 
and institutions, such as medical centers or universities offering 
physician residency and fellowship programs provided instruction on 
compliance with Medicare and Medicaid fraud and abuse laws to 
students and physician residents and fellows.  This study also assessed 
the extent to which, in 2010, medical schools and institutions offering 
physician residency and fellowship programs provided instruction on 
 
6 42 U.S.C.  1320a-7a. 
  OEI-01-10-00140  MEDICARE AND MEDICAID FRAUD AND ABUSE TRAINING IN MEDICAL EDUCATION  3   
   
I N T R O D U C T I O N  
compliance with the civil False Claims Act, the anti-kickback statute, 
and the physician self-referral statute. 
Data Collection and Analysis 
We identified deans at 131 accredited allopathic medical schools and                 
29 accredited osteopathic medical schools through the Association of 
American Medical Colleges and American Association of Osteopathic 
Colleges (hereinafter referred to as medical schools).  We also 
identified DIOs at the 660 institutions offering accredited residency 
and fellowship programs, as determined by the Accreditation Council 
for Graduate Medical Education.7 
We sent each identified dean and official a survey asking (1) what type 
of instruction medical students, resident physicians, and fellows 
received about Medicare and Medicaid fraud and abuse laws in 2010; 
and (2) what educational resources OIG could provide.   
We first contacted the deans and DIOs in April 2010.  We followed up 
twice with those who had not responded.  We received 131 responses 
from deans for an 82-percent response rate and 387 responses from 
DIOs for a 59-percent response rate. 
Limitations 
We did not independently verify information provided by medical school 
deans or DIOs. 
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspections approved by the Council of the Inspectors General on 
Integrity and Efficiency. 
 
 
7 We removed 21 institutions that offered only forensic pathology programs because they 
do not bill Medicare and Medicaid for services rendered. 
  OEI-01-10-00140  MEDICARE AND MEDICAID FRAUD AND ABUSE TRAINING IN MEDICAL EDUCATION  4   
   
F I N D I N G S  
 F I N D I N G S  
 
Despite lack of a Federal requirement,   Of the 131 deans who responded,  
44 percent of medical schools reported  57 (44 percent) indicated that they 
providing instruction to students on  provided instruction on Medicare 
and Medicaid fraud and abuse 
compliance with Medicare and Medicaid fraud 
laws.  Of those 57 deans,               
and abuse laws in 2010 
53 indicated that the instruction 
took place in the classroom.  However, 33 of those deans also indicated 
that classroom instruction was limited to about 2 hours or less.  Deans 
reported using other educational formats less often.  For example, of    
57 respondents, 23 reported using reading materials and 14 reported 
providing training in a clinical setting. 
About two-thirds of the 57 medical schools that provided instruction 
specifically reported covering the False Claims Act, the physician      
self-referral law, and the anti-kickback statute.  Thirty-eight 
respondents reported that the instruction covered the False Claims Act 
and the physician self-referral law, while 35 reported covering the anti-
kickback statute.  The deans indicated that their medical schools 
presented information in the classroom or through reading material. 
 
More than two-thirds of institutions offering  Of the 387 DIOs that responded to 
residency and fellowship programs reported  our survey, 263 (68 percent) 
reported providing instruction on 
instructing participants on compliance with 
fraud and abuse laws.  Of those                 
Medicare and Medicaid fraud and abuse laws   
263 DIOs, 212 (81 percent)  
in 2010 
reported conducting conferences 
and lectures.  One-hundred thirty-one (50 percent) respondents reported 
providing 4 hours or less of training per year.  Further, 100 (38 percent) 
respondents reported providing the training annually while an 
additional 58 (22 percent) reported providing training in the first year of 
residency. 
Hospital officials reported using other educational formats less often.  
For example, of 263 respondents, 135 (51 percent) reported using 
reading materials, 124 (47 percent) reported using online training, and 
117 (44 percent) reported providing training in a clinical setting.  
Over three-quarters of the hospitals that provided instruction specified 
the areas covered in their survey responses.  Two-hundred nine DIOs 
(79 percent) reported that the instruction covered the False Claims Act, 
  OEI-01-10-00140  MEDICARE AND MEDICAID FRAUD AND ABUSE TRAINING IN MEDICAL EDUCATION  5   
   
F I N D I N G S  
201 respondents (76 percent) reported that the instruction covered the 
anti-kickback statute, and 200 respondents (76 percent) reported that 
the instruction covered of the physician self-referral law. 
 
Almost all medical schools and institutions  One hundred twenty-one deans    
offering residency and fellowship programs  (92 percent) reported that they 
are interested in OIG-provided instructional  would be interested in receiving 
instructional materials covering 
materials relating to Medicare and Medicaid 
fraud and abuse laws.  Most deans 
fraud and abuse laws 
responded that they would like 
more information on the False Claims Act, the anti-kickback statute, 
and the physician self-referral law.  Of the 121 deans who indicated an 
interest in materials, 86 (71 percent) specified that they wanted a 
general overview of all Medicare and Medicaid fraud and abuse laws.  
Several of those respondents further explained that helpful material 
should highlight general principles rather than the details, because 
medical students will not be billing for several years.  
Among institutions offering residency and fellowship programs,              
347 (90 percent) reported that they would be interested in instructional 
materials covering fraud and abuse laws.  Most respondents stated that 
they were interested specifically in more information on the False 
Claims Act, the anti-kickback statute, and the physician self-referral 
law.   
Because of the large number of accredited residency programs at some 
institutions offering residency and fellowship programs, several 
respondents highlighted the value of having standardized educational 
materials covering fraud and abuse laws to distribute across programs.  
Other respondents indicated that they would like educational materials 
covering proper documentation, coding, and reimbursement. 
 
  OEI-01-10-00140  MEDICARE AND MEDICAID FRAUD AND ABUSE TRAINING IN MEDICAL EDUCATION  6   
   
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 C O N C L U S I O N  
 
We recognize that medical schools and institutions offering residency 
and fellowship programs face enormous challenges in providing a 
comprehensive medical education to their students and physicians-in-
training.  Despite these challenges, many reported providing fraud and 
abuse training in 2010.  However, this does not necessarily mean that 
the training offered was accurate and comprehensive nor that all 
students, residents, and fellows participated in the training. 
These efforts notwithstanding, opportunities exist for OIG to provide 
additional educational materials addressing these topics.  Such 
materials could provide medical schools and hospitals with a consistent 
starting point on which to build their training programs and would 
support OIGs efforts to promote voluntary compliance.  Toward that 
end, OIG plans to take the following steps:  
  Prepare educational materials appropriate for medical schools and 
institutions offering residency and fellowship programs.   
  Distribute the materials to medical schools and institutions that 
sponsor residency and fellowship programs.    
  Seek feedback from the medical schools and institutions offering 
residency and fellowship programs on ways to improve the 
materials.  Such feedback could include emerging compliance 
challenges that physicians, hospitals, and other providers face.   
  OEI-01-10-00140  MEDICARE AND MEDICAID FRAUD AND ABUSE TRAINING IN MEDICAL EDUCATION  7   
   
 A C K N O W L E D G M E N T S  
 
This report was prepared under the direction of Joyce M. Greenleaf, 
Regional Inspector General for Evaluation and Inspections in the 
Boston regional office, and Russell Hereford, Deputy Regional Inspector 
General. 
Chris Galvin served as the team leader for this study.  Other principal 
Office of Evaluation and Inspections staff from the Boston regional 
office who contributed to the report include Danielle Fletcher; central 
office staff who contributed include Arianne Spaccarelli. 
  OEI-01-10-00140  MEDICARE AND MEDICAID FRAUD AND ABUSE TRAINING IN MEDICAL EDUCATION  8    
 
 
Office of Inspector General 
http://oig.hhs.gov 
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 
amended, is to protect the integrity of the Department of Health and Human Services 
(HHS) programs, as well as the health and welfare of beneficiaries served by those 
programs.  This statutory mission is carried out through a nationwide network of audits, 
investigations, and inspections conducted by the following operating components: 
Office of Audit Services 
The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting 
audits with its own audit resources or by overseeing audit work done by others.  Audits 
examine the performance of HHS programs and/or its grantees and contractors in carrying 
out their respective responsibilities and are intended to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and 
mismanagement and promote economy and efficiency throughout HHS. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud, waste, or abuse and promoting 
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations 
of fraud and misconduct related to HHS programs, operations, and beneficiaries.  With 
investigators working in all 50 States and the District of Columbia, OI utilizes its resources 
by actively coordinating with the Department of Justice and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to criminal 
convictions, administrative sanctions, and/or civil monetary penalties. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to 
OIG, rendering advice and opinions on HHS programs and operations and providing all 
legal support for OIGs internal operations.  OCIG represents OIG in all civil and 
administrative fraud and abuse cases involving HHS programs, including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program guidance, publishes fraud alerts, and provides other 
guidance to the health care industry concerning the anti-kickback statute and other OIG 
enforcement authorities.