D

OFFICE OF 

INSPECTOR GENERAL 

epartment of Health and Human Services

 

MEDICARE AND MEDICAID 

FRAUD AND ABUSE TRAINING 

IN MEDICAL EDUCATION 

 

Daniel R. Levinson 

Inspector General 

October 2010 

OEI-01-10-00140 
 

 EXECUTIVE SUMMARY 

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 F RAUD AND A BUSE T RAINING IN M EDICAL E DUCATION i 
 

EXECUTIVE SUMMARY 

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 antikickback 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-intraining. 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 OIG’s 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 F RAUD AND A BUSE T RAINING IN M EDICAL E DUCATION ii 
 

OEI-01-10-00140 MEDICARE AND MEDICAID F RAUD AND A BUSE T RAINING IN M EDICAL E DUCATION iii 

EXECUTIVE SUMMARY 

 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. 
 

 TABLE OF CONTENTS 

EXECUTIVE SUMMARY .....................................i

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 

FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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 

 

CONCLUSION .............................................7 

ACKNOWLEDGMENTS .................................... 8
 

 INTRODUCTION 

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 F RAUD AND A BUSE T RAINING IN M EDICAL E DUCATION 1 
 

INTRODUCTION 

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 OIG’s 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 F RAUD AND A BUSE T RAINING IN M EDICAL E DUCATION 2 
 

INTRODUCTION 

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 F RAUD AND A BUSE T RAINING IN M EDICAL E DUCATION 3 
 

INTRODUCTION 

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. 

4 

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 F RAUD AND A BUSE T RAINING IN M EDICAL E DUCATION
 

FINDINGS FINDINGS 

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 

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. 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 antikickback statute. The deans indicated that their medical schools 

presented information in the classroom or through reading material. 

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 

Of the 387 DIOs that responded to 

our survey, 263 (68 percent) 

reported providing instruction on 

fraud and abuse laws. Of those 

263 DIOs, 212 (81 percent) 

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 F RAUD AND A BUSE T RAINING IN M EDICAL E DUCATION 5 
 

FINDINGS 

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 

offering residency and fellowship programs 

are interested in OIG-provided instructional 

materials relating to Medicare and Medicaid 

fraud and abuse laws 

One hundred twenty-one deans 

(92 percent) reported that they 

would be interested in receiving 

instructional materials covering 

fraud and abuse laws. Most deans 

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 F RAUD AND A BUSE T RAINING IN M EDICAL E DUCATION 6 
 

EXECUTIVE SUMMARY 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-intraining. 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 OIG’s 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 F RAUD AND A BUSE T RAINING IN M EDICAL E DUCATION 7 
 

OEI-01-10-00140 MEDICARE AND MEDICAID F RAUD AND A BUSE T RAINING IN M EDICAL E DUCATION 8 

 ACKNOWLEDGMENTS 

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. 
 

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 OIG’s 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.