Report: Health Care Fraud and Abuse Control program shows record recovery

The Departments of Justice and Health and Human Services (HHS) released a report on Monday detailing record-breaking recoveries resulting from efforts to combat healthcare fraud. The government’s healthcare fraud prevention and enforcement efforts recovered $4.2 billion in Fiscal Year (FY) 2012, up from nearly $4.1 billion in FY 2011, from individuals and companies that attempted to defraud federal health programs.

Over the last four years, enforcement efforts have recovered $14.9 billion, up from $6.7 billion over the prior four-year period, according to the report. Since 1997, the Health Care Fraud and Abuse (HCFAC) program, a joint effort between the Department of Justice and HHS has returned more than $23 billion to the Medicare Trust Funds. The success of the effort was attributed to the Health Care Fraud Prevention and Enforcement Action Team (HEAT), created in 2009.

In FY 2012, the Justice Department opened 1,131 new criminal healthcare fraud investigations involving 2,148 potential defendants, and a total of 826 defendants were convicted of healthcare fraud-related crimes during the year. The department also opened 885 new civil investigations.

The strike force coordinated a takedown in May 2012 that involved the highest number of false Medicare billings in the history of the strike force program. The takedown involved 107 individuals, including doctors and nurses, in seven cities, who were charged for their alleged participation in Medicare fraud schemes, involving about $452 million in false billings. As a part of the May 2012 takedown, HHS also suspended or took other administrative action against 52 providers using authority under the healthcare law to suspend payments until an investigation is complete.

In recent years, new tools to fight fraud have been implemented, including enhanced screenings and enrollment requirements, increased data sharing across the government, expanded recovery efforts for overpayments and greater oversight of private insurance abuses.  

Patricia Sheehan

Patricia Sheehan was Editor in Chief of I Advance Senior Care / Long Term Living from 2010-2013. She is now manager, communications at Nestlé USA.