National Health Care Fraud Abuse Control Program Reports Record Recoveries and Return on Investment

Through their Health Care Fraud Abuse Control program (“HCFAC”), the United States Departments of Justice (“DOJ) and the United States Department of Health and Human Services (“HHS) have recovered more than $19 billion from health care providers over the last five years.  A report released on February 26 shows that the program’s three-year return on investment in fraud and abuse investigations is $8.10 for every dollar spent – this is a record high for the 17-year-old program.  These numbers suggest that the federal government’s interest in investigating and prosecuting health care fraud and abuse is as strong as ever.

For perspective, the current five-year recovery amount – $19.2 billion – is more than double the $9.4 billion recovery for the previous five-year period.  All of this is despite the loss of $30.6 million as a result of the budget-related sequestration in 2013.

HCFAC is a creation of the 1996 HIPAA statute, and is a joint project of DOJ and HHS.  Moreover, the high reported return on investment illustrates that HCFAC is a money-maker for Medicare – HCFAC’s appropriations come from the Medicare Hospital Insurance Trust Fund, also known as the Medicare Part A Trust Fund.

In the last year alone, DOJ filed 137 cases in this area, and charged 345 individuals with crimes.  It secured 234 guilty pleas and 46 convictions.  Defendants sentenced in the 2013 fiscal year served an average of 52 months in prison.

Not to be outdone, the Centers for Medicare and Medicaid Services (“CMS) have banned over 225,000 individuals and entities from billing Medicare between March 2011 and September 2013.

The OIG Report may be accessed here: http://oig.hhs.gov/publications/docs/hcfac/FY2013-hcfac.pdf

The HHS Press Release may be accessed here: http://www.hhs.gov/news/press/2014pres/02/20140226a.html

Caitlin Monjeau and David Ross contributed this post.