The Health Insurance Portability and Accountability Act of 1996 (HIPAA) established the Health Care Fraud and Abuse Control Program (Program), which is a comprehensive program to combat fraud committed against public and private health plans.
The Program, which is under the joint direction of the United States Departments of Justice (DOJ) and Health and Human Services (HHS), marshals and coordinates federal, state and local law enforcement resources with respect to the investigation and prosecution of healthcare fraud and abuse.
DOJ and HHS report annually on the Programs’ accomplishments, and the departments’ most recent report highlights the following:
- More than $29.4 billion has been recovered and returned to the Medicare Trust Fund over the life of the Program.
- $2.4 billion was recovered in FY 2015, which reflects a decline from the $3.3 billion recovered in FY 2014. For every dollar spent on healthcare-related fraud and abuse investigations in the last three years, the government recovered $6.10, which likewise is down from the three-year $7.70 amount reported last year. (According to the report, sequestration of mandatory funding in 2015 limited resources for the government’s antifraud efforts in this area. Specifically, $22.0 million was sequestered from the Program in FY 2015, for a combined total of $74.2 million in the past three years.)
- Since the inception of the Medicare Strike Force (currently operating in nine geographic areas), more than 1,160 cases have been filed, charging nearly 2,540 defendants who collectively billed Medicare more than $8 billion.
- In FY 2015, DOJ opened 983 new criminal healthcare fraud and abuse investigations and 808 new civil healthcare fraud investigations. Criminal charges were filed in 463 cases, and 613 defendants were convicted.
- In FY 2015, the Office of Inspector General (OIG) for HHS conducted investigations leading to 800 criminal actions and 667 civil actions related to Medicare and Medicaid fraud and abuse.
- OIG excluded 4,112 individuals in FY 2015 for crimes related to Medicare, Medicaid and other healthcare programs, for patient abuse and / or neglect, and as a result of licensure revocations.
The effects of sequestration aside, the message is clear. With estimates of annual healthcare fraud in the tens of billions of dollars, the government remains committed to investigating vigorously healthcare fraud and abuse, and its efforts will continue to expand over the years. The return on investment is comparatively robust and provides a supporting narrative for continued expansion.
The government’s FY 2015 report is available at: http://oig.hhs.gov/reports-and-publications/hcfac.