The federal government won or negotiated more than $1.9 billion in judgments and settlements, and attained additional administrative impositions in health care fraud cases and proceedings in FY 2015, according to the latest HCFAC program annual report. These new efforts, together with prior year actions, resulted in a total of $2.4 billion in health fraud recoveries for FY 2015, $1.6 billion of which was transferred to the Medicare Trust Funds. The HCFAC program has been responsible for more than $29.4 billion in Medicare Trust Funds recoveries since it began in 1997.
In FY 2015, the Department of Justice (DOJ) opened 983 new criminal health care fraud investigations, with criminal charges filed in 463 cases and 613 defendants convicted of health care fraud-related crimes. Furthermore, Federal Bureau of Investigation efforts led to more than 625 “operational disruptions of criminal fraud organizations” in addition to “the dismantlement of the criminal hierarchy of more than 144 health care fraud criminal enterprises” in FY 2015. With regard to civil cases, DOJ opened 808 new civil health care fraud investigations and had 1,048 civil health care fraud cases pending at the end of the year.
In addition, HHS Office of Inspector General (OIG) investigations resulted in 800 criminal actions related to Medicare and Medicaid and 667 civil actions (e.g., false claims and unjust-enrichment lawsuits filed in federal district court, civil monetary penalties settlements, and administrative recoveries related to provider self-disclosure matters). The OIG also excluded 4,112 individuals and entities from participation in Medicare, Medicaid, and other federal health care programs for criminal convictions for crimes related to these programs, patient abuse or neglect, or as a result of licensure revocations.
The report also highlights tools the Administration is using to combat health program fraud and abuse, including: enhanced data analysis, predictive analytics, trend evaluation, and modeling approaches; stronger Medicare screening and enrollment requirements (which has resulted in deactivation of more than 500,000 enrollments); participation in the private/public Health Care Fraud Prevention Partnership; and expanded funding for Senior Medicare Patrol projects.