Federal health fraud recoveries for FY 2016 totaled $3.3 billion, according to the latest HCFAC program annual report. The HCFAC program is credited with more than $31.0 billion in Medicare Trust Funds recoveries since it began in 1997. With regard to criminal fraud, the Department of Justice (DOJ) opened 975 new criminal health care fraud investigations in FY 2016, with criminal charges filed in 480 cases and 802 defendants convicted of health fraud-related crimes. Federal Bureau of Investigation efforts also led to more than 555 “operational disruptions of criminal fraud organizations” in addition to “the dismantlement of the criminal hierarchy of more than 128 health care fraud criminal enterprises.” The, DOJ also opened 930 new civil health care fraud investigations and had 1,422 such cases pending at the end of the year.
HHS Office of Inspector General (OIG) investigations also resulted in 765 criminal actions related to Medicare and Medicaid and 690 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 excluded 3,635 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 due to licensure revocations.
The report highlights tools the Administration continues to use to detect health program fraud and abuse, including: data mining, predictive analytics, trend evaluation, and modeling approaches. Stronger Medicare screening and enrollment requirements also have resulted in deactivation of more than 652,000 enrollments.