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From Health Law Daily, March 20, 2015

HHS and DOJ returned $3.3B in 2014 through fraud enforcement

By Bryant Storm, J.D.

The federal government, through the national Health Care Fraud and Abuse Control (HCFAC) Program won or negotiated over $2.3 billion in health care fraud judgments and settlements in fiscal year (FY) 2014. Additionally, under the program, $3.3 billion was returned to the federal government and private individuals, according to the HHS and the Department of Justice (DOJ) annual report on HCFAC program status. The program continues to be a positive investment with the return on investment (ROI) for the HCFAC program over the last three years at $7.70 returned for each $1.00 spent (OIG Report, March 19, 2015).

Recoveries. Through the combined efforts of HHS and the DOJ, the Medicare Trust Funds received transfers of approximately $1.9 billion during FY 2014. Additionally, the Treasury received over $523 million in federal Medicaid money due to program successes. Since the program was started in 1997, the HCFAC account has returned over $27.8 billion to the Medicare Trust Funds. The recovery statistics are lower for FY 2014 than they were in FY 2013, when the HCFAC program was responsible for recovering $4.3 billion through health care fraud judgments, settlements, and administrative impositions (see U.S. Department of the Treasury and CMS recover $4.3 billion in health care fraud judgments and settlements, February 27, 2014). The HCFAC annual report indicates that due to sequestration of mandatory funding in 2014, HHS, the DOJ, and the FBI had fewer available resources to combat fraud. A total of $31.5 million was sequestered in FY 2014, bringing the two year reduction to the agencies as a result of sequestration to $62.1 million.

DOJ enforcement. According to the report, in FY 2014, the DOJ opened 924 new criminal health care fraud investigations and criminal charges were filed in 496 cases that involved 805 defendants. Of those defendants, 734 were convicted of health care fraud-related crimes during the year. Additionally, the DOJ opened 782 new civil health care fraud investigations to add to the 957 civil health care fraud matters that the DOJ had pending at the end of FY 2013. Also, in FY 2014, the FBI succeeded in producing over 605 operational disruptions of criminal fraud organizations and dismantled the criminal hierarchy of over 142 criminal enterprises engaged in health care fraud.

HHS enforcement. On the HHS Office of Inspector General (OIG) side of enforcement actions, investigations resulted in 867 criminal actions against individuals or entities for crimes involving Medicare and Medicaid. HHS investigations also led to 529 civil actions related to false claims, unjust-enrichment, civil monetary penalties (CMP), settlements, and administrative recoveries. The HHS OIG excluded 4,017 individuals and entities from participation in the federal health care programs.

Integrity. The report also discusses the program integrity activities of the HHS Office of the General Counsel (OGC). According to the annual report, the “OGC spent significant time and resources working with the relevant CMS client components to ensure that program integrity issues were reviewed and resolved” in light of specific provisions of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) that particularly support HCFAC priorities. The OGC integrity efforts focused on ACA provisions related to amendments to the Medicare and Medicaid provider and supplier enrollment requirements and overpayment provisions that specifically invoke the False Claims Act (FCA) (31 U.S. C. § 3729), the anti-kickback statute (AKS) (42 U.S.C. § 1320a-7b), and violations of the Stark law (42 U.S.C. § 1395nn).

MainStory: TopStory FraudNews CMSNews AuditNews MedicaidNews PaymentNews AntikickbackNews StarkNews ProgramIntegrityNews FCANews CMPNews

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