January 20, 2017

The American Health Lawyers association reported the following in its weekly Fraud and Abuse update:

The government won or negotiated more than $2.5 billion in healthcare fraud judgments and settlements in fiscal year (FY) 2016, the Departments of Health and Human Services (HHS) and Justice (DOJ) said in their Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2016 released January 19.

“In its twentieth year of operation, the Program’s continued success confirms the soundness of a collaborative approach to identify and prosecute the most egregious instances of health care fraud, to prevent future fraud and abuse, and to protect program beneficiaries,” the agencies said.

According to the report, as a result of 2016 and prior years’ efforts, over $3.3 billion was returned to the federal government or paid to private persons. The Medicare Trust Funds received transfers of approximately $1.7 billion, and $235.2 million in federal Medicaid funds was transferred to the Treasury in FY 2016, the report said.

  • The return on investment from 2014 to 2016 for the Health Care Fraud and Abuse Control Program (HCFAC)—which was established by the Health Insurance Portability and Accountability Act of 1996—is $5 returned for every $1 expended, the agencies said.
  • In FY 2016, DOJ opened 975 new criminal healthcare fraud investigations and filed criminal charges in 480 cases involving 802 defendants. A total of 658 defendants were convicted of healthcare fraud-related crimes during the year, the report said.
  • DOJ opened 930 new civil healthcare fraud investigations in FY 2016, with 1,422 civil health care fraud matters pending at the end of the fiscal year.
  • HHS Office of Inspector General (OIG) investigations resulted in 765 criminal actions in FY 2016 against individuals or entities.

OIG investigations also led to 690 civil actions, which include false claims and unjust-enrichment lawsuits filed in federal district court, civil monetary penalties settlements, and administrative recoveries related to provider self-disclosure matters, according to the report. OIG also excluded 3,635 individuals and entities in FY 2016.