Kusserow’s Corner: DOJ/HHS Report $4.3 Billion in Recoveries from Health Care Enforcement in 2013

The annual Health Care Fraud and Abuse Control (HCFAC) Program report has been released for 2013, citing results from the joint efforts of the Department of Justice (DOJ) and HHS. The HCFAC report states that the government’s health care fraud prevention and enforcement efforts recovered a record-breaking $4.3 billion in taxpayer dollars in Fiscal Year (FY) 2013, up from $4.2 billion in FY 2012; and over the last five years recoveries amounted to $19.2 billion, up from $9.4 billion over the prior five-year period. This is the fifth consecutive year that the program has increased recoveries over the past year, climbing from $2 billion in FY 2008 to over $4 billion every year since FY 2011. Since the inception of the HCFAC Program in 1997, it has returned more than $25.9 billion to the Medicare Trust Funds and treasury. The report also notes that for every dollar spent on health care-related fraud and abuse investigations through this and other programs in the last three years, the government recovered $8.10. This is the highest three-year average return on investment in the 17-year history of the HCFAC Program.

A large part of this came from efforts of the Health Care Fraud Prevention and Enforcement Action Team (HEAT), created in 2009 to prevent fraud, waste and abuse in Medicare and Medicaid programs that includes the Medicare Fraud Strike Force teams in nine areas across the country. In FY 2013, the Strike Force secured records in the number of cases filed (137), individuals charged (345), guilty pleas secured (234), and jury trial convictions (46). The defendants who were charged and sentenced are facing significant time in prison—an average of 52 months in prison for those sentenced in FY 2013, and an average of 47 months in prison for those sentenced since 2007. The DOJ also reported that in FY 2013, they opened 1,013 new criminal health care fraud investigations involving 1,910 potential defendants, and a total of 718 defendants were convicted of health care fraud-related crimes during the year. The Department also opened 1,083 new civil health care fraud investigations.

The report also cites the new authorities under the Affordable Care Act granted to HHS and CMS as being instrumental in increased enforcement of fraudulent activity in health care. In FY 2013, CMS announced the first use of its temporary moratoria authority granted by the Affordable Care Act. The action stopped enrollment of new home health or ambulance enrollments in three fraud hot spots around the country, allowing CMS and its law enforcement partners to remove bad actors from the program while blocking provider entry or re-entry into these already over-supplied markets.

In March 2011, CMS began an ambitious project to revalidate all 1.5 million Medicare enrolled providers and suppliers under the Affordable Care Act screening requirements. As of September 2013, more than 535,000 providers were subject to the new screening requirements and over 225,000 lost the ability to bill Medicare due to the Affordable Care Act requirements and other proactive initiatives. Since the Affordable Care Act, CMS has also revoked 14,663 providers and suppliers’ ability to bill the Medicare program. These providers were removed from the program because they had felony convictions, were not operational at the address CMS had on file, or were not in compliance with CMS rules.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2014 Strategic Management Services, LLC. Published with permission.