Kusserow on Compliance: DOJ and HHS OIG issue annual Health Care Fraud and Abuse Control Program Report

The HHS OIG and DOJ issued their annual Health Care Fraud and Abuse Control Program Report. The report outlines efforts undertaken annually as a result of HIPAA, which established the program to “coordinate federal, state, and local law enforcement activities with respect to health care fraud and abuse.” For FY 2019 the reported recoveries were $3.6 billion, of which about $2.5 billion was returned to the Medicare trust fund. The recoveries included judgments and settlements from fraud causes brought in 2019 and in prior years. In addition, the DOJ reported opening 1,060 new criminal health care fraud investigations, which led to charges against 814 defendants. The DOJ Civil Division opened 1,112 new civil health care fraud investigations. Medicare and Medicaid fraud investigations by HHS’s Office of Inspector General resulted in 747 criminal actions and 684 civil actions against individuals and entities. In 2019, HHS also excluded 2,640 individuals from participation in the Medicare and Medicaid programs. The breakdown of exclusions included 1,194 based on criminal convictions related to Medicare and Medicaid, 335 for other health care programs, 238 for patient abuse or neglect, and 576 as a result of state health care licensure revocations.

The report also provided information on the return on investment (ROI) for the HCFAC program over the last three years (2017 – 2019) at $4.2 returned for every $1.00 expended. Results were reported as being in large measure due to the Health Care Fraud Prevention and Enforcement Action Team (HEAT) that was designed to coordinate enforcement efforts related health care fraud. These teams are comprised of top-level law enforcement agents, prosecutors, attorneys, auditors, evaluators, and other staff from DOJ and HHS and their operating divisions, and are dedicated to joint efforts across government to both prevent fraud and enforce current anti-fraud laws around the country. The Strike Force teams are a key component of HEAT.


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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