By Jeffrey H. Brochin, J.D.
In fiscal year (FY) 2017, $2.6 billion was returned to the federal government or paid to private persons as a result of joint HHS and DOJ anti-fraud operations, according to the FY 2017 Health Care Fraud and Abuse Control Program (HCFACP) report. A return-on-investment (ROI) analysis of funding costs versus successful recovery for the last three years shows that for every $1.00 expended, $4.20 was recovered (Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2017, April 6, 2018).
HCFACP’s goals. Under the joint direction of the Attorney General and the Secretary of HHS, the program’s goals are:
- to coordinate federal, state and local law enforcement efforts relating to health care fraud and abuse with respect to health plans;
- to conduct investigations, audits, inspections, and evaluations relating to the delivery of and payment for health care in the United States;
- to facilitate enforcement of all applicable remedies for such fraud; and
- to provide education and guidance regarding complying with current health care law.
Fraudulent practices targeted. Among the fraudulent healthcare provider practices targeted by HCFACP efforts in FY 2017 were:
- providers operating "pill mills" out of their medical offices;
- providers submitting false claims to Medicare for ambulance transportation services;
- clinics submitting false claims to Medicare and Medicaid for physical and occupational therapy;
- drug companies paying kickbacks to providers to prescribe their drugs, and pharmacies soliciting and receiving kickbacks from pharmaceutical companies for promoting their drugs; and,
- companies misrepresenting capabilities of their electronic health record software to customers.
Impressive statistics. Last year, the DOJ opened 967 new criminal health care fraud investigations of which federal prosecutors filed criminal charges in 439 cases involving 720 defendants. A total of 639 defendants were convicted of healthcare fraud related crimes. The DOJ and HHS joint Medicare Fraud Strike Force filed 253 indictments and charges against 478 defendants who allegedly billed federal health care programs more than $2.3 billion. The Strike Force obtained more than 290 guilty pleas, litigated 33 jury trials and won guilty verdicts against 40 defendants, and it secured prison sentences for more than 300 defendants, with an average sentence of 50 months. Since its inception in 2007, Strike Force prosecutors have filed more than 1,660 cases charging more than 3,490 defendants who collectively billed the Medicare program more than $13 billion.
Keeping bad actors out. Beyond criminal prosecution, HHS remains vigilant in excluding providers and suppliers who committed fraud or engaged in the abuse or neglect of patients in federal health care programs. A total of 3,244 individuals and entities were excluded in FY 2017, while others were excluded as a result of licensure revocations. CMS also suspended a number of providers using suspension authority provided under the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148).
HHS is also empowered to suspend Medicare payments to providers during investigations of credible allegations of fraud, and during FY 2017, there were 551 related payment suspensions. More than 4 million claims are reviewed by Medicare each day resulting in more than one billion claims processed annually for timely payments to health care providers and suppliers. Given the daily volume of claims processed by Medicare and the significant cost associated with conducting medical review of an individual claim, CMS uses automated edits to help prevent improper payments without the need for manual intervention.
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