According to the FY 2014 HCFAC program report, more than $3.3 billion was recovered in FY 2014 as a result of the government’s health care fraud judgments and settlements, including $2.3 billion won or negotiated by the federal government in FY 2014. Since the HCFAC program began in 1997, it has returned more than $27.8 billion to the Medicare Trust Funds. In FY 2014, the Department of Justice (DOJ) opened 924 new criminal health care fraud investigations, with criminal charges filed in 496 cases and 734 defendants convicted of health care fraud-related crimes. The report also notes that the Federal Bureau of Investigation efforts led to “the dismantlement of the criminal hierarchy of more than 142 health care fraud criminal enterprises.” With regard to civil cases, DOJ opened 782 new civil health care fraud investigations and had 957 civil health care fraud cases pending at the end of the year.

In addition, HHS Office of Inspector General (OIG) investigations resulted in 867 criminal actions related to Medicare and Medicaid and 529 civil actions (e.g., false claims and unjust-enrichment lawsuits filed in federal district court, civil monetary penalties settlements, and administrative recoveries related to provider self-disclosure matters). The OIG also excluded more than 4,000 individuals and entities from participation in Medicare, Medicaid, and other federal health care programs for criminal convictions for crimes related to these programs, patient abuse or neglect, or as a result of licensure revocations.

Beyond enforcement activities, the annual report discusses CMS preventive measures to combat health program fraud and abuse, including enhanced screening provisions that have resulted in deactivation of 470,000 enrollments and revocation of 28,000 enrollments. CMS also has continued the temporary moratoria on the enrollment of new home health or ambulance service providers in specific geographic locations and applied advanced analytics to Medicare fee-for-service claims to identify and suspicious billing patterns, among other initiatives.

This article is presented for informational purposes only and is not intended to constitute legal advice.