Billions Recovered in Healthcare Fraud Battle

Healthcare fraud is a major problem worldwide. And in the United States alone, the National Heath Care Anti-Fraud Association “estimates conservatively that health care fraud costs the nation about $68 billion annually — about 3 percent of the nation's $2.26 trillion in health care spending.” That’s enough to make any fraud investigator stand up and take notice.

However, if the latest news from the U.S. Department of Justice (DOJ) is any indication, the tide may be turning for the better. According to a recent DOJ news release, the government recovered $2.4 billion in Fiscal Year (FY) 2015 as a result of health care fraud judgments, settlements and administrative impositions in health care fraud cases and proceedings. As the release points out:

Since its inception in 1997, the Health Care Fraud and Abuse Control (HCFAC) Program has returned more than $29.4 billion to the Medicare Trust Funds.  In this past fiscal year, the HCFAC program has returned $6.10 for each dollar invested.

This is an important step forward at a time when healthcare and insurance costs are still ballooning, and the Affordable Care Act (ACA) depends largely on keeping such costs from spiraling out of control. For about the past 10 years, government investigators have placed an emphasis on following healthcare cases in a more vigilant manner, recent headlines demonstrate an increase in prosecutions and recovery efforts.

Medicare is a traditional target for fraudsters, and the DOJ touts the efforts of the Medicare Fraud Strike Force in aggressively combating fraud. As the DOJ release states:

Since 2007, the Medicare Fraud Strike Force has charged over 2,536 individuals involved in more than $8 billion in fraud.  Many of these charges have resulted from coordinated, multi-district national takedowns. In June 2015, the Medicare Fraud Strike Force conducted its largest ever nationwide health care fraud takedown, which, for the first time, involved non-Strike Force participants and resulted in charges against a record 243 individuals for approximately $712 million in false Medicare and Medicaid billing.  Since its inception, the Medicare Fraud Strike Force has maintained a conviction rate of approximately 95 percent and an average term of incarceration of more than four years.

The DOJ also gives credit to the federal False Claims Act, which has been a tool in helping to recover more than $17.1 billion for the government in cases involving health care fraud. The DOJ noted additional steps that have helped fight fraud:

  • State-of-the-Art Fraud Detection Technology
  • Enhanced Provider Screening and Enrollment Requirements
  • Health Care Fraud Prevention Partnership (HFPP)
  • Senior Medicare Patrols

It is only through continuing and enhancing such efforts that healthcare fraud will be contained to a degree that limits the damage it can cause to patients, providers, insurance companies and the economy as a whole. For years, it has remained one of the most serious areas of fraud, with both financial implications and, at times, having dire consequences from those suffering from severe health problems. Increased action and enforcement from the DOJ is a welcome development, and we most hope it continues to pay positive dividends and help prevent, and detect, more fraud.