DOJ, HHS Announce $4.2B in Medicare Fraud Recoveries

For every dollar spent investigating Medicare fraud and abuse in the last three years the federal government recovered $7.90. That return on investment is the highest three-year average in the 16-year history of the Health Care Fraud and Abuse Program, federal officials announced on Monday.

"Our historic effort to take on the criminals who steal from Medicare and Medicaid is paying off: We are gaining the upper hand in our fight against healthcare fraud," Health and Human Services Secretary Kathleen Sebelius said in prepared remarks.

"This fight against fraud strengthens the integrity of our healthcare programs and helps us fulfill our commitment to our seniors."

The HCFAC—a joint initiative of the Department of Justice and HHS—in its annual report said that the government recovered $4.2 billion in fiscal 2012 and $4.1 billion in fiscal 2011.

Over the last four years federal officials have recovered $14.9 billion—up from $6.7 billion in the prior four year period—from drug companies, hospitals, physicians, healthcare executives, vendors and assorted scam artists. Since 1997 HCFAC has returned more than $23 billion to the Medicare Trust Funds.

Sebelius and U.S. Attorney General Eric Holder in a joint media release credited enhanced screenings and enrollment requirements, expanded recovery efforts for overpayments, increased data sharing among government agencies and greater oversight of private insurance abuses for the improved rates of recovery.

Sebelius and Holder also credited:

• The ongoing expansion of the coordinated Medicare Fraud Strike Force teams, which now operate in nine regions, including Medicare fraud hotbeds in Miami, Detroit, Houston, and Brooklyn. Using more advanced data analysis the teams can now fly red flags on irregular or suspiciously high-billing patterns that could signal fraudulent activity.  In May 2012, for example, the strike force arrested 107 people, including doctors and nurses, in seven cities who were charged in schemes involving about $452 million in bogus billings to Medicare. Strike force teams in nine cities worked investigations against 278 defendants who allegedly attempted to bilk Medicare of more than $1.5 billion.
• A new automated provider screening system that screened all 1.5 million Medicare-enrolled providers and flagged nearly 150,000 of them as ineligible or fraudulent.

On the civil front, Holder and Sebelius said the federal government recovered more than $3 billion in fiscal year 2012 under the False Claims Act, including price rigging by drug makers, illegal marketing of medical devices and drugs for uses not approved by the Food and Drug Administration, Medicare fraud by hospitals and other providers, and Stark Law anti-kickback violations.

In addition, the federal government collected nearly $1.5 billion in fines and forfeitures, and obtained 14 convictions under the Federal Food, Drug and Cosmetic Act.