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Fraud and Compliance
Agencies’ Anti-Fraud Efforts Led to $3.3 Billion Recovery in 2014 

The Health Care Fraud and Abuse Control Program (HCFAC) recovered $3.3 billion in fiscal year (FY) 2014 from individuals and companies, according to the HCFAC annual report released March 19.

In total, more than $27.8 billion has been returned to the Medicare Trust Fund over the life of the HCFAC program, a joint effort between the Departments of Justice (DOJ) and Health and Human Services (HHS).

HHS said in a press release that the recoveries reflect a two-pronged strategy used by the agencies to combat fraud and abuse. First, the agencies aim to prevent health care fraud and abuse in the first place instead of using the outdated “pay and chase” model by leveraging new authorities under the Affordable Care Act (ACA).
Second, the agencies’ Health Care Fraud Prevention and Enforcement Action Team (HEAT) is using real-time data analysis in lieu of prolonged subpoena and account analyses, “resulting in significantly shorter periods of time between fraud identification, arrest, and prosecution,” HHS said.
According to the report, the return on investment for the HCFAC program over the last three years (2012-2014) is $7.70 returned for every $1.00 expended. The 2014 figure is $2 higher than the average return on investment over the life of the HCFAC program and the third highest overall, the report said.
The Medicare Fraud Strike Force initiative, a key component of HEAT, was expanded to nine areas, the report noted, resulting in 165 indictments, informations, and complaints involving charges filed against 353 defendants who allegedly collectively billed the Medicare program approximately $830 million.
Since its inception, Strike Force prosecutors have filed more than 963 cases, charging more than 2,097 defendants who collectively billed the Medicare program more than $6.5 billion, according to the report.

The agencies reported that DOJ in FY 2014 opened 924 new criminal health care fraud investigations and 782 new civil health care fraud investigations. Criminal charges were filed in 496 cases involving 805 defendants, with a total of 734 defendants convicted of health care fraud-related crimes during the year.
The HHS Office of Inspector General (OIG) conducted investigations leading to 867 criminal actions against individuals or entities that engaged in Medicare and Medicaid fraud-related crimes, and 529 civil actions, which include false claims and unjust-enrichment lawsuits filed in federal court, civil monetary penalties settlements, and administrative recoveries related to provider self-disclosure matters.
OIG also excluded 4,017 individuals in FY 2014 based on criminal convictions for crimes related to Medicare and Medicaid (1,310) or other health care programs (432), for patient abuse or neglect (189), and as a result of licensure revocations (1,744), the report said.
Another powerful tool in the administration’s arsenal to combat health care fraud is the federal False Claims Act, a fact sheet said.  In FY 2014, DOJ obtained $2.3 billion in settlements and judgments from civil cases and has recovered more than $15.2 billion since January 2009.
The fact sheet also highlighted other fraud fighting tools made available under the ACA, including enhanced provider screening and enrollment requirements. The ACA required the Centers for Medicare & Medicaid Services to revalidate all existing 1.5 million Medicare suppliers and providers under new risk-based screening requirements, which resulted in deactivation of more than 470,000 enrollments and revocation of nearly 28,000 enrollments, the fact sheet said.
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