The HIPAA Act of 1996 required the establishment of a national Health Care Fraud and Abuse Control Program (HCFAC) under the direction of the Attorney General and the Secretary of the Department of Health and Human Services.  The Program was designed to coordinate Federal, State and local law enforcement activities with respect to health care fraud and abuse, and has a requirement to detail in an Annual Report the amounts deposited and appropriated to the Medicare Trust Fund as well as the source of the deposits.

Last month, the Department of Health and Human Services and the Department of Justice released their 2017 Annual HCFAC Program Report.  The Executive Summary is detailed below:

Monetary Results:

During Fiscal Year 2017, the Federal Government won or negotiated over $2.4 billion in health care fraud judgments and settlements, and it attained additional administrative impositions in health care fraud cases and proceedings.  As a result of these efforts, as well as those of preceding years, in 2017 $2.6 billion was returned to the Federal Government or paid to private persons.  Of this $2.6 billion, the Medicare Trust Funds received transfers of approximately $1.4 billion during this period, and $406.7 million in Federal Medicaid money was similarly transferred separately to the Treasury.

Enforcement Actions:

In Fiscal Year 2017, the Department of Justice (DOJ) opened 967 new criminal health care fraud investigations. Federal prosecutors filed criminal charges in 439 cases involving 720 defendants and a total of 639 defendants were convicted of health care fraud-related crimes during the year.  Also in FY 2017, DOJ opened 948 new civil health care fraud investigations and had 1,086 civil health care fraud matters pending at the end of the fiscal year.  In FY 2017, investigations conducted by HHS’ Office of Inspector General (HHS-OIG) resulted in 788 criminal actions against individuals or entities that engaged in crimes related to Medicare and Medicaid, and 818 civil actions, which include false claims and unjust-enrichment lawsuits filed in federal district court, civil monetary penalties (CMP) settlements, and administrative recoveries related to provider self-disclosure matters. HHS-OIG also excluded 3,244 individuals and entities from participation in Medicare, Medicaid, and other federal health care programs.

The OIG identifies many priority areas for HCFAC funding including protecting beneficiaries from prescription drug abuse, improving oversight of the Medicare Advantage program, strengthening Medicaid program integrity, and improving care for vulnerable populations (e.g. home health and hospice).