Your Compliance Sh^% Better Be Together!

April 26, 2012

The U.S. Justice Department said in a report to Congress back in February that the government recovered nearly $4.1 billion in civil and criminal health care fraud enforcement actions last year, the highest-ever annual amount. Attorney General Eric Holder Jr said his office last year opened more than 1,100 new criminal health care fraud investigations with potentially more than 2,500 defendants. The government has more than 1,800 health care fraud investigations pending. The DOJ Civil Division recovered $2.4 billion under the False Claims Act. Click here for the report.

The report said the FBI last year “continued to aggressively expand its involvement” in whistleblower investigations. DOJ and Department of Health and Human Services officials touted significant whistleblower investigations and recoveries, including $750 million from SB Pharmco Puerto Rico Inc. and more than $313 million from Forest Pharmaceuticals Inc. The government’s Medicare Fraud Strike Forces—teams of federal agents, analysts and prosecutors—have targeted health care fraud in a number of cities, including Tampa, Chicago and Dallas.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) established a national Health Care Fraud and Abuse Control Program (HCFAC or the Program) under the joint direction of the Attorney General and the Secretary of the Department of Health and Human Services (HHS)1, acting through the Inspector General, designed to coordinate Federal, state and local law enforcement activities with respect to health care fraud and abuse. In its fifteenth year of operation, the Program=s continued success again confirms the soundness of a collaborative approach to identify and prosecute the most egregious instances of health care fraud, to prevent future fraud or abuse, and to protect program beneficiaries.

Monetary Results

During Fiscal Year (FY) 2011, the Federal government won or negotiated approximately $2.4 billion in health care fraud judgments and settlements2, 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 FY 2011, approximately $4.1 billion was deposited with the Department of the Treasury and the Centers for Medicare & Medicaid Services (CMS), transferred to other Federal agencies administering health care programs, or paid to private persons during the fiscal year. Of this $4.1 billion, the Medicare Trust Funds3 received transfers of approximately $2.5 billion during this period, and over $599.9 million in Federal Medicaid money was similarly transferred separately to the Treasury as a result of these efforts. The HCFAC account has returned over $20.6 billion to the Medicare Trust Funds since the inception of the Program in 1997.

Enforcement Actions

In FY 2011, the Department of Justice (DOJ) opened 1,110 new criminal health care fraud investigations involving 2,561 potential defendants. Federal prosecutors had 1,873 health care fraud criminal investigations pending, involving 3,118 potential defendants, and filed criminal charges in 489 cases involving 1,430 defendants. A total of 743 defendants were convicted of health care fraud-related crimes during the year. Also in FY 2011, DOJ opened 977 new civil health care fraud investigations and had 1,069 civil health care fraud matters pending at the end of the fiscal year. In FY 2011, Federal Bureau of Investigation (FBI) heath care fraud investigations resulted in the operational disruption of 238 criminal fraud organizations, and the dismantlement of the criminal hierarchy of more than 67 criminal enterprises engaged in health.

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