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Government Priority


The report gave credit to President Obama’s efforts to make the elimination of fraud, waste and abuse a top priority in his administration, citing the passage and implementation of the Health Care Fraud Prevention & Enforcement Action Team (HEAT).


Created in 2009 to prevent fraud, waste and abuse in the Medicare and Medicaid programs, HEAT continues to crack down on the fraud perpetrators. Since its inception, the Departments of Justice and HHS have enhanced their coordination through HEAT and increased the number of Medicare Fraud Strike Force teams.  During FY 2011, HEAT and the Medicare Fraud Strike Force expanded local partnerships and helped educate Medicare beneficiaries about how to protect themselves against fraud, according to the news release.


The report said efforts to reduce fraud would continue to improve with the new tools and resources provided by the Affordable Care Act (ACA), including enhanced screenings and enrollment requirements, increased government-wide data sharing, expanded overpayment recovery efforts, and greater oversight of private insurance abuses.


“This report reflects unprecedented successes by the Departments of Justice and Health and Human Services in aggressively preventing and combating health care fraud, safeguarding precious taxpayer dollars and ensuring the strength of our essential health care programs,” said Attorney General Eric Holder in a news release.  “We can all be proud of what’s been achieved in the last fiscal year by the Department’s prosecutors, analysts and investigators-and by our partners at HHS. These efforts reflect a strong, ongoing commitment to fiscal accountability and to helping the American people at a time when budgets are tight.”


“Fighting fraud is one of our top priorities and we have recovered an unprecedented number of taxpayer dollars,” said HHS Secretary Kathleen Sebelius. “Our efforts strengthen the integrity of our health care programs, and meet the President’s call for a return to American values that ensure everyone gets a fair shot, everyone does their fair share, and everyone plays by the same rules.”


Interagency Cooperation


In FY 2011, the total number of cities with strike force prosecution teams was increased to nine, all of which include investigators and prosecutors from the Justice Department, the FBI, and the HHS Office of Inspector General. The strike force teams use advanced data-analysis techniques to identify high billing levels in healthcare fraud hot spots so that other interagency teams can target emerging or migrating schemes along with chronic fraud by criminals masquerading as healthcare providers or suppliers.


In FY 2011, strike force operations charged a record number of 323 defendants, who allegedly billed the Medicare program more than $1 billion. Strike force teams secured 172 guilty pleas, convicted 26 defendants at trial and sentenced 175 defendants to prison. The average prison sentence in strike force cases was more than 47 months.


Charges and Convictions


Including strike force matters, federal prosecutors filed criminal charges against a total of 1,430 defendants for healthcare fraud related crimes. This is the highest number of healthcare fraud defendants charged in a single year in the department’s history.  Including strike force matters, a total of 743 defendants were convicted for healthcare fraud-related crimes during the year.


In criminal matters involving the pharmaceutical and device manufacturing industry, the department obtained 21 criminal convictions and $1.3 billion in criminal fines, forfeitures, restitution and disgorgement under the Food, Drug and Cosmetic Act.  These matters included the illegal marketing of medical devices and pharmaceutical products for uses not approved by the Food and Drug Administration (FDA) or the distribution of products that failed to conform to the strength, purity or quality required by the FDA.


The departments also continued their successes in civil health care fraud enforcement during FY 2011, recovering approximately $2.4 billion through cases brought under the False Claims Act (FCA).  Findings included unlawful pricing by pharmaceutical manufacturers, illegal marketing of medical devices and pharmaceutical products for uses not approved by the FDA, Medicare fraud by hospitals and other institutional providers, and violations of laws against self-referrals and kickbacks. This marked the second year in a row that more than $2 billion has been recovered in FCA healthcare matters and, since January 2009, the department has used the FCA to recover more than $6.6 billion in federal healthcare dollars.


Tuesday’s issuance of the fraud prevention and enforcement report coincided with the announcement of a proposed rule from the Centers for Medicare and Medicaid Services aimed at recollecting Medicare program overpayments. Before the ACA, providers and suppliers did not face a deadline for returning taxpayers’ money.


The HCFAC annual report can be found here, oig.hhs.gov/publications/hcfac.asp.  For more information on the joint DOJ-HHS Strike Force activities, visit: www.StopMedicareFraud.gov/.


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Chuck Buck

Chuck Buck is the publisher of RACmonitor and is the program host and executive producer of Monitor Monday.

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