Efforts to combat fraud in the US Medicare and Medicaid healthcare programs resulted in a record USD 4.2 billion recovered from individuals and companies trying to cheat the system.

The Health Care Fraud and Abuse (HCFAC) Program annual reported showed that fraud prevention and enforcement efforts in Fiscal Year (FY) 2012 were up from nearly USD 4.1 billion in FY 2011. Over the last four years, the Obama administration’s enforcement efforts have recovered a total of USD 14.9 billion from individuals and companies who attempted to defraud US federal health programs serving seniors, and taxpayers who sought payments to which they were not entitled. These figures are more than double the USD 6.7 billion recovered during the prior four-year period. Since 1997, the HCFAC Program has returned more than USD 23 billion to the Medicare Trust Funds.

According to the report, the success of the joint US Department of Justice (Washington DC, USA) and Health and Human Services (HHS; Washington DC, USA) effort was made possible by the Health Care Fraud Prevention and Enforcement Action Team (HEAT), created in 2009. The strike force teams use advanced data analysis techniques to identify high-billing levels in health care fraud hot spots so that interagency teams can target emerging or migrating schemes, as well as with chronic fraud by criminals masquerading as health care providers or suppliers. The strike force coordinated a takedown in May 2012 that involved the highest number of false Medicare billings in the history of the strike force program.

The takedown involved 107 individuals, including doctors and nurses who were charged for their alleged participation in Medicare fraud schemes involving about USD 452 million in false billings. Other strike force operations in the nine cities where teams are based resulted in 117 indictments and complaints involving charges against 278 defendants who allegedly billed Medicare more than USD 1.5 billion in fraudulent schemes. In FY 2012, 251 guilty pleas and 13 jury trials were litigated, with guilty verdicts against 29 defendants. The average prison sentence in these cases was more than 48 months.

“In the past fiscal year, our relentless pursuit of health care fraud resulted in the disruption of an array of sophisticated fraud schemes and the recovery of more taxpayer dollars than ever before,” said US Attorney General Eric Holder. “This report demonstrates our serious commitment to prosecuting health care fraud and safeguarding our world-class health care programs from abuse.”

“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 health care fraud,” said HHS Secretary Kathleen Sebelius. “This fight against fraud strengthens the integrity of our health care programs and helps us fulfill our commitment to our seniors.”

Related Links:
US Department of Justice
Health and Human Services