Enforcement Trends

After 5 Down Years, Federal Enforcement ROI Increases—But Just a Tad

Like any other business, federal health care fraud law enforcement has to account for its return on investment (ROI). And for the previous six years, that ROI had been in steady decline. But ROI reversed directions and began moving north again in Fiscal Year 2019. That’s the main takeaway of the new joint HHS and DOJ report on the financial performance of the Health Care Fraud and Abuse Control Program (Program) during the past fiscal year. While federal fraud fighting is still not nearly as profitable as it was six years ago, FY 2019 may at least signal a positive change in trajectory.

After Years of Trending Down, ROI Ticks Slightly Up

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) established the Program under the joint direction of the Attorney General and HHS Secretary, acting through the OIG, to coordinate federal, state and local law enforcement activities with respect to health care fraud and abuse. The Annual Report describes the Program’s financial performance in the previous fiscal year.

Arguably, the most significant metric in the report is Program ROI, which measures how much money the Program returns for every dollar invested. Program ROI is calculated by dividing the total monetary results to the Federal government (not including relator payments) by the annual appropriation for the Program Account in a given year (not including portions of CMS funding dedicated to the Medicare Integrity Program.

And since FY 2013 when ROI peaked at $8.10, ROI has been trending steadily down, with five consecutive years of decline. FY 2019 finally saw the losing streak come to an end, with ROI increasing from $4.00 to $4.20 in 2019.

 Annual Program ROI, FY 2013 to FY 2019

FY 2013 FY 2014 FY 2015 FY 2016 FY 2017 FY 2018 FY 2019
$8.10 $7.70 $6.10 $5.00 $4.20 $4.00 $4.20

 

By the Numbers

During FY 2019, the federal government won or negotiated over $2.6 billion in health care fraud judgments and settlements. That’s up from $2.3 billion in FY 2018, even though the number of convictions during the same period actually declined from 872 to 578. Of course, civil actions have traditionally been the cash cow of federal enforcement efforts.

 

Metric FY 2019 FY 2018
Total recoveries $2.6 billion $2.3 billion
New DOJ criminal health care fraud investigations 1,060 1,139
New DOJ Civil Health care fraud investigations 1,112 918
New Criminal cases filed 485 572
Convictions 528 872
Criminal action resulting from OIG Investigations 747 649
Exclusions issued by OIG 2,640 2,712

 

Takeaway

Because the annual Program ROI can vary from year to year depending on the number and type of cases that are settled or adjudicated during that year, DOJ and HHS use a three-year rolling average ROI for results contained in the report,” the agencies explain in their report. But while rolling averages and a modest gain in FY 2019 may take off some of the edge for a particular year, they can’t conceal the long-term trend. Simply put, the return on enforcement dollars is only about 50% of what it used to be just seven years ago.

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