ENFORCEMENT

Federal Fraud and Abuse Recoveries Down from Prior Fiscal Year

By Kelly A. Briganti, Editorial Director, G2 Intelligence

Despite robust enforcement efforts and large scale investigations and takedowns, the overall recovery received in government coffers last year was down from the prior year. The Department of Justice (DOJ) and Department of Health and Human Services (HHS) released their annual report regarding the achievements of the Health Care Fraud and Abuse Control (HCFAC) Program for Fiscal Year 2015 and it indicates the government recovered $2.4 billion in judgments, settlements and administrative penalties from fraud cases. A press release announcing the report touts that recovery as a return on investment of $6.10 for every dollar spent during the last three years. Impressive numbers, yet not quite as impressive as 2014’s—when the government reported $3.3 billion in recoveries and estimated $7.70 per dollar spent over the prior three years.

Overall, since the HCFAC program’s launch in 1997, the government has recovered $29.4 billion for the Medicare Trust Fund. Recoveries in any one year are the culmination of efforts that span more than one fiscal year of course. This year the report indicates that for 2015, the government “won or negotiated over $1.9 billion in health care fraud judgments and settlements.” That’s down from the $2.3 billion reported as won or negotiated in Fiscal Year 2014.

This year’s report lauds the achievements of state-of-the-art fraud detection technology including Centers for Medicare & Medicaid’s Fraud Prevention System (FPS), enhanced provider screening and enrollment and the Health Care Fraud Prevention Partnership (HFPP). The FPS uses predictive analytics to spot suspicious billing patterns before claims are paid and the government credits the program with assisting in saving up to $820 million since 2011. The HFPP is a joint effort between the government and private insurers, states and associations to prevent health care fraud. Finally, the report also praises the payoff of involving beneficiaries in the fight against fraud through the Senior Medicare Patrol. However that program experienced a decline between 2013 and 2014 with regard to recoveries attributable to its efforts.

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