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Government Report: Big Bucks Recovered in Crackdown on Health Care Fraud

More than $4 billion returned to Medicare and Treasury coffers in 2012 (Feb. 11)

Attorney General Eric Holder and Health and Human Services (HHS) Secretary Kathleen Sebelius have released a new report showing that for every dollar spent on health care-related fraud and abuse investigations during the last 3 years, the government recovered $7.90. According to the report, this is the highest 3-year average return on investment in the 16-year history of the Health Care Fraud and Abuse Control (HCFAC) program.

The government’s health care fraud prevention and enforcement efforts recovered a record $4.2 billion in taxpayer dollars in fiscal year (FY) 2012 — up from nearly $4.1 billion in FY 2011 — from individuals and companies who attempted to defraud federal health programs serving seniors and taxpayers or who sought payments to which they were not entitled. Over the last 4 years, the administration’s enforcement efforts have recovered $14.9 billion — up from $6.7 billion over the prior 4-year period. Since 1997, the HCFAC program has returned more than $23 billion to the Medicare Trust Funds.

Teams of investigators 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 chronic fraud by criminals masquerading as health care providers or suppliers.

In FY 2012, the Justice Department opened 1,131 new criminal health care fraud investigations involving 2,148 potential defendants, and a total of 826 defendants were convicted of health care fraud-related crimes during the year.

In May 2012, the government strike force coordinated a “takedown” that involved 107 individuals — including physicians and nurses — in seven cities, who were charged for their alleged participation in Medicare fraud schemes involving approximately $452 million in false billings. As a part of this effort, the HHS also suspended or took other administrative action against 52 providers using authority under the health care law to suspend payments until an investigation is complete.

The new authorities under the Affordable Care Act granted to HHS and the Centers for Medicare & Medicaid Services (CMS) were instrumental in clamping down on fraudulent activity in health care, the report says. In FY 2012, CMS began the process of screening all 1.5 million Medicare-enrolled providers through the new Automated Provider Screening system, which quickly identifies ineligible and potentially fraudulent providers and suppliers prior to enrollment or revalidation to verify the data. As a result, nearly 150,000 ineligible providers have been eliminated from Medicare’s billing system.

Source: U.S. Dept. of Health & Human Services; February 11, 2013.

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