The Health Care Fraud and Abuse Control Program (HCFAC) that was established under the Health Insurance Portability and Accountability Act of 1996 (HIPPA) coordinates federal, state, and local health care fraud and abuse enforcement actions.
How Big Of A Problem Is Health Care Fraud And Abuse In The United States?
For Fiscal Year 2010, approximately $2.5 billion in health care fraud judgments and settlements were won or negotiated. The Medicare Trust Fund received approximately $2.86 billion for 2010 (and from prior years) and Federal Medicaid recovered over $683.2 million during the same period. The Medicare Trust Fund has recovered over $18.0 billion from HCFAC efforts since 1997.
Health Care Fraud-Related Criminal Cases In 2010
For Fiscal Year 2010, the U.S. Department of Justice (DOJ) opened 1,116 new criminal health care fraud investigations involving 2,095 potential criminal defendants. For Fiscal Year 2010, federal prosecutors had 1,787 health care fraud criminal investigations pending involving 2,977 potential criminal defendants. They filed criminal charges in 488 cases involving 931 criminal defendants. And for Fiscal Year 2010, 726 criminal defendants were convicted of health care fraud-related crimes.
Just one of the many examples of health care fraud-related criminal cases resolved during Fiscal Year 2010 (and not the worst fraud case) occurred in July, 2010 when the U.S. District Court in Miami, Florida sentenced the founder of a Miami-area HIV/AIDS infusion clinic to 120 months in federal prison and the clinic’s owner and operator to 70 months in federal prison arising out of a $5.8 million Medicare fraud that resulted from false claims being submitted for injection and infusion treatments that were either not provided or not medically necessary (kickbacks were allegedly paid to Medicare beneficiaries to obtain their Medicare numbers and their signatures for the false claims submitted to Medicare). Two of the other criminal defendants received sentences of 84 months and 33 months in federal prison, respectively. Restitution was ordered against four of the criminal defendants in the amount of $2.7 million.
Need another example of how health care fraud costs the taxpayers? On July 16, 2010, federal prosecutors in Brooklyn, New York unsealed charges against 22 criminal defendants involving an alleged scheme to submit fraudulent claims totaling about $78 million for physical therapy, occupational therapy, and durable medical equipment.
Health Care Fraud-Related Civil Cases In 2010
For Fiscal Year 2010, the DOJ opened 942 new civil health care fraud investigations and had 1,290 civil health care fraud matters pending at the end of the year.
Health Care Fraud-Related Enforcement Actions In 2010
U.S. Department of Health and Human Services (HHS) Office of Inspector General excluded 3,340 individuals and entities that included 894 convicted of crimes related to Medicare and Medicaid and 263 related to other health care programs, 247 related to patient abuse or neglect, and 1,582 resulting from license revocations. Civil monetary penalties were imposed against providers and suppliers who knowingly submitted false claims under Federal programs, as well as others.
How Effective Is HCFAC?
In terms of return on investment (ROI – how much money was recovered for every dollar spent), HCFAC has returned $4.9 for every $1 spent since the program began. The ROI for 2008 to 2010, on average, was $6.8 for every $1 spent.
What Can You Do If You Know Someone Who Is Defrauding Medicare Or Medicaid?
There is a Federal law known as the False Claims Act that imposes liability of people and companies that defraud federal programs, including Medicare. The False Claims Act includes provisions for private persons (whistleblowers) to file claims on behalf of the government (a qui tam lawsuit) who may then receive a portion of amounts recovered (typically between 15 % to 25%).
Many medical malpractice lawyers also handle claims under the False Claims Act. By bringing a claim under the False Claims Act, you not only possibly benefit yourself by receiving a portion of the amount that the government receives but you also benefit all taxpayers. Visit our website or call us toll free at 800-295-3959 if you wish to discuss a possible claim under the False Claims Act.