The Health Insurance Portability and Accountability Act of 1996 (HIPAA) established a national Health Care Fraud and Abuse Control Program (HCFAC) under the joint direction of the Attorney General and the Department of Health and Human Services (HHS) Secretary, acting through the Office of Inspector General (OIG). The HCFAC was designed to coordinate federal, state and local law enforcement activities with respect to health care fraud and abuse. Under Section 1817(k)(5) of the Social Security Act, the Attorney General and the HHS Secretary provide the required Annual Report detailing expenditures and revenues under the Health Care Fraud and Abuse Control Program for Fiscal Year 2016. The HHS Secretary and Attorney General jointly certify the necessary amount to finance anti-fraud investigations from the Health Care Fraud and Abuse Control Account. The maximum amounts available for certification are specified in the Act.
The following highlights the reported statistical accomplishments for the last year.
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2016 Statistical Results
- $2.5 billion in health care fraud judgments and settlements with administrative impositions; total of $3.3 billion returned to the Federal Government or paid to private persons.
- $1.7 billion returned to the Medicare Trust Funds.
- $235.2 million transferred separately to the Treasury.
- Monetary recoveries provided a return of $5 for every dollar spent on cases investigated.
- Since inception of the Program in 1997, $31 billion returned to the Medicare Trust Funds.
- 975 new criminal health care fraud cases opened with 480 cases involving 802 defendants.
- 658 defendants were convicted of health care fraud-related crimes during the year.
- 930 new civil health care fraud cases opened with 1,422 matters pending at year’s end.
- FBI disrupted 555 criminal fraud organizations and dismantled 128 others.
- OIG investigations resulted in 765 criminal actions against individuals and entities.
- OIG brought 690 civil actions with CMP settlements and self-disclosures.
- OIG excluded 3,635 individuals.
- Medicare Fraud Strike Force filed 246 charges against 482 defendants in $2.8 billion in fraud.
- Strike Force obtained 260 guilty pleas and jury trial verdicts against 32 defendants.