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2019 Health Care Fraud and Abuse Control Program Report: Summary of Results

Richard P. Kusserow | July 2020

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 Department of Justice (DOJ) and Department of Health and Human Services (HHS) Office of Inspector General (OIG) to coordinate federal, state and local law enforcement activities with respect to health care fraud and abuse. The HCFAC Annual Report for Fiscal Year (FY) 2019 (Report) results evidenced the federal government winning or negotiating over $2.6 billion in health care fraud judgments and settlements, in addition to other health care administrative impositions. As a result of these efforts, $3.6 billion was paid to private persons or returned to the federal government in FY 2019. The funds returned to the federal government included the Medicare Trust Fund receiving $2.5 billion, in addition to the $148.6 million transferred to the U.S. Department of Treasury.

During FY 2019, the DOJ opened 1,060 new criminal health care fraud investigations and filed criminal charges in 485 cases involving 814 defendants. A total of 528 defendants were convicted of health care fraud-related crimes during the year. In addition, the DOJ opened 1,112 new civil health care fraud investigations and had 1,343 civil health care fraud matters pending at the end of the FY. The Federal Bureau of Investigation’s (FBI) efforts resulted in over 558 operational disruptions of criminal fraud organizations and the dismantling of the criminal hierarchy of more than 151 criminal health care fraud schemes. The HHS OIG’s investigations resulted in 747 criminal actions and 684 civil actions against individuals or entities that engaged in fraud related to Medicare and Medicaid. They also excluded 2,640 individuals and entities from participation in Medicare, Medicaid, and other federal health care programs. The breakdown of exclusions included the following: 1,194 exclusions based on criminal convictions related to Medicare and Medicaid; 335 exclusions from other health care programs; 238 exclusions for patient abuse or neglect; and 576 exclusions as a result of state health care licensure revocations.

About the Author

Richard P. Kusserow established Strategic Management Services, LLC to assist health care organizations develop, implement and assess compliance programs. Mr. Kusserow has worked with health care organizations to conduct compliance program effectiveness evaluations, deliver advisory services, develop policies and procedures and deliver compliance and internal investigations training.

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