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Health Care Fraud and Abuse Control Program Annual Report: Recap of DOJ and OIG Investigative Results for FY 2021

Richard P. Kusserow | July 2022

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The National Health Care Fraud and Abuse Control Program was created by the Health Insurance Portability and Accountability Act of 1996 under the joint direction of the Departments of Justice (DOJ) and Health and Human Services Office of Inspector General (OIG) to coordinate federal, state, and local law enforcement activities concerning health care fraud and abuse and to submit an annual report. According to the report for Fiscal Year 2021, there were more than $5.0 billion in health care fraud judgments and settlements in addition to other health care administrative impositions. Almost $1.9 billion was returned to the Federal Government or paid to private persons. Of this returned amount, the Medicare Trust Fund received transfers of approximately $1.2 billion plus almost $98.7 million in Federal Medicaid money that was similarly transferred separately to the Centers for Medicare and Medicaid Services. The DOJ and OIG estimate their efforts had a return on investment of $4 for every $1 expended. 

OIG investigations resulted in 504 criminal actions against individuals or entities that engaged in crimes related to Medicare and Medicaid as well as 669 civil actions filed in federal district court, which included civil monetary penalty settlements. The OIG also excluded 1,689 individuals and entities from participation in federal health care programs. Among these were exclusions based on criminal convictions for crimes related to Medicare and Medicaid (569) or other health care programs (267), beneficiary abuse or neglect (145), and because of state health care licensure revocations (536). During the past year, the DOJ opened more than 830 new criminal healthcare fraud investigations, down from 1,150 last year and 1,060 the year before. Criminal charges were filed for 460 cases, roughly in line with the average of past years, and 310 defendants were convicted in prosecution.

For more information on this topic, contact Richard Kusserow at rkusserow@stategicm.com.

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About the Author

Richard P. Kusserow established Strategic Management Services, LLC, after retiring from being the DHHS Inspector General, and has assisted over 2,000 health care organizations and entities in developing, implementing and assessing compliance programs.

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