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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