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DOJ Opened a Staggering 975 New Criminal Health Care Fraud Investigations and 930 New Civil Health Care Fraud Investigations in FY 2016

January 30, 2017

This month the U.S. Department of Health and Human Services (HHS) and the Department of Justice (DOJ) issued their Health Care Fraud and Abuse Control (HCFAC) Program Annual Report. The HCFAC Program exists to coordinate the identification and prosecution of health care fraud cases across federal and state law enforcement activities. A full copy of the annual report is available here.

According to the annual report, DOJ opened 975 new health care fraud investigations in 2016, with federal prosecutors filing criminal charges in 480 cases involving 802 defendants. The report also reveals that a total of 658 defendants were convicted of health care fraud-related crimes in FY 2016.

For civil health care fraud enforcement, 930 new investigations were launched and 1,422 civil health care fraud matters were pending at the end of the fiscal year.

HHS also excluded 3,635 individuals and entities from participation in federal health care benefit programs for Medicare and Medicaid related criminal convictions as well as for patient abuse or neglect or as a result of licensure revocations.

During FY 2016, these federal enforcement agencies garnered over $2.5 billion in health care fraud judgments and settlements. According to the report, the return on investment for the HCFAC program between 2014 and 2016 is $5.00 returned for every $1.00 expended.

This new report shows that federal health care oversight and enforcement agencies continue to aggressively pursue allegations of fraud and abuse, which can quickly escalate to a criminal or civil enforcement action.

The report also reinforces that coordination among health care benefit programs and enforcement agencies is a focus of fraud prevention activities among these agencies. Providers may face scrutiny from Medicare auditors, Medicaid utilization review teams, HHS-OIG affirmative enforcement efforts, Medicaid Fraud Control Unit activities, and reviews performed by Special Investigative Units (SIUs) from Medicaid-contracted Managed Care Organizations or private insurance companies.

If you are facing an audit, subpoena, or other inquiry from a health care benefit program or government enforcement agency and have questions about how to respond, please contact Eric Atkinson, Mike Gill, or a member of HDJN’s Fraud and Abuse team.

The information contained in this advisory is for general educational purposes only. It is presented with the understanding that neither the author nor Hancock, Daniel, Johnson & Nagle, PC, is offering any legal or other professional services. Since the law in many areas is complex and can change rapidly, this information may not apply to a given factual situation and can become outdated. Individuals desiring legal advice should consult legal counsel for up-to-date and fact-specific advice. Under no circumstances will the author or Hancock, Daniel, Johnson & Nagle, PC be liable for any direct, indirect, or consequential damages resulting from the use of this material.