This summer, the United States Department of Health and Human Services (HHS) and Department of Justice (DOJ) released the Health Care Fraud and Abuse Control (HCFAC) Program FY 2019 Annual Report. This annual report identifies federal enforcement activities and the subsequent results from October 1, 2018 through September 30, 2019.
Overall, DOJ investigations and enforcement actions decreased slightly from FY 2018 to FY 2019 but were generally consistent with FY 2018. The overall number of Office of Inspector General (OIG) investigations and enforcement actions were also consistent. However, the proportion of criminal cases to civil cases increased in FY 2019 compared to FY 2018.
Judgments and Settlements
Overall, there was a total of $2.6 billion in total judgments and settlements for healthcare fraud, a $300 million increase compared to FY 2018. When it came to total amounts recovered, though, that amounted to $3.6 billion – an increase of $1 billion when compared to FY 2018. Of that $3.6 billion, about $2.5 billion was returned to the Medicare trust fund. The total amounts recovered includes recoveries related to prior years and more than $250 million in payments to qui tam relators.
While the HCFAC budget expenditures totaled $1.06 billion by DOJ and HHS (a $28 million increase from FY 2018), the calculated return on investment was $4.20 returned for every $1.00 spent – an increase from the three-year ROI in FY 2018 of $4.00 per $1.00 spent.
DOJ Enforcement Actions
In FY 2019, DOJ conducted 1,060 new criminal healthcare fraud investigations and 1,112 new civil healthcare fraud investigations. This is a slight decrease from FY 2018, when DOJ conducted 1,139 criminal investigations and 1,203 civil investigations.
Federal Bureau of Investigation (FBI) investigative efforts resulted in over 558 operational disruptions of criminal fraud organizations and the dismantlement of the criminal hierarchy of more than 151 health care fraud criminal schemes.
OIG Enforcement Actions
In FY 2019, HHS OIG initiated 747 new criminal actions (an increase from 679 criminal actions initiated in FY 2018) and 684 new civil actions (a decrease from the 795 civil actions initiated in FY 2018).
In FY 2019, HHS OIG excluded 2,640 individuals and entities from participating in federal healthcare programs – a minor decrease from the 2,712 exclusions in FY 2018. Of the 2,640 exclusions, 45% were based on criminal convictions related to Medicare and Medicaid, 12% were based on criminal convictions related to other healthcare programs, 22% were based on state licensure revocations, and 9% were based on patient abuse or neglect.
Copies of the Reports