News: OIG releases Health Care Fraud and Abuse Control Program FY 2020 Report

During fiscal year 2020, the federal government won or negotiated more than $1.8 billion in healthcare fraud judgements and settlements, according to the OIG’s fiscal year 2020 Health Care Fraud and Abuse Control Program (HCFAC) report. These efforts, in conjunction with those of preceding years, returned nearly $3.1 billion to the federal government in 2020.

The HCFAC program was designed to coordinate federal, state, and local law enforcement activities with respect to healthcare fraud and abuse. HHS and the Department of Justice (DOJ) are required to release a detailed annual report with the amounts deposited and appropriated to the Medicare Trust Funds and the source of such deposits.

The DOJ opened 1,148 new criminal healthcare investigations in 2020. Criminal charges were filed in 412 cases involving 679 defendants, and a total of 440 defendants were convicted of healthcare fraud related crimes.

Also in 2020, the DOJ opened 1,097 new civil healthcare fraud investigations and had 1,489 civil healthcare fraud matters pending at the end of the year. The FBI efforts resulted in approximately 407 operational disruptions of criminal fraud organizations and “the dismantlement of the criminal hierarchy of more than 101 healthcare fraud criminal enterprises.”

Investigations conducted by the OIG in fiscal year 2020 resulted in 578 criminal actions against entities or individuals who engaged in crimes related to Medicare and Medicaid. More than 780 civil actions (including false claims and unjust-enrichment lawsuits) were also found.

The OIG excluded 2,148 individuals and entities from participating in Medicare, Medicaid, or other federal healthcare programs. Exclusions were based on criminal convictions for crimes related to Medicare and Medicaid (891) or to other healthcare programs (316) for patient abuse or neglect (230), and as a result of healthcare licensure revocations (509).

Numerous audits and evaluations were also issued by the OIG. These audits were issued with recommendations that would “correct program vulnerabilities and save Medicare and Medicaid funds” when implemented.

The report notes that the DOJ, FBI, and OIG had fewer resources to fight healthcare fraud and abuse in 2020 due to sequestration of mandatory funds. A total of $11.0 million was sequestered from the HCFAC program in 2020, for a combined total of $150.6 million in mandatory funds sequestered in the past eight years, according to the report. Including funds sequestered from the FBI ($70.0 million in the past eight years), $220.6 million has been sequestered from mandatory HCFAC funds since the year 2013.

Editor’s note: The 2020 HCFAC report can be found here.