The Department of Justice and the Department of Health and Human Services recovered a record $4.3 billion in fiscal year 2013, resulting from joint enforcement efforts to combat healthcare-related fraud and abuse. The agencies also obtained records in the numbers of new cases, charges, guilty pleas, and jury convictions reached.

The $4.3 billion in recoveries surpasses the previous year's record recoveries of $4.2 billion, according to the government's annual Health Care Fraud and Abuse Control Program report. This is the fifth consecutive year the program has increased recoveries over the past year, climbing from $2 billion in fiscal year 2008 to over $4 billion every year since fiscal year 2011.

The joint Justice Department and HHS enforcement efforts are part of the Health Care Fraud Prevention & Enforcement Action Team (HEAT), a joint initiative announced in May 2009 between Justice Department and HHS to focus their efforts to prevent and deter Medicare fraud and enforce current anti-fraud laws around the country.

With operations in nine locations, the strike force in fiscal year 2013 also secured records in the number of cases filed (137); individuals charged (345); guilty pleas secured (234); and jury trial convictions (46). Also in fiscal year 2013, the Justice Department opened 1,013 new criminal healthcare fraud investigations involving 1,910 potential defendants. A total of 718 defendants were convicted of healthcare fraud-related crimes during the year.  The Justice Department also opened 1,083 new civil healthcare fraud investigations.

Better Analytics

HHS Secretary Kathleen Sebelius credited the increase in recovered funds, in part, to better data analytic programs that help spot healthcare fraud. “New enrollment screening techniques are proving effective in preventing high-risk providers from getting into the system, and the new computer analytics system that detects and stops fraudulent billing before money ever goes out the door is accomplishing positive results—all of which are adding to savings for the Medicare Trust Fund,” she said. 

In March 2011, the Centers for Medicare and Medicaid Services launched an ambitious project to revalidate all 1.5 million Medicare enrolled providers and suppliers under the Affordable Care Act screening requirements. As of September 2013, more than 535,000 providers were subject to the new screening requirements, and over 225,000 lost the ability to bill Medicare due to the Affordable Care Act requirements and other proactive initiatives. 

Since the Affordable Care Act, CMS has also revoked 14,663 providers and suppliers' ability to bill the Medicare program. According to HHS, “these providers were removed from the program because they had felony convictions, were not operational at the address CMS had on file, or were not in compliance with CMS rules.”

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