2011 Was a Good Year in Medicare Fraud Battle

The Department of Justice recovered nearly $4.1 billion stolen in healthcare fraud schemes during 2011, according to the Obama administration.  That is a 58 percent increase when compared with 2009.  “This is an unprecedented achievement — and it represents the highest amount ever recovered in a single year,” said Attorney General Eric Holder.  The Justice Department reported that more than 1,400 people were charged with fraud in 500 cases.  More than 700 have been convicted.  “We’re regaining the upper hand in our fight against healthcare fraud,” said Health and Human Services Secretary Kathleen Sebelius.  The numbers are part of the Health Care Fraud and Abuse Control Program Annual Report, which is submitted to Congress every year.

Holder and Sebelius gave credit to their Medicare Fraud Strike Force teams for tracking down crime in areas with “hot spots” of unexplained Medicare billing.  The strike forces include prosecutors and investigators from the FBI, the Justice Department and the Health and Human Services Office of Inspector General.

According to Sebelius, aggressively pursuing health care fraud is a great investment.  “Over the last three years, for every dollar we’ve spent, we’ve put more than seven dollars back in the hands of American taxpayers,” she said.  The money goes into the Medicare Trust Fund, the U.S. Treasury and state treasuries.

From 2009 to 2011, the federal government collected $7.20 for every dollar spent on fighting fraud, according to the HHS inspector general.  That’s an increase from the $5.10 for every dollar spent between 1997 and 2008.  “It demonstrates that our collaborative efforts to prevent, identify and prosecute the most egregious instances of health care fraud have never been stronger,” Holder said.  “Over the years, we’ve seen that as these crimes harm all of us — government agencies and programs, insurers and healthcare providers, and individual patients.”

The Health Care Fraud Prevention and Enforcement Action Teams (HEAT) sent 175 people to prison, with an average sentence of 47 months, according to the Justice Department.  The teams were created in 2009.  “I expect that we will be expanding those efforts to additional cities,” said Peter Budetti, director for the Centers for Medicare and Medicaid Services’ Center for Program Integrity.

The Patient Protection and Affordable Care Act (ACA) sets aside $350 million in healthcare fraud-fighting funds. One of the law’s provisions requires  providers and suppliers wishing to participate in the Medicare, Medicaid, and the Children’s Health Insurance Program that have been deemed to be at higher risk of fraud or abuse to undergo license checks and site visits to confirm legitimacy.

Writing in the Christian Science Monitor, Warren Richey puts this in historical perspective.  According to Richey, “During President Bush’s eight years in office, nearly $1.6 billion was recovered on average each year by federal agents and prosecutors.  In contrast, the Obama administration has recovered an average $3.6 billion per year during each of the past three years.  Fighting healthcare fraud is essential in an administration that is seeking to dramatically increase the level of federal control over the nation’s health insurance system.

But it is unclear from the report to what extent the increased recoveries are a function of more efficient law enforcement or simply the rampant nature of fraud against the government.  Estimates are that healthcare fraud diverts more than $60 billion a year from public health care to criminal enrichment.  Administration officials insist they are bringing fraud, waste, and abuse under control.”

In its fiscal year 2013 budget, HHS proposes to continue making progress against healthcare fraud by increasing support through mandatory and discretionary funding.  The mandatory funding level is $1.3 billion. HHS is requesting $610 million in discretionary funds.  In its FY 2013 budget request, the Justice Department requested $294.5 million in mandatory and discretionary funding to continue the fight against  healthcare fraud.

According to Holder, the department’s civil division filed 1,000 new civil cases in addition to 1,000 pending actions.  The work resulted in $2.4 billion in recoveries under the federal False Claims Act, he said.  “These are stunning numbers,” Holder said.

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