Federal Healthcare Fraud Prevention and Enforcement Efforts Remain in High Gear


The federal government’s fraud prevention and enforcement efforts recovered $3.3 billion in federal healthcare funds from individuals and companies according to a recent report issued by the Department of Justice (DOJ) and the Department of Health and Human Services (HHS).  The $3.3 billion recovery was a result of the Health Care Fraud and Abuse Control Program (HCFAC), which is a national program jointly administered by the U.S. Attorney General and the Office of the Inspector General (OIG) of HHS.  Although HCFAC has been in existence since 1997, it has become more active in recent years.  In the last three years, HCFAC recovered $7.70 for every dollar spent, which is about $2 higher than the average return on investment in HCFAC since its inception.

Since the passage of the Affordable Care Act, HCFAC has employed a two-pronged strategy in its fraud prevention and enforcement efforts.  The first prong of the strategy is to continue aggressive enforcement efforts against suspected fraudsters.  But HCFAC’s new emphasis is on its second prong, which is to use real-time data analysis and other techniques to prevent fraud.

The Centers for Medicare and Medicaid Services (CMS) is in the process of implementing several projects intended to prevent fraud against federal healthcare programs such as Medicare and Medicaid.  The Affordable Care Act required CMS to revalidate all existing providers and suppliers in the Medicare program using new screening criteria.  CMS expects to complete all revalidations in the spring of 2015.  So far, CMS has deactivated approximately 470,000 enrollments and revoked almost 28,000 enrollments in the Medicare program.  In addition, CMS continues to use its Fraud Prevention System, which it rolled out over the last few years.  The Fraud Prevention System builds on technology first used by credit card companies to apply advanced analytics to all Medicare fee-for-service claims to identify aberrant and suspicious billing patterns in real time.

In sum, all providers that participate in the Medicare and Medicaid programs can expect continued scrutiny by the federal government in the years ahead.  It is as important as ever for all providers to maintain robust and up-to-date compliance programs.

David Dirr is an attorney at the Northern Kentucky office of Dressman Benzinger LaVelle and is a member of the firm’s healthcare and litigation practice groups.  He is licensed to practice in Ohio, Kentucky, and Indiana.  David’s areas of practice include Medicare and Medicaid reimbursement, anti-kickback law, the Stark law, and the False Claims Act.