Healthcare Fraud Efforts Net $5B in FY 2021

The federal government’s crackdown on healthcare fraud resulted in more than $5 billion in judgments and settlements in Fiscal Year (FY) 2021, according to a new report from the U.S. Department of Health and Human Services and Department of Justice. It’s significantly more than the $3.1 billion recovered in FY 2020.

As a result of last year’s efforts, as well as those of preceding years, almost $1.9 billion was returned to the federal government or paid to private persons in FY 2021. Of this $1.9 billion, the Medicare Trust Funds received transfers of approximately $1.2 billion during this period, in addition to the almost $97 million in federal Medicaid money that also was transferred separately to the Centers for Medicare & Medicaid Services (CMS).

Efforts by various agencies resulted in both civil and criminal charges being filed in FY 2021 as well as exclusions from federal healthcare programs:

• The Department of Justice (DOJ) opened 831 new criminal healthcare fraud investigations and prosecutors filed criminal charges in 462 cases involving 741 defendants.

• A total of 312 defendants were convicted of healthcare fraud related crimes in FY 2021.
• DOJ opened 805 new civil healthcare fraud investigations and had 1,432 civil healthcare fraud matters pending at the end of the fiscal year.

• Federal Bureau of Investigation (FBI) investigative efforts resulted in more than 559 operational disruptions of criminal fraud organizations and the dismantlement of the criminal hierarchy of more than 107 healthcare fraud criminal enterprises.

• Investigations conducted by HHS’s Office of Inspector General (HHS-OIG) resulted in 504 criminal actions against individuals or entities that engaged in crimes related to Medicare and Medicaid, and 669 civil actions, which include false claims and unjust-enrichment lawsuits filed in federal district court, and civil monetary penalty (CMP) settlements.

• HHS-OIG also excluded 1,689 individuals and entities from participating in Medicare, Medicaid, and other federal healthcare programs. Among these were exclusions based on criminal convictions for crimes related to Medicare and Medicaid (569) or to other healthcare programs (267), for beneficiary abuse or neglect (145), and as a result of state healthcare licensure revocations (536).

The federal government has said its efforts are paying off and that the return on investment for the Health Care Fraud and Abuse Control Program (HCFAC) over the last three years is $4 for every $1 spent.

Healthcare Strike Force Efforts

The Health Care Fraud Strike Force was set up in 2007 and operates in 24 districts across the country including Miami and Tampa/Orlando, along with the National Rapid Response Strike Force (NRRSF) which was created in September 2020. It targets large-scale and multi-jurisdictional schemes occurring across the country. NRRSF has led efforts to crackdown on healthcare fraud related to the COVID-19 pandemic. One example is the 2021 COVID-19 Health Care Fraud Enforcement Action, which resulted in charges against 14 defendants in seven federal districts across the United States for their alleged participation in various healthcare fraud schemes that exploited the COVID-19 pandemic and resulted in more than $143 million in false billings.

During FY 2020, Strike Force accomplishments, as well as U.S. Attorneys’ Offices (USAOs) accomplishments, included:

• Filing 263 indictments, information, and complaints involving charges against 405 defendants who allegedly billed federal healthcare programs and private insurers more than $4.7 billion.

• Obtaining 254 guilty pleas and trying 24 jury trials, with guilty verdicts against 30 defendants.

• Securing imprisonment for 254 sentenced defendants, with an average of nearly 42 months of incarceration per sentenced defendant.

Since its inception, Strike Force prosecutors filed more than 2,100 cases charging more than 4,600 defendants who collectively billed federal healthcare programs and private insurers approximately $23 billion. More than 3,000 defendants pleaded guilty, and more than 390 others were convicted in jury trials. More than 2,800 defendants were sentenced to prison for an average term of approximately 50 months.

In September 2020, the Criminal Division’s Health Care Fraud Unit organized and led a historic national takedown, in collaboration with numerous state and federal agencies which involved 345 charged defendants across 51 federal districts, including more than 100 doctors, nurses, and other licensed medical professionals. They were collectively charged with submitting more than $6 billion in allegedly false and fraudulent claims to federal healthcare programs and private insurers, including more than $4.5 billion connected to schemes that involved telemedicine fraud, more than $845 million involving substance abuse treatment facilities, or “sober homes,†and more than $806 million relating to other healthcare fraud and illegal opioid distribution schemes across the country.

The report also outlines numerous significant criminal and civil investigations, many of which we have featured in our weekly blogs.

Our team of highly skilled attorneys and consultants are here to help you before you become the focus of an investigation and will aggressively defend you should you become the target of one. Give us a call at 305-358-4500 or email info@vitalehealthlaw.com.