DOJ Report Reveals Fraud and Abuse Recoveries Declined in Fiscal Year 2015

The Department of Justice (DOJ) and Department of Health and Human Services (HHS) released their annual report regarding the achievements of the Health Care Fraud and Abuse Control (HCFAC) Program for Fiscal Year 2015 and it indicates the government recovered $2.4 billion in judgments, settlements and administrative penalties from fraud cases.

A press release announcing the report touts that recovery as a return on investment of $6.10 for every dollar spent over the last three years. Impressive numbers, yet not quite as impressive as 2014's— when the government reported $3.3 billion in recoveries and estimated a $7.70 return per dollar spent over the prior three years. The recovery in 2015 is also lower than that of 2013 which recorded $4.3 billion recovered and estimated $8 return for each dollar spent over the prior three years.

Overall, since the HCFAC program's launch in 1997, the government has recovered $29.4 billion for the Medicare Trust Fund. Recoveries in any one year are the culmination of efforts that span more than one fiscal year. This year's report indicates that for 2015, the government "won or negotiated over $1.9 billion in health care fraud judgments and settlements." That's down from the $2.3 billion reported as won or negotiated in Fiscal Year 2014 and $2.6 billion won or negotiated in Fiscal Year 2013. Note, however, that enforcement efforts don't appear to be waning. In its 2017 Budget Request, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) is requesting a total budget of $419 million to oversee the administration of the HHS programs—that includes $334 million for oversight of Medicare and Medicaid and the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative.

This year's report touts the achievements of state-of-the-art fraud detection technology including Centers for Medicare & Medicaid Services' Fraud Prevention System (FPS), enhanced provider screening and enrollment and the Health Care Fraud Prevention Partnership (HFPP). The FPS uses predictive analytics to spot suspicious billing patterns before claims are paid and the government credits the program with assisting in saving up to $820 million since 2011. The HFPP is a joint effort between the government and private insurers, states and associations to prevent health care fraud. Finally, the report also praises the payoff of involving beneficiaries in the fight against fraud through the Senior Medicare Patrol. However, that program experienced a decline between 2013 and 2014 with regard to recoveries attributable to its efforts. (See National Intelligence Report, Aug. 20, 2015, p. 4)

Takeaway: Despite robust enforcement and big settlements announced last year, the DOJ reports fewer dollars recovered than in prior years.