Report: Federal agencies fighting healthcare fraud recouped $3.1B in 2020

Spearheaded by the Departments of Justice, and Health and Human Services, efforts to investigate and prosecute healthcare fraud resulted in the government recovering billions, including about $2.1 billion for the Medicare Trust Funds.

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Last year, almost $3.1 billion was returned to the federal government or paid to private persons following investigations into healthcare fraud, according to a new report.

Released by the Department of Health and Human Services and Department of Justice this month, the report details the law enforcement activities undertaken through the Health Care Fraud and Abuse Control Program. The program was established by the Health Insurance Portability and Accountability Act of 1996 and is under the joint direction of the attorney general and the HHS secretary.

The Department of Justice opened 1,148 new criminal healthcare fraud investigations in fiscal year 2020, with federal prosecutors filing criminal charges in 412 cases involving 679 defendants.

A total of 440 defendants were convicted of healthcare fraud-related crimes during the year.

Further, the Justice Department opened 1,079 new civil fraud investigations last year. The department had 1,498 civil fraud matters pending by the end of the year, including ones from prior to 2020.

Investigations conducted by HHS’ Office of Inspector General resulted in 578 criminal actions against individuals or entities that engaged in crimes related to Medicare and Medicaid, and 781 civil actions, which include false claims and unjust enrichment lawsuits filed in federal district court.

The federal government won or negotiated more than $1.8 billion in judgments and settlements in fiscal year 2020. Because of these efforts, as well as those of preceding years, almost $3.1 billion was returned to the government or private persons.

Of this $3.1 billion, the Medicare Trust Funds received transfers of approximately $2.1 billion. Another $128.2 million in federal Medicaid money was transferred to the treasury.

Specifically, with regard to violations of the False Claims Act and Anti-Kickback Statute, the OIG recovered more than $8.2 million in affirmative enforcement actions.

Among these was a large national takedown last September that resulted in charges against 345 individuals for submitting more than $6 billion in false claims to federal healthcare programs and private insurers. The fraudulent claims included more than $4.5 billion connected to telemedicine and more than $845 million linked to substance abuse treatment facilities and illegal opioid distribution schemes across the country.

The report also highlighted the first-ever kickback action against an EHR developer for receiving payment from a pharmaceutical company.

In January 2020, EHR developer Practice Fusion agreed to pay $145 million to resolve criminal and civil liability related to its soliciting and receiving kickbacks from a major opioid company. Practice Fusion allegedly implemented clinical decision support alerts designed to increase prescriptions for the drug company’s products in exchange for payment, according to the report.

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