Recently, the Annual Report of the Departments of Health and Human Services and Justice was released, highlighting health care fraud and abuse control for fiscal year (FY) 2020. According to the report, the Department of Justice (DOJ) recouped almost $2 billion ($1.8 billion) in connection with healthcare fraud allegations. As a result of those efforts and efforts from preceding years, nearly $3.1 billion was returned to the Federal Government and private individuals.
Since the start of the COVID-19 public health emergency in March 2020, the Centers for Medicare and Medicaid Services (CMS), the United States Department of Health and Human Services Office of Inspector General (HHS OIG), and other law enforcement agencies worked together to investigate and prosecute healthcare fraud from select risk areas, including unnecessary laboratory testing related to COVID-19, genetic sequencing, and cardiac panels.
DOJ Investigations
In FY 2020, the DOJ opened 1,148 new criminal health care fraud investigations and federal prosecutors filed criminal charges in 412 cases involving 679 defendants. A total of 440 defendants were convicted of health care fraud related crimes during the year. DOJ also opened 1,079 new civil health care fraud investigations and had 1,498 civil health care fraud matters pending at the end of the fiscal year.
Since March 2020, United States Attorneys Offices have been actively pursuing pandemic-related fraud, including using civil injunctions to shut down fraudsters peddling phony cures, prosecuting COVID-19-related scams, investigating failure of care at nursing facilities impacted by COVID-19, and investigating False Claims Act matters alleging fraud on Medicare and Medicaid related to the pandemic or stimulus health care funding.
The report cited the following as some examples of notable fraud cases:
- The Medicine Shoppe/Advantage Pharmacy investigations, in which four Districts coordinated a large investigation of compounded drug fraud, resulting in 40 convictions to date
- The Practice Fusion EHR case, which resulted in a $145.0 million payment to resolve criminal and civil liability. The investigation arose from evidence discovered by a USAO and is the first case involving kickbacks paid by a pharmaceutical manufacturer to an EHR company and
- Several large pharmaceutical pricing cases brought under the FCA and AKS based on allegations of price-fixing and market allocation in the generic pharmaceutical industry.
HHS OIG Investigations
In FY 2020, investigations conducted by HHS’s Office of Inspector General (HHS-OIG) 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, civil monetary penalties (CMP) settlements, and administrative recoveries related to provider self-disclosure matters. HHS-OIG also excluded 2,148 individuals and entities from participation in Medicare, Medicaid, and other federal health care programs. Among these were exclusions based on criminal convictions for crimes related to Medicare and Medicaid (891) or to other health care programs (316), for patient abuse or neglect (230), and as a result of state health care licensure revocations (509). HHS-OIG also issued numerous audits and evaluations with recommendations that, when implemented, would correct program vulnerabilities and save Medicare and Medicaid funds.
According to the report, during FY 2020, HHS-OIG issued 178 audit reports and 44 evaluations, resulting in 689 new recommendations issued to HHS operating divisions. HHS operating divisions also implemented 286 recommendations during FY 2020.
Sneak Peak
The report also gives a preview of what’s to come, saying that in 2021 and 2022, DOJ will have more resources, more complete data, and therefore “more effective and efficient oversight of healthcare fraud.” It’s anticipated that this increase will have a “steady increase in healthcare related audits, inspections, and investigations.”