Uptick in Health Care Fraud and Abuse Investigations

The Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) established a national Health Care Fraud and Abuse Control Program (“HCFAC”) under the joint direction of the Department of Justice (“DOJ”) and the Department of Health and Human Services (“HHS”). HCFAC coordinates federal, state and local enforcement actions designed to “prevent future abuse” and to “protect program beneficiaries.” HCFAC Annual Report for Fiscal Year 2013. 

During fiscal year 2013, the DOJ opened 1,083 new civil health care fraud investigations and 1,013 criminal health care fraud investigations. Id. The number of new investigations opened annually has remained relatively constant over the past few years. Between fiscal years 2010 and 2013, these investigations accounted for an average annual recovery for the federal government of $4 billion (money recovered on behalf of state Medicaid programs is estimated to be an additional $1.7 annually). The DOJ closes about as many cases as it opens, so the average settlement amount per opened investigation is approximately $2.85 million.

As demonstrated by the numbers, health care fraud and abuse investigation is an area of focus for the federal government. The Affordable Care Act (“ACA”) has increased the federal government’s ability to detect and investigate health care fraud. Among the changes implemented by the ACA are increased funding for investigation, heightened screening and compliance requirements, increased penalties, and better data sharing between all federally-supported health care programs.

KDDK health care law attorneys have experience advising health care providers about proper billing and reporting procedures. KDDK attorneys also have experience defending health care providers facing federal investigations. For additional information, please contact any member of the KDDK Health Care Law Practice Team.

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