The Department of Health and Human Services And The Department of Justice have released the Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2017. The Feds have released a strong report for FY2017 and the fraud they have been working to combat. Everyone, including those in the NEMT industry, should take note! Remember to ensure you and your employees are properly trained and understand the legal consequences surrounding Fraud Waste and Abuse requirements.


The Health Insurance Portability and Accountability Act of 1996 (HIPAA) established a national Health Care Fraud and Abuse Control Program (HCFAC or the Program) under the joint direction of the Attorney General and the Secretary of the Department of Health and Human Services (HHS). 1 , acting through the Inspector General, designed to coordinate federal, state and local law enforcement activities with respect to health care fraud and abuse. In its twenty-first year of operation, the Program’s continued success confirms the soundness of a collaborative approach to identify and prosecute the most egregious instances of health care fraud, to prevent future fraud and abuse, and to protect program beneficiaries. Monetary Results During Fiscal Year (FY) 2017, the Federal Government won or negotiated over $2.4 billion in health care fraud judgments and settlements. 2, and it attained additional administrative impositions in health care fraud cases and proceedings. As a result of these efforts, as well as those of preceding years, in FY 2017 $2.6 billion was returned to the Federal Government or paid to private persons. Of this $2.6 billion, the Medicare Trust Funds3 received transfers of approximately $1.4 billion during this period, and $406.7 million in Federal Medicaid money was similarly transferred separately to the Treasury as a result of these efforts.

Enforcement Actions In FY 2017, the Department of Justice (DOJ) opened 967 new criminal health care fraud investigations. Federal prosecutors filed criminal charges in 439 cases involving 720 defendants. A total of 639 defendants were convicted of health care fraud-related crimes during the year.Also in FY 2017, DOJ opened 948 new civil health care fraud investigations and had 1,086 civil health care fraud matters pending at the end of the fiscal year. In FY 2017, the FBI investigative efforts resulted in over 674 operational disruptions of criminal fraud organizations and the dismantlement of the criminal hierarchy of more than 148 health care fraud criminal enterprises. In FY 2017, investigations conducted by HHS’ Office of Inspector General (HHS-OIG) resulted in 788 criminal actions against individuals or entities that engaged in crimes related to Medicare and Medicaid, and 818 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 3,244 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 (1,281) or to other health care programs (309), for patient abuse or neglect (266), and as a result of licensure revocations (973). HHS-OIG also issued numerous audits and evaluations with recommendations that, when implemented, would correct program vulnerabilities and save program funds.

Sequestration Impact Due to sequestration of mandatory funding in 2017, there were fewer resources for DOJ, FBI, HHS, and HHS-OIG to fight fraud and abuses against Medicare, Medicaid, and other health care programs. A total of $20.7 million was sequestered from the HCFAC program in FY 2017, for a combined total of $115.5 million in the past five years. Including funds sequestered from the FBI and the FY 2013 discretionary HCFAC sequester, the total equals $161.7 million in the past five years.

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