The 24th Annual Report from the U.S. Department of Health and Human Services (HHS) and the U.S. Department of Justice (DOJ) reports that the Federal Government won or negotiated more than $1.8 billion in health care fraud judgments and settlements in Fiscal Year (FY) 2020. HIPAA established a national Health Care Fraud and Abuse Control Program under the joint direction of the Attorney General and the Secretary of HHS, which is designed to coordinate federal, state, and local law enforcement activities related to health care fraud and abuse.

What You Need to Know:

• Enforcement actions against individuals and entities working in the health care industry are likely to increase.  
• Affected parties should review and update compliance plans and policies to ensure those documents are up to date in order to minimize the chances of being subject to a government investigation or claim.

​​The Annual Report notes that the Federal Government’s return on investment (ROI) during the last three years (FY 2018– FY 2020) was $4.30 returned for every $1.00 spent. The ROI is often used to support continued federal expenditures to stop and prevent fraudulent activities in the health care delivery system.

The Annual Report summarizes the Federal Government’s ‘significant’ criminal and civil investigations from ‘ambulance and transportation services’ through ‘substance abuse treatment centers.’ Not surprisingly, the Federal Government’s activities include efforts to combat COVID-19 fraud and the opioid crisis.

DOJ Enforcement Actions

During FY 2020, the DOJ initiated 1,148 new criminal health care fraud investigations. Of these investigations, 440 defendants were convicted of health care fraud-related crimes. In the civil arena, the DOJ opened 1,079 new civil health care fraud investigations and had 1,498 civil health care fraud matters pending. The Federal Bureau of Investigation’s (FBI’s) efforts resulted in more than 407 operational disruptions of criminal fraud organizations. According to the Annual Report, the FBI dismantled the hierarchy of more than 101 health care fraud criminal enterprises.

HHS Office of Inspector General Enforcement Actions

In FY 2020, HHS’s Office of Inspector General (OIG) investigations resulted in 578 criminal actions and 781 civil actions related to Medicare and Medicaid, which include false claims and unjust enrichment lawsuits, civil monetary penalty settlements, and administrative recoveries related to provider self-disclosures. In addition, the OIG excluded 2,148 individuals and entities from participation in federal health care programs. These exclusions were based on criminal convictions for crimes related to Medicare, Medicaid, and other health care programs, patient abuse or neglect, and as a result of state health care licensure revocations. The OIG also initiated numerous audits and evaluations to save Medicare and Medicaid funds.

Looking Ahead

Although the DOJ and HHS had fewer resources to fight fraud and abuse in 2020 due to sequestration, the Annual Report suggests that in 2021 and 2022, these enforcement bodies will have additional resources. As a result, the DOJ and OIG will be able to increase oversight efforts and, as stated in the Annual Report, the government expects to see “a steady increase in healthcare related audits, inspections, and investigations.”

Even during a global pandemic, this Annual Report should be a warning signal and an opportunity to be proactive to every party and person working in or with the health care industry. Now is the time to review compliance plans and policies to ensure those documents are up to date and to minimize the chances of being subject to a government investigation or claim. Engaging advisers to assist with these proactive activities will be critical as fraud allegations and investigations continue to rise.