Last week, HHS and DOJ issued the Health Care Fraud and Abuse Control (HCFAC) Program FY 2019 Annual Report detailing federal enforcement activities and results during the federal fiscal year (FY) 2019, which ran from October 1, 2018 through September 30, 2019. The HCFAC Program is a national initiative, under the joint direction of the U.S. Attorney General and the Secretary of HHS, to coordinate federal, state, and local law enforcement activities with respect to healthcare fraud and abuse. The report indicates that total judgments, settlements and amounts recovered increased in FY 2019 compared to FY 2018. DOJ investigations and enforcement actions decreased slightly but were generally consistent with the prior year. The overall number of OIG investigations and enforcement actions was also consistent, but the overall proportion of criminal cases compared to civil cases increased in FY 2019. This article summarizes the key metrics detailed in the report.

Monetary Results for DOJ and HHS in FY 2019

• $2.6 billion in total judgments and settlements for healthcare fraud, which represents an increase of $300 million compared to FY 2018.
• $3.6 billion in total amounts recovered, which represents an increase of $1 billion compared to FY 2018. This amount includes recoveries corresponding to prior years and also includes approximately $254 million in payments to private qui tam relators.
• $1.06 billion in HCFAC budget expenditures by DOJ and HHS, which represents an increase of $28 million compared to FY 2018.
• Calculated three-year return on investment (ROI) of $4.20 returned for every $1.00 spent, which represents an increase from the calculated three-year ROI of $4.00 per $1.00 reported for FY 2018.

DOJ Enforcement Actions in FY 2019

• 1,060 new criminal healthcare fraud investigations and 1,112 new civil healthcare fraud investigations, which represents a slight decrease from the 1,139 criminal and 1,203 civil investigations in FY 2018.
• 814 defendants charged in 485 criminal cases, which represents a slight decrease from the 872 defendants charged in 572 cases in FY 2018.

OIG Enforcement Actions in FY 2019

• 747 new criminal actions, which represents an increase from the 679 criminal actions initiated in FY 2018.
• 684 new civil actions, which represents a decrease from the 795 civil actions initiated in FY 2018.
• 2,640 individuals and entities excluded from participating in federal healthcare programs, which represents a slight decrease from the 2,712 exclusions in FY 2018. Of these, 45% were based on criminal convictions relating to Medicare and Medicaid, 12% were based on criminal convictions relating to other healthcare programs, 9% were based on patient abuse or neglect and 22% were based on state licensure revocations.

Please click here for a copy of the FY 2019 Annual Report. A copy of the FY 2018 Annual Report is available here.