Healthcare fraud recoveries reach $5.6B in 2016

The Department of Health and Human Services Office of Inspector General expects healthcare fraud and abuse recoveries to reach more than $5.6 billion in fiscal year 2016.

Federal regulators expect healthcare fraud recoveries to reach more than $5.6 billion in fiscal year 2016—dwarfing last year’s total of $3.25 billion.

This year’s figure includes nearly $1.2 billion in audit receivables and $4.46 billion in investigative receivables, according to Department of Health and Human Services Office of Inspector General’s semiannual report (PDF) to Congress. The agency's previous report said recoveries were on pace to exceed $5 billion in 2016.

The report also highlights an ongoing trend in which the agency’s civil actions are eclipsing criminal ones. Civil actions totaled 708 this year compared to 682 in FY 2015, while criminal actions totaled 844 this year in 2016 compared to 925 last year.

Civil monetary penalty recoveries also have increased almost five-fold over the past three years, the report notes. Given that federal authorities are planning to double the civil penalties for False Claims Act violations, that trend is likely to continue.

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Here are some other highlights from the report:

  • The OIG reported the exclusion of 3,635 individuals and entities from participation in federal healthcare programs in FY 2016.
  • Health Care Fraud Strike Force teams’ efforts resulted in 207 criminal actions and $321 million in investigative receivables. That includes a massive fraud takedown that resulted in criminal and civil charges against 301 individuals.
  • The OIG notes that it will "continue to conduct investigations and reviews to address the ongoing problems created by opioid abuse and the emerging problems linked to compounded drugs.” A report from the agency in June found that recent spikes in spending on compounded drugs and commonly abused opioids contributed to a 167 percent rise in Medicare Part D spending over the past decade.
  • Noting the agency’s work to combat false billings and improper payments within federal healthcare programs, the OIG points to a report from earlier this year that found Medicare improperly paid millions of dollars for “unlawfully present” beneficiaries in 2013 and 2014.

Additionally, the report details the agency’s efforts to conduct oversight of HHS grants, encourage provider enrollment safeguards and oversight, and ensure that providers offer HHS beneficiaries adequate quality care in the appropriate setting.