Consumer Fraud

Fight against health care fraud gains momentum, recovers billions for Medicare

osha whistle Fight against health care fraud gains momentum, recovers billions for MedicareFor every one dollar the U.S. government spent on investigating health care-related fraud and abuse in the last three years, it recovered more than $8.00, the U.S. Justice Department said in a statement about its annual Health Care Fraud and Abuse Control (HCFAC) program report.

According to U.S. officials, the return of $8.10 for every $1 spent cracking down on health care fraud marks the highest three-year average in the HCFAC program’s 17-year history. Thanks to stepped-up measures in combatting fraud directed against Medicare, Medicaid, and other taxpayer-funded health care programs, the federal government was able to recover a record $4.3 billion in fiscal year 2013 – up from a $4.2 billion recovery in 2012.

These efforts have resulted in $19.2 billion in recoveries from individuals and companies in the last five years – an increase of nearly 50 percent over the previous five-year period in which $9.4 billion was recovered. The HCFAC program has recovered $26 billion to Medicare and the U.S. treasury since it was launched in 1997.

“With these extraordinary recoveries, and the record-high rate of return on investment we’ve achieved on our comprehensive health care fraud enforcement efforts, we’re sending a strong message to those who would take advantage of their fellow citizens, target vulnerable populations, and commit fraud on federal health care programs,” Attorney General Eric Holder said in a statement.

The steady rise of government health care funds recovered in recent years can be attributed in part to the Health Care Fraud Prevention and Enforcement Action Team (HEAT), an agency launched in 2009 as a joint effort between the Justice Department and the Department of Health and Human Services.

HEAT currently operates Medicare Fraud Strike Force teams in nine areas of the U.S. whose sole purpose is to pinpoint and investigate sources of health care fraud through the use of advanced data analysis techniques. The technology employed by the Strike Force allows U.S. officials to identify emerging and migrating fraud schemes as well as target “chronic fraud by criminals masquerading as health care providers or suppliers.”

Another powerful weapon in the fight against health care fraud is the federal False Claims Act (FCA), which gives individuals in the private sector the power to sue on behalf of the U.S. government when they have knowledge and evidence of fraud committed against taxpayer-funded agencies and programs.

The FCA’s qui tam, or “whistleblower” provisions help employees become the eyes and ears of the federal government inside pharmaceutical companies, hospitals, clinics, and other establishments where health care fraud frequently occurs. Whistleblowers whose FCA lawsuits result in a judgment for the U.S. or settlement receive up to 30 percent of the recovery.


U.S. Department of Justice