October 18, 2012

Report: Subjects of Healthcare Fraud investigation topped 10,000 in 2010

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WASHINGTON, D.C. – The number of individuals and organizations investigated for healthcare fraud topped 10,000 in 2010, according to recently released data compiled by the U.S. Department of Health and Human Services Office of the Inspector General and the U.S. Department of Justice.

To be precise, 10,187 subjects that year were investigated for fraud in Medicare, Medicaid and/or the Children’s Health Insurance Program, better known as CHIP. The subjects of investigations included various types of providers and suppliers such as physicians, hospitals, durable medical equipment suppliers, home health agencies and pharmacies, authorities said.

The aforementioned data was separated into criminal and civil cases – for the former, medical facilities such as clinics or practices were the most frequently investigated subjects, while for the latter, hospitals and medical facilities were the most frequently investigated.

Criminal cases outnumbered civil cases in 2010 by more than a three-to-one ratio, the report indicated. Of 7,848 criminal cases, about 40 percent targeted medical facilities or durable medical equipment suppliers, a figure similar to that recorded in 2005. And of the 2010 criminal cases, 85 percent were not referred to the Department of Justice for prosecution (of those cases that were pursued for prosecution, officials said, most yielded guilty verdicts, guilty pleas or pleas of no contest).

Of 2,339 civil cases, more than one-third targeted medical facilities or hospitals, and quantitatively, that figure was up about 35 percent from 2005, the report indicated. Nearly half of the 2010 civil cases were pursued for prosecution, and about 55 percent resulted in judgments or settlements.

In all, 2010 saw about 2,200 subjects excluded from participation in federal healthcare programs due to fraud convictions or other reasons such as license revocation, officials said. A whopping 60 percent of those subjects were in the nursing profession, a figure dwarfing the next-most affected provider type (pharmacies and individuals, at 7 percent). 

Data collected from 10 state Medicaid Fraud Control Units (MCFUs) also indicated that more than 40 percent of subjects investigated for healthcare fraud in Medicaid and CHIP were home healthcare providers or healthcare practitioners. Civil fraud cases pursued by those MFCUs in 2010 resulted in judgments and settlements totaling nearly $829 million, of which $509 million, or nearly 60 percent, affected pharmaceutical manufacturers.

The recent report was merely the latest in a long line of reports detailing the federal government’s efforts to combat fraud, waste and abuse in healthcare. The U.S. Government Accountability Office has designated both Medicare and Medicaid as “high-risk” programs in part because their size and complexity make them vulnerable to fraud.

Investigations into suspected healthcare fraud and related activities are joint efforts conducted by the Department of Health, the Department of Justice and the 93 U.S. Attorney’s Offices nationwide. MFCUs investigate fraud in states’ Medicaid and CHIP programs.

In the 2011 fiscal year the federal government spent a little more than $600 million on such functions, officials said.

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Mark Spivey is a national correspondent for www.racmonitor.com and www.ICD10monitor.com.

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Mark Spivey

Mark Spivey is a national correspondent for RACmonitor and ICD10monitor who has been editing and writing reports for the websites for eight years.

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