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Source: Policy and Medicine
Recently, the Annual Report of the Departments of Health and Human Services and Justice was released, highlighting health care fraud and abuse control for fiscal year (FY) 2020. According to the report, the Department of Justice (DOJ) recouped almost $2 billion ($1.8 billion) in connection with healthcare fraud allegations. As a result of those efforts and efforts from preceding years, nearly $3.1 billion was returned to the Federal Government and private individuals.
Since the start of the COVID-19 public health emergency in March 2020, the Centers for Medicare and Medicaid Services (CMS), the United States Department of Health and Human Services Office of Inspector General (HHS OIG), and other law enforcement agencies worked together to investigate and prosecute healthcare fraud from select risk areas, including unnecessary laboratory testing related to COVID-19, genetic sequencing, and cardiac panels.
DOJ Investigations
In FY 2020, the DOJ opened 1,148 new criminal health care fraud investigations and federal prosecutors filed criminal charges in 412 cases involving 679 defendants. A total of 440 defendants were convicted of health care fraud related crimes during the year. DOJ also opened 1,079 new civil health care fraud investigations and had 1,498 civil health care fraud matters pending at the end of the fiscal year.
Since March 2020, United States Attorneys Offices have been actively pursuing pandemic-related fraud, including using civil injunctions to shut down fraudsters peddling phony cures, prosecuting COVID-19-related scams, investigating failure of care at nursing facilities impacted by COVID-19, and investigating False Claims Act matters alleging fraud on Medicare and Medicaid related to the pandemic or stimulus health care funding.
The report cited the following as some examples of notable fraud cases:
- The Medicine Shoppe/Advantage Pharmacy investigations, in which four Districts coordinated a large investigation of compounded drug fraud, resulting in 40 convictions to date
- The Practice Fusion EHR case, which resulted in a $145.0 million payment to resolve criminal and civil liability. The investigation arose from evidence discovered by a USAO and is the first case involving kickbacks paid by a pharmaceutical manufacturer to an EHR company and
- Several large pharmaceutical pricing cases brought under the FCA and AKS based on allegations of price-fixing and market allocation in the generic pharmaceutical industry.