Healthcare Business News

GAO outlines targets, costs of anti-fraud efforts

By Rich Daly
Posted: October 9, 2012 - 5:30 pm ET

Medical facilities—such as medical centers, clinics and medical practices—were the category of healthcare provider most likely to face fraud-related criminal investigations in 2010, according to a report that aims to help direct future anti-fraud efforts.

Medical facilities were the subjects of nearly 25% of the 7,848 federal criminal fraud cases in 2010, according to a Government Accountability Office report (PDF) issued Tuesday. And durable medical equipment suppliers comprised about 16% of such cases. Those same categories of healthcare companies comprised a nearly identical combined percentage of criminal cases in 2005.

Meanwhile, hospitals—which received 41% of federal healthcare spending in 2010—were the subject of less than 5% of criminal fraud cases, according to the GAO report.

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However, hospitals were the most frequent subjects of federal civil fraud cases in 2010, comprising about 20% of such cases. About 18% of such cases involved separate medical facilities.

Meanwhile, home healthcare providers and healthcare practitioners accounted for over 40% of the 2,742 subjects investigated for healthcare fraud among reviewed cases in Medicaid and the Children's Health Insurance Program in 2010, according to GAO's analysis of data from 10 state Medicaid fraud units.

Nationally, state Medicaid anti-fraud efforts resulted in nearly $829 million in judgments and settlements in 2010 with pharmaceutical manufacturers paying more than 60%, or $509 million, of the total.

The inspector general reported its investigations in 2010 resulted nearly $960 million in fines or restitution.

Meanwhile, the federal government spent at least $608 million fighting fraud in Medicare and Medicaid in that timeframe and states spent an unknown additional on antifraud efforts in their Medicaid programs.

The study found that the HHS inspector general opened about 8,900 cases in 2010, or nearly 2,800 more cases than in 2005, while the 94 U.S. attorney's offices the Justice Department case load was “approximately the same” in both years.

HHS' inspector general also excluded nearly 2,200 people from future participation in Medicare, of whom about 60% were nurses.

One of the requestors, Sen. Tom Harkin (D-Iowa), chairman of the Health, Education, Labor and Pensions Committee, said in a written statement that that report highlights the “excellent work” of investigators fighting federal health care fraud.

“Their findings also demonstrate the continued importance of investing in fraud detection, prevention and prosecution,” he said. “These investments provide a significant return, protecting taxpayer dollars, weeding out bad actors, and improving quality of care for beneficiaries.”

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