According to the Department of Health and Human Services (HHS) and the Department of Justice (DOJ) Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year (FY) 2022, civil healthcare fraud settlements and judgments under the False Claims Act exceeded $1.6 billion, in addition to other healthcare administrative impositions won or negotiated by the federal government.
The report says that in FY 2022 the DOJ opened 809 new criminal healthcare fraud investigations. Federal prosecutors filed criminal charges in over 419 cases involving at least 680 defendants, and more than 477 defendants were convicted of healthcare fraud related crimes during the year. The DOJ also opened more than 774 new civil healthcare fraud investigations and had over 1,288 civil healthcare fraud matters pending at the end of the fiscal year.
Investigations conducted by HHS’s Office of Inspector General (HHS-OIG) during this time period resulted in 661 criminal actions against individuals or entities that engaged in crimes related to Medicare and Medicaid, and 726 civil actions, which include false claims, unjust-enrichment lawsuits filed in federal district court, and civil monetary penalty (CMP) settlements. HHS-OIG also excluded 2,332 individuals and entities from participation in Medicare, Medicaid, and other federal healthcare programs. Among these were exclusions based on criminal convictions for crimes related to Medicare and Medicaid (983) or to other healthcare programs (433), for beneficiary abuse or neglect (305), and as a result of state healthcare licensure revocations (372).
In FY 2022, the Federal Bureau of Investigation (FBI) opened 625 new healthcare fraud investigations. 3,103 investigations were pending at the end of FY 2022. Investigative efforts throughout the fiscal year produced 495 criminal healthcare fraud convictions, 389 indictments, and 190 informations. In addition, investigative efforts resulted in over 499 operational disruptions of criminal fraud organizations and the dismantlement of more than 132 healthcare fraud criminal enterprises.
Compliance Perspective
Issue
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) established a national Health Care Fraud and Abuse Control Program (HCFAC or the Program) under the joint direction of the Attorney General and the Secretary of HHS, acting through the Inspector General, designed to coordinate federal, state, and local law enforcement activities with respect to healthcare fraud and abuse. In its 26th year of operation, the Program uses a collaborative approach to identify and prosecute the most egregious instances of healthcare fraud, prevent future fraud and abuse, and protect program beneficiaries. Skilled nursing facilities are required to have an effective compliance and ethics program that is effective in preventing and detecting criminal, civil, and administrative violations to reduce the likelihood of fraud, waste, and abuse of government funds.
Discussion Points
- Review your policies and procedures for operating an effective compliance and ethics program. Ensure that your policies are reviewed at least annually and updated when new information becomes available.
- Train all staff on your compliance and ethics policies and procedures upon hire and at least annually. Ensure that they understand that an effective compliance and ethics program is everyone’s responsibility. Document that these trainings occurred and file the signed document in each employee’s education file.
- Periodically perform audits to ensure that all staff are aware of compliance and ethics policies and guidelines and understand their responsibility to report any concerns to their supervisor, the compliance and ethics officer, or via the anonymous hotline. Provide the audit information and any necessary action steps to the compliance and ethics committee and the governing body.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
