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What You Need to Know From the 2014 HCFAC Report: Top 5 Statistics

Posted By: Bret S. Bissey, MBA, FACHE, CHC, CMPE / April 13, 2015

5 takeaways-hcfac report 2014-meditractOn March 19, 2015 the Departments of Justice (DOJ) and Health and Human Services (HHS) released their annual “Health Care Fraud and Abuse Control Program (HCFAC) Report” for 2014. This report summarizes the results of the HCFAC Programs efforts to protect the financial viability of the Medicare Trust Fund. These efforts include a far-reaching program to combat fraud and abuse in healthcare, including both public and private health plans. This information is produced annually and should be utilized by healthcare providers to reinforce the importance of their compliance efforts.

One of the biggest changes indicated in this report is how the governments’ strategy in these initiatives is shifting. They are now focused on proactively preventing fraud and abuse and investigating cases through data analytics. This is a change from the historical practice of long audits and investigations focused on finding existing problems. The government believes these new initiatives will “… result in significantly shorter periods of time between fraud identification, arrest and prosecution.”

Top five statistics from the report:

  1. $3.3 billion was recovered in taxpayer dollars from individuals and companies attempting to defraud federal healthcare programs.
  2. $7.70 for every dollar invested in healthcare related fraud and abuse investigations in the last three years was recovered –an impressive return on investment that indicates these initiatives will continue.
  3. 4,017 individuals and entities were excluded from participation in Medicare, Medicaid and other federal healthcare programs.
  4. 1,197 defendants were sentenced to prison for an average term of 47 months and the DOJ opened 924 new criminal healthcare fraud investigations.
  5. $2.3 billion in settlements and judgments were obtained by the DOJ Civil Division and U.S. Attorney’s offices from civil cases involving federal healthcare programs, bringing to the total sum to 15.2 billion since 2009.

Take home message from the DOJ:

Audits, investigations, fines, penalties, sanctions and other consequences for non-compliant actions will continue to occur as the DOJ and HHS seeks to curb abuse and fraud. It is critical for healthcare organizations to continue to operate an effective compliance program. Make sure your hospital board and leadership continues to allocate the appropriate resources for staff, technology and audits needed for your compliance programs to operate effectively. As the compliance environment continues to change and healthcare organizations face increased scrutiny, compliance program must be viewed as an important investment and not just the cost of doing business.

Bret S. Bissey, MBA, FACHE, CHC, CMPE

Prior to joining MediTract, Mr. Bissey was the SVP, chief ethics and compliance officer at UMDNJ, where he successfully led the compliance program to adherence with a rigorous five-year Corporate Integrity Agreement with the DHHS/OIG that occurred following a Deferred Prosecution Agreement. Prior to UMDNJ, Bissey served as the director of the Regulatory Compliance Practice at IMA Consulting, the chief compliance and privacy officer at Deborah Heart and Lung Center (operating under a CIA) and the VP of compliance at Cabot Marsh/QuadraMed. Mr. Bissey earned a Bachelor of Science in business administration and marketing from Shippensburg University of Pennsylvania and an MBA in marketing and healthcare administration from Wilkes University. Mr. Bissey is a frequent national speaker on healthcare compliance and is the author of The Compliance Officer’s Handbook. He is a Fellow of the American College of Healthcare Executives and a member of the Health Care Compliance Association (CHC), American College of Medical Practice Executives and the Healthcare Financial Management Association.