DOJ Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2011 August 16 2013
DOJ Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2011 DOJ Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2011 DOJ Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2011

HHS and DOJ Annual Report 2011 About the Fraud and Abuse Program

In February of this year, Health and Human Services and the Department of Justice released the Annual Report for the Health Care Fraud and Abuse Control Program for year 2011.


Some notable highlights from the Report:
  • During Fiscal Year (FY) 2011, the Federal government won or negotiated approximately $2.4 billion in health care fraud judgments and settlements.
  • In FY 2011
    • the DOJ opened 1,110 new criminal health care fraud investigations involving 2,561 potential defendants
    • Federal prosecutors had 1,873 health care fraud criminal investigations pending, involving 3,118 potential defendants, and filed criminal charges in 489 cases involving 1,430 defendants.
    • 743 defendants were convicted of health care fraud-related crimes during the year
    • the DOJ opened 977 new civil health care fraud investigations and had 1,069 civil health care fraud matters pending at the end of the fiscal year
    • the FBI's heath care fraud investigations resulted in the operational disruption of 238 criminal fraud organizations, and the dismantlement of the criminal hierarchy of more than 67 criminal enterprises engaged in health care fraud
    • HHS’ Office of Inspector General (HHS/OIG) excluded 2,662 individuals and entities

Where do these enforcement powers come from?


The Social Security Act Section 1128C(a), as established by the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191, HIPAA), created the Health Care Fraud and Abuse Control Program, a far-reaching program to combat fraud and abuse in health care, including both public and private health plans.

As was the case before HIPAA, amounts paid to Medicare in restitution or for compensatory damages must be deposited in the Medicare Trust Funds. HIPAA requires that an amount equaling recoveries from health care investigations – including criminal fines, forfeitures, civil settlements and judgments, and administrative penalties – also be deposited in the Trust Funds. All funds deposited in the Trust Funds as a result of HIPAA are available for the operations of the Trust Funds.

HIPAA appropriates monies from the Medicare Hospital Insurance Trust Fund to an expenditure account, called the Health Care Fraud and Abuse Control Account (the Account), in amounts that the Secretary and Attorney General jointly certify as necessary to finance anti-fraud activities. The maximum amounts available for certification are specified in HIPAA. Certain of these sums are to be used only for activities of the HHS/OIG, with respect to the Medicare and Medicaid programs. In FY 2006, the Tax Relief and Health Care Act (TRHCA) (P.L 109-432, §303) amended the Act so that funds allotted from the Account are ―available until expended. TRHCA also allowed for yearly increases to the Account based on the change in the consumer price index for all urban consumers (all items; United States city average) (CPI-U) over the previous fiscal year for fiscal years for 2007 through 2010. In FY 2010, the Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act, collectively referred to as the Affordable Care Act (P.L. 111-148, ACA) extended permanently the yearly increases to the Account based upon the change in the consumer price index for all urban consumers or CPI-U.

In FY 2011, the Secretary and the Attorney General certified $297.7 million in mandatory funding for appropriation to the Account. Additionally, Congress appropriated $310.4 million in discretionary funding. HCFAC appropriations generally supplement the direct appropriations of HHS and DOJ that are devoted to health care fraud enforcement and funded approximately three-fourths of HHS/OIG’s appropriated budget in FY 2011. (Separately, the FBI received $128.4 million from HIPAA.)

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