On February 11, 2013, the 2012 fiscal year (FY) end report was released for The Health Care Fraud and Abuse Control Program (HCFAC). Jointly established by the U.S. Department of Health and Human Services (HHS) and the Department of Justice (DOJ) under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the goal of HCFAC is to coordinate the prevention and prosecution of healthcare fraud and abuse.  The report states that a record $4.2 billion in taxpayer dollars were recovered in FY 2012 and returned to the Centers for Medicare and Medicaid Services (CMS), the U.S. Treasury, and other healthcare administration programs, among others.¹

HCFAC’s accomplishments in 2012 include 1,131 new criminal and 885 new civil healthcare fraud investigations, and convicting 826 defendants of healthcare related crimes.  Additionally, over 83 criminal enterprises found to have engaged in healthcare fraud were successfully dismantled by the Federal Bureau of Investigations, and 3,131 entities were excluded from participating in the Medicare and Medicaid program as a result of certain violations.²  Over $3 billion of the $4.2 billion recovered in 2012 was negotiated from civil settlements and judgments related to False Claims Act (FCA) violations.³

In FY 2012, over $600 million in federal funds were allotted to support the HCFAC Program.⁴  Despite the significant expenditure, the Return on Investment (ROI) of HCFAC for the past three years (2010-2012) is estimated at $7.90 for every $1.00 of the program’s expenditure, which far outstrips the ROI since the program’s inception ($5.40 for every $1.00 spent in 1996).⁵ 

The recent success of the program can largely be attributed to the Health Care Fraud Prevention and

Enforcement Action Team (HEAT), established in May 2009 in a joint effort by HHS and DOJ to crack down on Medicare and Medicaid waste, fraud, and abuse; reduce healthcare costs; and, highlight best practices to improve quality of care.⁶ 

Tools utilizing HCFAC to assist in combating fraud include continuing training efforts; enhanced screenings and enrollment requirements; increased transparency and data sharing; and, increased oversight and recovery efforts.  As a result of the increased attention and resources provided to support HEAT and similar initiatives, $14.9 billion has been recovered from 2008 to 2012, over half of the $23 billion recovered since the inception of HCFAC in 1996.⁷  Given the federal governments increased focus on combating fraud and abuse, and eliminating waste in the healthcare delivery system, it is likely that HCFAC will continue the trend of increasing recoveries and activities in 2013.