The fight against health care fraud, waste, and abuse is a critical undertaking to protect both consumers and taxpayer dollars. Spearheading this battle in the United States is the Health Care Fraud and Abuse Control (HCFAC) Program. But who exactly created this pivotal program and what impact has it had since its inception?
The Health Care Fraud and Abuse Control Program was not created by a single individual, but rather established through legislative action. It was mandated by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This landmark legislation, signed into law by President Bill Clinton, addressed various aspects of healthcare, and Title II of HIPAA specifically focused on preventing health care fraud and abuse. Therefore, in essence, the U.S. Congress created the Health Care Fraud and Abuse Control Program through HIPAA.
HIPAA called for the establishment of a comprehensive program to coordinate federal, state, and local law enforcement activities to combat healthcare fraud and abuse. It allocated dedicated funding for these efforts through the Health Care Fraud and Abuse Control Account. This account is fueled by civil and criminal fines, penalties, and administrative recoveries in health care fraud cases, ensuring a sustained financial commitment to fighting fraud.
Key Federal Agencies at the Helm of the HCFAC Program
While Congress legislated the HCFAC Program into existence, its operational execution and ongoing development are driven by a collaborative effort of several key federal agencies. These agencies work in concert to detect, prevent, and prosecute health care fraud across the nation. The primary agencies involved include:
- The Department of Health and Human Services (HHS): As the cabinet-level department overseeing most of the government’s health and human services programs, HHS plays a central role. Within HHS, the Office of Inspector General (OIG) is particularly critical. HHS-OIG is responsible for protecting the integrity of HHS programs, including Medicare and Medicaid, by detecting and preventing fraud, waste, and abuse. The OIG conducts audits, evaluations, and investigations to ensure accountability and efficiency.
- The Department of Justice (DOJ): The DOJ is the law enforcement arm of the federal government and is essential for prosecuting health care fraud cases. The DOJ works closely with HHS-OIG and other agencies to bring criminal and civil actions against individuals and entities engaged in fraudulent activities. Their efforts include pursuing cases under the False Claims Act and other relevant statutes.
- The Centers for Medicare & Medicaid Services (CMS): CMS is the agency within HHS responsible for administering Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). As the payer for these massive healthcare programs, CMS is on the front lines of detecting and preventing fraud. CMS implements various program integrity measures, utilizes advanced fraud detection technologies, and collaborates with law enforcement to safeguard taxpayer dollars.
Evolution and Expansion of the HCFAC Program
Since its inception in 1997, the HCFAC Program has continuously evolved to meet the ever-changing landscape of health care fraud. Initially focused on a “pay and chase” approach, reacting to fraud after it occurred, the program has strategically shifted towards proactive fraud prevention. This evolution has been fueled by advancements in technology, enhanced data analytics, and stronger partnerships between the public and private sectors.
A significant milestone in this evolution was the creation of the Health Care Fraud Prevention and Enforcement Action Team (HEAT). Established as a joint initiative between HHS, OIG, and DOJ, HEAT intensifies the fight against health care fraud through coordinated efforts. A key component of HEAT is the Medicare Fraud Strike Force, an interagency team targeting emerging and migrating fraud schemes. The Strike Force brings together analysts, investigators, and prosecutors from OIG and DOJ to dismantle sophisticated fraud operations, including those perpetrated by criminals posing as legitimate healthcare providers.
The Impact and Success of the HCFAC Program
The HCFAC Program has demonstrated remarkable success in combating health care fraud and recovering taxpayer funds. The numbers speak volumes about its effectiveness:
- Financial Recoveries: In Fiscal Year 2016 alone, the government recovered over $3.3 billion in health care fraud cases through judgments, settlements, and administrative actions. Since its inception, the HCFAC Program has returned over $31 billion to the Medicare Trust Funds. Impressively, in FY 2016, the program returned $5.0 for every dollar invested.
- Medicare Fraud Strike Force Impact: Since 2007, the Medicare Fraud Strike Force has charged over 3,018 individuals involved in schemes totaling more than $10.8 billion in fraudulent billings. These actions often involve large-scale national takedowns, disrupting major fraud networks. For instance, a nationwide takedown in June 2016 resulted in charges against 301 individuals, including medical professionals, for approximately $900 million in false billings.
- False Claims Act Utilization: The federal False Claims Act has proven to be a powerful tool, enabling the DOJ to secure over $2.5 billion in settlements and judgments in FY 2016 from civil cases related to fraud against federal health care programs like Medicare and Medicaid.
Technological Advancements and Collaborative Partnerships
The HCFAC Program’s success is also attributed to its embrace of cutting-edge technologies and collaborative partnerships.
- State-of-the-Art Fraud Detection Technology: HHS-OIG continually enhances its data analysis capabilities, employing predictive analytics, trend evaluation, and modeling to identify and target potential fraud. CMS utilizes the Fraud Prevention System (FPS), a sophisticated technology similar to those used by credit card companies, to analyze Medicare fee-for-service claims in real-time and detect suspicious billing patterns before payments are made.
- Enhanced Provider Screening and Enrollment: Recognizing provider enrollment as a critical gateway to Medicare billing, CMS has implemented stricter screening and enrollment requirements. These measures, including site visits and revalidation processes, have led to the deactivation and revocation of over 652,000 enrollment records of ineligible providers since 2011.
- Health Care Fraud Prevention Partnership (HFPP): The Obama Administration initiated the Health Care Fraud Prevention Partnership (HFPP), bringing together private insurers, states, and associations to combat fraud on a national scale. HFPP participants share information and best practices to detect and prevent fraudulent billings. By FY 2016, HFPP membership had grown to 70 organizations, representing over 65 percent of insured individuals in the U.S., demonstrating the power of public-private collaboration.
Ongoing CMS Fraud Prevention Efforts
Beyond the initiatives directly funded by the HCFAC Program, CMS undertakes numerous other program integrity activities. These include:
- Integrated Medicare and Medicaid Efforts: CMS works to integrate fraud prevention efforts across Medicare and Medicaid, providing guidance to states and stakeholders on program integrity.
- Payment Suspension Authority: CMS utilizes the authority granted by the Affordable Care Act to suspend Medicare payments to providers under credible fraud allegations or reliable evidence of overpayments. In FY 2016, there were 508 active payment suspensions, with 291 new suspensions imposed during the year.
- Medicaid/CHIP Financial Management: CMS employs funding specialists to improve financial oversight of Medicaid and CHIP. In FY 2016, these efforts led to the removal of an estimated $608 million in questionable Medicaid costs and averted an estimated $666 million in improper reimbursements through preventive measures.
- Open Payments Program: The Open Payments program promotes transparency by publishing data on financial relationships between the health care industry and healthcare providers. In FY 2016, CMS published data on $7.5 billion in payments and ownership interests, enhancing public awareness and accountability.
Conclusion: A Multi-Faceted Approach to Safeguarding Healthcare
The Health Care Fraud and Abuse Control Program, born from the HIPAA legislation and driven by the collaborative efforts of HHS-OIG, DOJ, CMS, and other agencies, stands as a critical defense against health care fraud. Its evolution from a reactive approach to proactive prevention, coupled with technological innovation and public-private partnerships, has yielded significant results in recovering taxpayer dollars and protecting consumers. While the fight against health care fraud is ongoing, the HCFAC Program remains at the forefront, adapting and innovating to safeguard the integrity of the healthcare system for years to come.
