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The Department of Health and Human Services (HHS) and the Department of Justice (DOJ) recently released its “Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2022” (the “Report”), highlighting continued enforcement and recovery actions under the Health Care Fraud and Abuse Control Program (HCFAC). During fiscal year 2022 (FY 2022), over $1.7 billion was returned through HCFAC’s enforcement actions.

HCFAC uses advanced data analytics to monitor and target high-risk public and private healthcare programs, providers, and trends to identify HHS’s most significant risk areas and to better target fraud, abuse, and waste. The FY 2022 report highlighted a number of key enforcement initiatives including telemedicine fraud and exploitation, unnecessary COVID-19 testing and services along with fraudulently obtained COVID-19 relief funds, and opioid and prescription drug abuse. We believe that HCFAC will continue to focus on these key priority enforcement areas in the coming years.

Enforcement Highlights for FY 2022

In FY 2022, the DOJ opened more than 809 new criminal healthcare fraud investigations and more than 774 new civil healthcare fraud investigations. HHS-OIG conducted investigations resulting in 661 criminal actions against individuals related to Medicare and Medicaid, as well as 726 civil actions, including false claims, unjust-enrichment lawsuits, and civil monetary penalty settlements.

Major Accomplishments for FY 2022

While the Report outlined major civil and criminal enforcement actions across a broad range of healthcare practices and fields, the most significant actions related to:

  • COVID-19 diagnostic testing;
  • durable medical equipment;
  • genetic testing;
  • home health providers;
  • hospice care;
  • laboratory testing;
  • managed care;
  • prescription drugs and opioids;
  • substance use treatment centers; and
  • telemedicine.

In FY 2022, criminal charges were brought against 21 defendants for their alleged activities exploiting COVID-19 programs. Additionally, criminal charges were brought against 14 defendants for their alleged involvement in unlawful opioid distribution.

Future Enforcement Areas

HHS-OIG noted that HCFAC will continue to focus on these major enforcement initiatives:

  • Medicare and Medicaid fraud, waste, and abuse, including in priority areas such as protecting beneficiaries from prescription drug abuse, including opioid abuse.
  • Enhancing program integrity in noninstitutional care settings, such as home health and hospice care.
  • Strengthening Medicaid program integrity, including working with state partners to enhance the effectiveness of the MFCUs.
  • Strengthening oversight of nursing homes, Medicare Advantage managed care plans, Medicaid managed care programs, value-based models, Medicare hospital payments efficiency, telehealth and other remote care expansion, and cybersecurity.
  • Using Strike Force teams, particularly NRRSF, to conduct major enforcement actions, particularly to address fast-developing healthcare fraud and abuse issues.
  • Continuing to engage with partners like the Federal Bureau of Investigation to target large-scale criminal enterprises; corporate-level fraud, waste, and abuse; and public safety and patient harm matters, to include those arising from the ongoing prescription opioid abuse epidemic.
  • COVID-19 fraud, waste and abuse such as additional, unnecessary services, unnecessary laboratory testing, healthcare technology schemes, and fraudulently obtained COVID-19 healthcare relief funds.

Looking Ahead

While this year’s recoveries are lower compared to prior years, over the last three years HCFAC has returned $2.90 for every $1.00 expended. As we blogged about previously, the DOJ plans to increase its number of prosecutors specializing in healthcare fraud. Given the continued success of HCFAC’s enforcement actions along with plans to increase prosecutors, we expect seeing continued enforcement targeting healthcare fraud and abuse in the coming year.