Print Friendly VersionHealthcare Fraud Fact Sheet
- Healthcare fraud is occurring nationwide, from schemes such as large-scale Medicare over-billing to a family doctor billing an insurance company for a lab test not done. It has even led to unnecessary heart surgery.
- Peter Keisler, who oversees the Justice Department's civil-fraud unit, said that "the most frequent defendant in fraud cases today is in health care" and that the industry now accounts for "the lion's share of fraud, both in number of cases and dollar amounts -- and those numbers are going up." (Wall Street Journal, June 7, 2005)
- The OIG continues to be an aggressive force within the Department of Health and Human Services to improve the efficiency of the Department and to punish those who defraud its programs. On June 13, 2005, the Office of Inspector General reported savings and expected recoveries of nearly $17 billion. Compare that to the year 2000, when savings and recoveries totaled $1.2 billion—an incredible increase in just five years where savings and recoveries have experienced an increase of over 1400%.
- The total number of investigations conducted has increased a much slower rate between 2000 and 2005. With 1,695 exclusions, 258 criminal actions, and 105 civil actions to date in 2005, the anticipated total number of investigations could reach 4,116. In 2000 the reported total was 4,050. That’s an increase of just 1.6%.
- The government has recognized the need to address and eliminate the existence of healthcare fraud for decades. But it wasn’t until 1993 that Attorney General Janet Reno named healthcare fraud as the second major new initiative of the Department of Justice, second only to violent crime.
- Medicare and/or Medicaid generates between 40% and 60% of a healthcare organization’s revenue. When a healthcare provider defrauds Medicare, it can signal the demise of that organization.
- In November 2004, changes to the Federal Sentencing Guidelines took effect that significantly impact profit and non-profit organizations in all industries. Such changes included heightened leadership accountability, mandatory compliance policies and procedures, improved communication between the compliance officer and upper management and boards of directors, required compliance training at all levels, periodic risk assessments, and ongoing monitoring to name a few. Healthcare organizations must be proactive to review their compliance programs.
