Two Federal Agencies Announced War on Health Insurance Fraud

Ernie Shannon's picture

Federal officials released a report today claiming to have recovered more than $4 billion during health insurance fraud prevention efforts in 2011. Attorney General Eric Holder and Health and Human Services Secretary Kathleen Sebelius jointly announced the news during a morning conference in Washington and credited an organization called the Health Care Fraud Prevention and Enforcement Action Team (HEAT) for the achievement.

“This report reflects unprecedented successes by the Departments of Justice and Health and Human Services in aggressively preventing and combating health care fraud, safeguarding precious taxpayer dollars and ensuring the strength of our essential health care programs,” said Holder.

With nearly $1 trillion expected to be spent on health care by the federal government during the next ten years, the potential for health insurance fraud in a program that size is rampant. Critics have suggested that it will be next to impossible to properly police expenditures at that level.


In response, Sebelius said, “Fighting fraud is one of our top priorities and we have recovered an unprecedented number of taxpayer dollars. Our efforts strengthen the integrity of our health care programs and meet the president’s call for a return to American values that ensure everyone gets a fair shot, everyone does their fair share, and everyone plays by the same rules.”

To assure the fairness Sebelius mentioned, the government is deploying “strike force” teams in various cities around the country. As of today, nine cities have the teams that use advanced data analysis techniques to identify high billing levels in health insurance fraud hot spots so that interagency teams can target emerging or migrating schemes along with chronic fraud by criminals masquerading as health care providers or suppliers. The thought of strike force teams joining federal prosecutors and others combing financial data causes concern among civil libertarians. They fear a further retrenching of civil liberties already at risk from some provisions of the Affordable Care Act. However, administration officials say the aggressive effort to nab health care fraud criminals is critical.

In FY 2011, strike force operations charged a record number of 323 defendants who allegedly collectively billed the Medicare program more than $1 billion. Strike force teams secured 172 guilty pleas, convicted 26 defendants at trial and sentenced 175 defendants to prison. The average prison sentence in strike force cases was more than 47 months.

The fraud prevention and enforcement report announced today coincides with the announcement of a proposed rule from the Centers for Medicare and Medicaid Services aimed at collecting overpayments in the Medicare program. Thanks to the Affordable Care Act, the two agency chieftains said, there will be a specific timeframe by which self-identified overpayments must be reported and returned.