The Health Care Fraud and Abuse Control Program (HCFAC) is a joint Department of Justice (DOJ) and Department of Health and Human Services (HHS) program created to combine the efforts of the two agencies to reduce fraud in healthcare. The program was founded in 1996 and coordinates federal, state, and local law enforcement in regards to healthcare fraud and abuse. In April, the HCFAC released its annual performance report for 2017.
In 2017, the program won or negotiated $2.4 billion in healthcare fraud judgements and settlements. In total, $2.6 billion was returned to the Federal Government or private parties. Of those $2.6 billion, $1.4 billion went to Medicare trust funds, with $406.7 million being transferred back to the Medicaid program.
In FY 2017 there was a total of 967 new criminal healthcare fraud investigations opened. Of those 967, federal prosecutors filed criminal charges in 439 cases. Their expected ‘return on investment’ over the last three years has been $4.20 for every dollar spent.
As a part of the program, there have been multiple initiatives implemented at CMS to prevent and reduce fraud, such as the National Correct Coding Initiative (NCCI). The NCCI is a set of 12 automated edits designed to reduce fraud in Medicare Part B. The two components of this are Procedure-to-Procedure (PTP) edits, and Medically Unlikely Edits (MUE). PTP edits prevent payment for billing code pairs that should not be reported together, and MUEs prevent payment for an inappropriate quantity of the same service on the same day. According to the report, PTPs and MUEs saved Medicare $186.9 million and $359.8 million, respectively.
As always, ADVOCATE will keep you up to date on this and all issues impacting radiology as they become available.
Kirk Reinitz, CPA