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  4.  → Government and health-care fraud, Part 1: Why the crackdown?

Government and health-care fraud, Part 1: Why the crackdown?

The United States Government, along with state governments, have made it clear that they plan to crackdown on health-care fraud. The reasons behind this focus were recently discussed in two reports.

The first report, “Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2017” explained that the government recovered over $2 billion from those who attempted to defraud the federal government. The second, “Investigating and Combating Health Insurance Fraud,” explained that the $2 billion in recouped assets was only a drop in the bucket. The authors behind this report estimate the government losses tens of billions of dollars due to health care fraud on an annual basis.

With these numbers in mind it is no surprise that the government is focusing efforts on these crimes. In an effort to address this trend, we will provide two posts that review these recent reports. This first piece will discuss the types of health care fraud cases the government is pursuing and some statistics. The second will be a follow-up piece that will delve into the tools used to investigate allegations of this type of criminal activity as well as how physicians and other medical professionals can protect themselves against allegations.

What types of health-care fraud allegations does the government commonly pursue? The government often pursues the following:

  • Fraudulent billing
  • Illegal kickbacks
  • Misuse of prescription drugs
  • Performance of medically unnecessary treatments

These allegations are often pursued by the Health Care Fraud Prevention and Enforcement Action Team (HEAT). The agency is a collaborative effort that includes enforcement agents, prosecutors and other DOJ staff to investigate and prosecute against health-care crimes.


What are the statistics for these crimes? The DOJ reported 967 new criminal health-care fraud investigations in 2017. These investigations led to the conviction of 639 individuals.

The DOJ also reports 948 civil health-care fraud investigations in 2016.

It is important to note physicians are not the only professionals at risk of becoming the subject of these allegations. The report also notes the government conducted investigations on ambulatory service providers, dental practices, drug companies and nursing homes.