DoJ combating health care fraud

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The U.S. Department of Justice (DoJ) continues its efforts to combat health care fraud and other criminal acts against the health care system by strengthening its overall enforcement.

Working closely with the Department of Health and Human Services, the DoJ has guided the enforcement efforts of the national Health Care Fraud and Abuse Control Program (HCFAC) since its inception in 1997. This program was designed to coordinate federal, state and local law enforcement on cases of health care fraud and abuse as part of the Health Insurance Portability and Accountability Act (HIPAA).

According to a fact sheet released by the Department on May 28, last fiscal year claimed the following accomplishments:
  • U.S. Attorneys' Offices opened 878 new criminal health care fraud investigations involving 1,548 potential defendants.
  • Federal prosecutors had 1,612 health care fraud criminal investigations pending, involving 2,603 potential defendants, and filed criminal charges in 434 cases involving 786 defendants.
  • A total of 560 defendants were convicted for health care fraud-related crimes during the year.

The department also highlighted its efforts to combat fraud involving a wide spectrum of health care providers and suppliers including doctors, dentists, hospitals, pharmacies, durable medical equipment providers, home health providers, and pharmaceutical and device manufacturers under the False Claims Acts. This included claims settlements against businesses such as Merck & Company, CVS, and Medtronic.

Don Jackson, director of threat intelligence at SecureWorks, told on Thursday that he thinks that the DoJ is doing a good job overall at catching those who commit fraud against the health care system, but he is concerned that the department's focus was and will likely remain on large, high-profile cases.

“A lot of smaller cases will never see the light of day, even though that's where the biggest problem lies,” Jackson said. “These are the cases that are dealing with individual access and are siphoning off one record.”

Health care breaches and the related crimes are increasing faster than any other type of identity theft crimes, Jackson added.

“Health care is a huge complicated network to begin with,” he said, “and technology enables the opportunities for more access and more opportunities for fraud.”

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