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United States Government Accountability Office: 
GAO: 

Report to Congressional Requesters: 

September 2013: 

Health Care Fraud and Abuse Control Program: 

Indicators Provide Information on Program Accomplishments, but 
Assessing Program Effectiveness is Difficult: 

GAO-13-746: 

GAO Highlights: 

Highlights of GAO-13-746, a report to congressional requesters. 

Why GAO Did This Study: 

GAO has designated Medicare and Medicaid as high-risk programs partly 
because their size, scope, and complexity make them vulnerable to 
fraud. Congress established the HCFAC program and provided funding to 
HHS and DOJ to help reduce fraud and abuse in Medicare and Medicaid. 

GAO was asked to examine how HHS and DOJ are using funds to achieve 
the goals of the HCFAC program, and to examine performance assessments 
and other metrics that HHS and DOJ use to determine the program’s 
effectiveness. This report (1) describes how HHS and DOJ obligated 
funds for the HCFAC program, (2) examines how HHS and DOJ assess HCFAC 
activities and whether key program outputs have changed over time, and 
(3) examines what is known about the effectiveness of the HCFAC 
program in reducing health care fraud and abuse. 

To describe how HHS and DOJ obligated funds, GAO obtained financial 
information from HHS and DOJ for fiscal year 2012. To examine how HHS 
and DOJ assess HCFAC activities and whether key outputs have changed 
over time, GAO reviewed agency reports and documents, and interviewed 
agency officials. To examine what is known about the effectiveness of 
the HCFAC program, GAO conducted a literature review and interviewed 
experts. 

In comments on a draft of this report, HHS noted examples of CMS’s 
efforts to reduce health care fraud, though these examples were not 
included in the HCFAC return-on-investment calculation. Additionally, 
HHS and DOJ provided technical comments, which GAO incorporated as 
appropriate. 

What GAO Found: 

fiscal year 2012, the Department of Health and Human Services (HHS), 
HHS Office of Inspector General (HHS-OIG), and the Department of 
Justice (DOJ) obligated approximately $583.6 million to fund Health 
Care Fraud and Abuse Control (HCFAC) program activities. About 78 
percent of obligated funds were from mandatory HCFAC appropriations 
(budgetary resources provided in laws other than appropriation acts), 
11 percent of obligated funds were from discretionary HCFAC 
appropriations (budgetary resources provided in appropriation acts), 
and 12 percent were obligated funds from other appropriations that 
HHS, HHS-OIG, and DOJ used to support HCFAC activities. HCFAC funds 
were obligated to support a variety of activities, including 
interagency Medicare Fraud Strike Force Teams-—which provide 
additional investigative and prosecutorial resources in geographic 
areas with high rates of health care fraud—-located in 9 cities 
nationwide. 

HHS, HHS-OIG, and DOJ use several indicators to assess HCFAC 
activities, as well as to inform decision-makers about how to allocate 
resources and prioritize those activities. For example, in addition to 
other indicators, the United States Attorneys’ Offices use indicators 
related to criminal prosecutions, including the number of defendants 
charged and the number of convictions. Additionally, many of the 
indicators that HHS, HHS-OIG, and DOJ use—-such as the dollar amount 
recovered as a result of fraud cases-—reflect the collective work of 
multiple agencies since these agencies work many health care fraud 
cases jointly. Outputs from some key indicators have changed in recent 
years. For example, according to the fiscal year 2012 HCFAC report, 
the return-on-investment—the amount of money returned to the 
government as a result of HCFAC activities compared with the funding 
appropriated to conduct those activities—has increased from $4.90 
returned for every $1.00 invested for fiscal years 2006-2008 to $7.90 
returned for every $1.00 invested for fiscal years 2010-2012. 

Several factors contribute to a lack of information about the 
effectiveness of HCFAC activities in reducing health care fraud and 
abuse. The indicators agencies use to track HCFAC activities provide 
information on the outputs or accomplishments of HCFAC activities, not 
on the effectiveness of the activities in actually reducing fraud and 
abuse. For several reasons, assessing the impact of the program is 
challenging. For example, it is difficult to isolate the effect that 
HCFAC activities, as opposed to other efforts such as changes to the 
Medicare provider enrollment process, may have in reducing health care 
fraud and abuse. It is also difficult to estimate a health care fraud 
baseline-—a measure of the extent of fraud—-that is needed to be able 
to track whether the amount of fraud has changed over time as a result 
of HCFAC or other efforts. HHS has a project under way to establish a 
baseline of probable fraud in home health care, and will determine 
whether this approach to estimating a baseline of fraud should be 
expanded to other areas of health care. Results from this project and 
other studies could provide HHS and DOJ with additional information 
regarding which activities are the most effective in reducing health 
care fraud and abuse, and could potentially inform agency decisions 
about how best to allocate limited resources. 

View [hyperlink, http://www.gao.gov/products/GAO-13-746]. For more 
information, contact Kathleen M. King at (202) 512-7114 or 
kingk@gao.gov or Eileen R. Larence at (202) 512-8777 or 
larencee@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

Agencies Obligated $583.6 Million for HCFAC Activities in Fiscal Year 
2012; Most Obligations Were for Personnel: 

Agencies Use Several Indicators to Assess HCFAC Activities, and Some 
Key Outputs Changed Over Time: 

Several Factors Contribute to Lack of Information about the 
Effectiveness of HCFAC Activities: 

Concluding Observations: 

Agency Comments: 

Appendix I: Health Care Fraud and Abuse Control (HCFAC) Program 
Activities Conducted by Agencies in Fiscal Year 2012: 

Appendix II: Health Care Fraud and Abuse Control (HCFAC) Program 
Obligations for Fiscal Years 2008 through 2012: 

Appendix III: Indicators Used by Agencies to Assess Health Care Fraud 
and Abuse Control (HCFAC) Program Activities: 

Appendix IV: Key Outcomes and Outputs of Health Care Fraud and Abuse 
Control (HCFAC) Program Activities: 

Appendix V: Comments from the Department of Health and Human Services: 

Appendix VI: GAO Contacts and Staff Acknowledgments: 

Tables: 

Table 1: Total Health Care Fraud and Abuse Control (HCFAC) Obligations 
By Agency Component and Strike Force Location, Fiscal Year 2012: 

Table 2: Agencies, Components, and Health Care Fraud and Abuse Control 
(HCFAC) Program Activities: 

Table 3: Obligations For Health Care Fraud and Abuse Control (HCFAC) 
Program Activities, Fiscal Years 2008-2012, By Agency and Component 
and Type of Appropriations: 

Table 4: Total Health Care Fraud and Abuse Control (HCFAC) Program 
Obligations by Strike Force Location and Fiscal Year, 2008 through 
2012: 

Table 5: Collective Indicators Reported in the Annual Health Care 
Fraud and Abuse Control (HCFAC) Program Report, and Outcomes/Outputs 
for Associated Indicator, for Fiscal Year 2012: 

Table 6: Indicators That Are Used by the HHS Components to Assess 
Health Care Fraud and Abuse Control Program Activities, Source of 
Indicators, and Outcomes/Outputs for Associated Indicator, for Fiscal 
Year 2012: 

Table 7: Indicators That Are Used by the Department of Health and 
Human Services Office of Inspector General (HHS-OIG) to Assess Health 
Care Fraud and Abuse Control (HCFAC) Program Activities, Source of 
Indicators, Associated Target (if any), and Outcomes/Outputs for 
Associated Indicator, for Fiscal Year 2012: 

Table 8: Indicators That Are Used by the Department of Justice (DOJ) 
Components to Assess Health Care Fraud and Abuse Control (HCFAC) 
Program Activities, Source of Indicators, Associated Targets (if any), 
and Outcomes/Outputs for Associated Indicator, for Fiscal Year 2012: 

Table 9: Key Program Outcomes/Outputs of Health Care Fraud and Abuse 
Control (HCFAC) Program Activities, Fiscal Years 2008 through 2012: 

Figures: 

Figure 1: Appropriations for the Health Care Fraud and Abuse Control 
(HCFAC) Program for Fiscal Year 2012, By Agency: 

Figure 2: Fiscal Year 2012 Health Care Fraud and Abuse Control (HCFAC) 
Obligations (in Millions), by Agency Component and Type of 
Appropriations: 

Figure 3: Health Care Fraud and Abuse Control (HCFAC) Program Return-
on-Investment, Fiscal Years 2008 through 2012: 

Figure 4: Selected Key Program Outputs and Total Obligations for 
Health Care Fraud and Abuse Control (HCFAC) Program Activities, Fiscal 
Years 2008 through 2012: 

Abbreviations: 

ACL: Administration for Community Living: 

ASPE: Office of the Assistant Secretary for Planning and Evaluation: 

ASPA: Office of the Assistant Secretary for Public Affairs: 

CMS: Centers for Medicare & Medicaid Services: 

CHIP: Children's Health Insurance Program: 

DOJ: Department of Justice: 

EOUSA: Executive Office for United States Attorneys: 

FBI: Federal Bureau of Investigation: 

FDA: Food and Drug Administration: 

HCFAC: Health Care Fraud and Abuse Control: 

HEAT: Health Care Fraud Prevention and Enforcement Action Team: 

HHS: Department of Health and Human Services: 

HHS-OIG: Department of Health and Human Services' Office of Inspector 
General: 

HIPAA: Health Insurance Portability and Accountability Act of 1996: 

JMD: Justice Management Division: 

OAS: Office of Audit Services: 

OCIG: Office of Counsel to the Inspector General: 

OEI: Office of Evaluation and Inspections: 

OGC: Office of General Counsel: 

OI: Office of Investigations: 

OMP: Office of Management and Policy: 

SMP: Senior Medicare Patrol: 

Strike Force: Medicare Fraud Strike Force: 

USAOs: U.S. Attorneys' Offices: 

[End of section] 

GAO:
United States Government Accountability Office: 
441 G St. N.W. 
Washington, DC 20548: 

September 30, 2013: 

The Honorable Thomas R. Carper: 
Chairman: 
The Honorable Tom Coburn, M.D. 
Ranking Member: 
Committee on Homeland Security and Governmental Affairs: 
United States Senate: 

The Honorable Orrin G. Hatch: 
Ranking Member: 
Committee on Finance: 
United States Senate: 

The Honorable Charles E. Grassley: 
Ranking Member: 
Committee on the Judiciary: 
United States Senate: 

The Honorable Claire McCaskill: 
Chairman: 
Subcommittee on Financial and Contracting Oversight: 
Committee on Homeland Security and Governmental Affairs: 
United States Senate: 

GAO has designated Medicare and Medicaid as high-risk programs because 
their size, scope, and complexity make them particularly vulnerable to 
fraud and abuse.[Footnote 1] According to the Department of Health and 
Human Services' Office of Inspector General (HHS-OIG), common health 
care fraud schemes include providers or suppliers billing for services 
or supplies not provided or not medically necessary, purposely billing 
for a higher level of service than that provided, and paying kickbacks 
to providers for referring beneficiaries for specific services or to 
certain entities. To help reduce fraud and abuse in health care 
programs, including Medicare and Medicaid, Congress established the 
Health Care Fraud and Abuse Control (HCFAC) program as a part of the 
Health Insurance Portability and Accountability Act of 1996 (HIPAA). 
[Footnote 2] The departments of Health and Human Services (HHS) and 
Justice (DOJ) jointly administer the HCFAC program and, in fiscal year 
2012, received over $486 million in HCFAC appropriations. Several 
components within HHS and DOJ receive appropriations to carry out 
HCFAC activities, including the Centers for Medicare & Medicaid 
Services (CMS)--the agency within HHS that administers Medicare, 
Medicaid, and the Children's Health Insurance Program (CHIP)[Footnote 
3]--the HHS-OIG, and DOJ's components--the Civil, Civil Rights, 
Criminal, and Justice Management divisions, the U.S. Attorneys' 
Offices (USAOs), and the Federal Bureau of Investigation (FBI). 
[Footnote 4],[Footnote 5] 

By statute, HHS and DOJ are required to issue a joint report annually 
to Congress on the amounts appropriated through the HCFAC program, and 
the amounts recovered as a result of HCFAC activities. In fiscal year 
2012, HHS and DOJ reported having won or negotiated over $3 billion in 
health care judgments and settlements through the activities of the 
HCFAC program. The agencies also reported obtaining additional 
administrative penalties in health care fraud cases and proceedings as 
a result of these activities. In fiscal year 2012, about $4.2 billion 
was collected, a portion of which was deposited into the Medicare 
Trust Funds as a result of health care judgments and settlements and 
administrative penalties (including those that occurred before fiscal 
year 2012). We have previously reported that although there have been 
convictions involving multimillion dollar schemes that defrauded the 
Medicare program, there are no reliable estimates of the amount of 
fraud in the Medicare program or for the health care industry as a 
whole.[Footnote 6] Additionally, although HHS and DOJ work to reduce 
health care fraud and abuse through the HCFAC program, concerns have 
been raised about whether the HCFAC program has been effective in 
reducing health care fraud and abuse. 

Given these concerns, you asked us to examine how HHS and DOJ have 
used their appropriations to achieve the goals of the HCFAC program, 
and to examine performance assessments and other metrics HHS and DOJ 
use to determine the HCFAC program's performance and effectiveness. 
This report (1) describes how HHS and DOJ obligated funds for the 
HCFAC program; (2) examines how HHS and DOJ assess HCFAC activities 
and whether key program outputs have changed over time; and (3) 
examines what is known about the effectiveness of the HCFAC program in 
reducing health care fraud and abuse. 

For our review, we included agencies within HHS (including HHS-OIG) 
and DOJ that received mandatory and discretionary HCFAC funding in 
fiscal year 2012 whose activities are described in the annual HCFAC 
report,[Footnote 7] and whose funding is included in the annual 
report's return-on-investment calculation (which compares the amount 
of monetary results to the federal government, such as funds returned 
to the Medicare Trust Funds as a result of HCFAC activities, with the 
funding appropriated to conduct those activities).[Footnote 8], 
[Footnote 9] For CMS, we only included the HCFAC funding that was 
included in the HCFAC return-on-investment calculation.[Footnote 10] 
We excluded all of the remaining HCFAC funding that CMS receives 
because it is not included in the HCFAC return-on-investment 
calculation and generally supports program integrity activities in 
Medicare Parts C and D, which are similar to the activities conducted 
under the Medicare Integrity Program.[Footnote 11] 

To describe how HHS and DOJ obligated funds for the HCFAC program, we 
obtained information about how the agencies obligated their HCFAC 
appropriations for fiscal year 2012, by expenditure category (such as 
personnel).[Footnote 12],[Footnote 13] We received this information 
from the HHS, HHS-OIG, and DOJ components that received HCFAC funding. 
[Footnote 14] Additionally, we obtained information on obligations of 
other appropriations that HHS, HHS-OIG, and DOJ components used to 
support HCFAC activities.[Footnote 15] Additionally, we interviewed 
officials at HHS and DOJ components, and reviewed agency documents to 
examine the process by which HHS and DOJ have obligated HCFAC funds. 
We reviewed the data for any errors and followed up with agency 
officials for clarification when necessary. On the basis of these 
activities, we determined that these data were sufficiently reliable 
for the purpose of our report. 

To examine how HHS and DOJ assess HCFAC activities, and whether key 
program outputs have changed over time, we interviewed officials from 
HHS, HHS-OIG, and DOJ to obtain information on indicators reported by 
their agencies. We asked these officials about indicators listed in 
the HCFAC report, as well as other indicators that HHS, HHS-OIG, and 
DOJ components use to assess HCFAC activities. We also collected 
information from agency officials about how they use the indicators 
and other data analyses to determine how to target HCFAC resources and 
prioritize activities. We reviewed agency documents, including the 
fiscal year 2012 HCFAC report, agency annual and semi-annual reports, 
strategic plans, performance plans, congressional budget 
justifications, and other reports to obtain information on HCFAC 
activities that HHS, HHS-OIG, and DOJ components conducted. We 
reviewed the return-on-investment calculation outlined in the HCFAC 
report to determine what funding and amounts recovered are included, 
as well as the method used to calculate the return-on-investment. 
[Footnote 16] To examine whether key program outputs have changed from 
fiscal year 2008 to 2012, we reviewed current and past HCFAC reports. 
We selected outputs from the annual HCFAC report to review, which the 
agencies consider to be key program outputs. For this analysis, we 
also took account of other funding (i.e., funds that agencies used to 
support HCFAC activities that were not specifically appropriated for 
the HCFAC program). We also interviewed agency officials regarding 
other factors that may have contributed to changes in program outputs 
in specific years. 

To examine what is known about the effectiveness of the HCFAC program 
in reducing health care fraud and abuse, we conducted a review of 
relevant literature to identify measures used to assess the 
effectiveness of law enforcement programs, challenges associated with 
evaluating law enforcement programs, and the issues related to 
establishing a baseline estimate of the type and extent of fraud 
needed to measure progress over time. We included in our search both 
health care fraud enforcement programs specifically and law 
enforcement programs in general. We conducted literature searches in 
44 online databases with health care and/or law enforcement content 
containing peer-reviewed publications and government reports to 
identify studies published from January 2003 through March 2013 using 
health care fraud, law enforcement, and performance measurement search 
terms. We conducted a preliminary review of abstracts for over 300 
articles and selected 49 articles for closer review based on the 
following criteria: the article (1) identified performance indicators 
to assess the effectiveness of enforcement programs in general or 
health care fraud enforcement programs specifically; (2) discussed 
establishing a health care fraud baseline; or (3) identified 
challenges in evaluating law enforcement programs. Additionally, we 
interviewed HHS and DOJ officials to obtain information on the 
effectiveness of HCFAC activities and to determine the status of 
efforts by a CMS contractor to establish a health care fraud baseline. 
We also interviewed experts on health care fraud to discuss strengths 
and limitations of measuring the effectiveness of health care fraud 
enforcement programs, such as the HCFAC program.[Footnote 17] 

We conducted this performance audit from September 2012 to September 
2013 in accordance with generally accepted government auditing 
standards. Those standards require that we plan and perform the audit 
to obtain sufficient, appropriate evidence to provide a reasonable 
basis for our findings and conclusions based on our audit objectives. 
We believe that the evidence obtained provides a reasonable basis for 
our findings and conclusions based on our audit objectives. 

Background: 

Health Care Fraud and Abuse Control Program: 

The HCFAC program was established under HIPAA to (1) coordinate 
federal, state, and local law enforcement efforts to control fraud and 
abuse associated with health plans; (2) conduct investigations, 
audits, evaluations, and inspections of delivery and payment for 
health care in the United States; (3) facilitate the enforcement of 
federal health care fraud and abuse laws; (4) provide guidance to the 
health care industry in the form of advisory opinions, safe harbor 
notices, and special fraud alerts; and (5) establish a national 
database of adverse actions against health care providers.[Footnote 18] 

HIPAA requires that HHS and DOJ issue a joint annual report to 
Congress that outlines the amounts returned to the Medicare Trust 
Funds for the previous fiscal year under various categories, such as 
amounts of criminal fines and civil monetary penalties--penalties for 
certain activities, such as knowingly presenting a Medicare claim that 
is not medically necessary. Additionally, HHS and DOJ are required to 
report the amounts deposited into and expended from the Medicare Trust 
Funds to conduct HCFAC activities during the previous fiscal year and 
the justification for those expenditures. In addition to the mandatory 
appropriations provided under HIPAA, which Congress increased in 2010, 
DOJ and HHS-OIG have received discretionary funding through annual 
appropriations for the HCFAC program since fiscal year 2009.[Footnote 
19] 

The annual HCFAC report includes a summary of the key HCFAC activities 
that the agencies and their components carried out and provides 
information on the outputs or outcomes of those activities. For 
example, the report includes information on the amount of money 
returned to the Medicare Trust Funds as a result of HCFAC activities. 
Additionally, the report includes sections that describe the 
activities each agency and component that received HCFAC funding 
conducted. These sections provide information on the outputs of each 
component's activities. For example, DOJ's USAO section highlights the 
number of new criminal investigations initiated and the number of 
civil matters pending. 

HCFAC Appropriations: 

HHS and DOJ receive funding from several appropriations to conduct 
their HCFAC program activities. Figure 1 describes HCFAC 
appropriations to HHS, HHS-OIG, and DOJ. Mandatory funds are 
appropriated by HIPAA from the Medicare Trust Funds, and are available 
until expended, meaning that the funds can be spent in other years. 
[Footnote 20] A large portion of these funds are appropriated to HHS-
OIG; the law appropriates the remainder to both HHS and DOJ, which 
must determine together how to allocate the funds--referred to as the 
wedge--between the agencies. 

Figure 1: Appropriations for the Health Care Fraud and Abuse Control 
(HCFAC) Program for Fiscal Year 2012, By Agency: 

[Refer to PDF for image: illustration] 

Medicare Trust Funds: 

Mandatory HCFAC Funding: $294.8 million: 
Appropriated to HHS-OIG: $196.1 million; 
Wedge for HHS and DOJ: $98.7 million; HHS and DOJ reach an agreement 
on how to allocate the wedge funds between them. 

Discretionary HCFAC Funding: 
Appropriated to HHS-OIG and DOJ: Each received $29.7 million. 

General Funds: 

Mandatory Funding for FBI: $131.9 million. 

Four pie-charts: 

HHS-OIG: 
Received $225.8 million in total, the majority was mandatory funding 
and a smaller portion was discretionary funding. 

HHS: 
Received $37.5 million in total. All of HHS’s funding was mandatory 
HCFAC funding and represents 38 percent of the wedge. 

DOJ: 
Received $90.9 million in total; $61.2 million was mandatory HCFAC 
funding (representing 62 percent of the wedge) and $29.7 million is 
HCFAC discretionary funding. DOJ allocated a portion of its 
discretionary funding to the FBI. 

FBI: 
Received $135.3 million in total; $131.9 million was mandatory funding 
and $3.4 million was from DOJ’s portion of HCFAC discretionary funding. 

Source: GAO analysis of fiscal year 2012 annual HCFAC report and other 
agency documents. 

Note: In fiscal year 2012, total appropriations to the Department of 
Health and Human Services (HHS), HHS's Office of Inspector General 
(HHS OIG), and the Department of Justice (DOJ) for HCFAC activities 
amounted to $486.1 million. This includes the $131.9 million in 
mandatory appropriations that the Federal Bureau of Investigation 
(FBI) received to conduct health care fraud and abuse activities and 
the portion of the DOJ discretionary funding that it allocated to the 
FBI ($3.4 million). 

[End of figure] 

In each fiscal year, beginning with fiscal year 2009, Congress 
appropriated discretionary funding to DOJ and HHS-OIG to finance 
activities conducted under the HCFAC program. In addition, Congress 
also appropriated discretionary funds to CMS for program integrity 
activities it conducts in Medicare and Medicaid, which was outside the 
scope of our review.[Footnote 21] Although the FBI is a component of 
DOJ and was allocated a portion of DOJ's discretionary HCFAC funding 
(about $3.4 million), the FBI also received mandatory funding under 
HIPAA to conduct health care fraud and abuse activities. This 
mandatory funding was appropriated from the general fund of the U.S. 
Treasury. 

In addition to the HCFAC mandatory and discretionary funding that HHS, 
DOJ, and its components receive, the agencies use funding from other 
appropriations to support HCFAC activities. For example, HHS's Office 
of General Counsel (OGC) uses appropriations from HHS's General 
Departmental Management appropriation to support its HCFAC activities. 

Activities Conducted Under the HCFAC Program: 

HHS and DOJ components conduct a variety of activities under the HCFAC 
program using mandatory and discretionary HCFAC funding. Among other 
activities, HHS components identify and investigate fraud through 
programs, including the Administration for Community Living's (ACL) 
Senior Medicare Patrol programs, which are designed to educate and 
train Medicare beneficiaries to identify fraud. HHS's OGC supports a 
variety of program integrity work, including assisting DOJ on False 
Claims Act cases.[Footnote 22] HHS's Food and Drug Administration 
(FDA) conducts the Pharmaceutical Fraud Program, which is designed to 
detect pharmaceutical, biologics, and medical device fraud. CMS uses a 
portion of HHS's HCFAC funding to improve its financial oversight of 
the Medicaid program and CHIP, and for a pilot project related to 
fraud in community mental health centers. CMS also uses its portion of 
HCFAC funding to support its efforts related to the Medicare Fraud 
Strike Force (Strike Force) teams, which consist of investigators and 
prosecutors who use advanced data analysis techniques to identify, 
investigate, and prosecute potentially fraudulent billing patterns in 
geographic areas with high rates of health care fraud. 

HHS-OIG conducts a variety of activities to identify and reduce fraud, 
waste, and abuse. For example, HHS-OIG assesses civil monetary 
penalties and imposes other administrative penalties--such as 
excluding individuals and entities from participating in federal 
health care programs--against individuals and entities for certain 
types of conduct. Each of HHS-OIG's components receives HCFAC funding 
for the work it conducts. Among other activities: 

* The Office of Investigations (OI) coordinates and conducts 
investigations of allegations of fraud, waste, and abuse in Medicare 
and Medicaid. 

* The Office of Evaluation and Inspections (OEI) conducts national 
evaluations on issues related to preventing fraud, waste, and abuse, 
and promoting economy, efficiency, and effectiveness of HHS programs. 

* The Office of Audit Services (OAS) conducts independent audits of 
HHS programs, grantees, and contractors. 

* The Office of Counsel to the Inspector General (OCIG) exercises the 
authority to impose civil and administrative penalties related to 
health care fraud, as well as issue advisory opinions. 

* The Office of Management and Policy (OMP) provides management, 
guidance, and resources in support of the other HHS-OIG components. 

DOJ's components have the primary role in enforcing U.S. laws related 
to health care fraud and abuse, including both criminal and civil 
matters. For example: 

* The Criminal Division prosecutes criminal health care fraud and 
leads the Strike Force teams. 

* The Civil Division represents the U.S. in civil fraud matters, such 
as False Claims Act cases and has the authority to bring criminal 
charges under the Federal Food, Drug, and Cosmetic Act. 

* The USAOs litigate or prosecute civil and criminal health care fraud 
cases in their 94 districts throughout the country and are part of the 
Strike Force teams. 

* The Civil Rights Division enforces several laws related to cases of 
abuse, substandard care, or needless institutionalization of certain 
individuals. 

* The Justice Management Division (JMD) provides financial oversight 
of the DOJ components. 

* The FBI serves as an investigative agency with jurisdiction in both 
federal and private health insurance programs, and participates in 
task forces and undercover operations to investigate health care fraud. 

Although the agencies and components conduct certain activities 
without assistance from other agencies and components, HHS, CMS, HHS-
OIG, and DOJ--including the FBI--frequently collaborate to investigate 
and prosecute fraud in federal health care programs. For example, HHS-
OIG, FBI, and DOJ investigators and prosecutors comprise Strike Force 
teams. Table 2 in appendix I provides further detail on these 
activities. 

Agencies Obligated $583.6 Million for HCFAC Activities in Fiscal Year 
2012; Most Obligations Were for Personnel: 

In fiscal year 2012, HHS, HHS-OIG, and DOJ obligated approximately 
$583.6 million to fund HCFAC activities. About 78 percent of obligated 
funds were from mandatory HCFAC appropriations, 11 percent of 
obligated funds were from discretionary HCFAC appropriations, and 12 
percent of obligated funds were from other appropriations.[Footnote 
23] Most of the obligations for HCFAC activities were for personnel 
costs; some agencies reported obligating funds for services under 
contract and supplies. Additionally, HHS-OIG and DOJ obligated over 8 
percent of their HCFAC funds to support Strike Force teams located in 
9 cities nationwide. 

HHS, HHS-OIG, and DOJ Obligated $583.6 Million in Fiscal Year 2012; 12 
Percent of Obligated Funds Came From Other Appropriations: 

In fiscal year 2012, HHS, HHS-OIG, and DOJ reported $583.6 million in 
obligations for HCFAC activities.[Footnote 24] This total includes 
obligations of mandatory (about 78 percent) and discretionary (about 
11 percent) HCFAC appropriations and other appropriations not specific 
to the HCFAC program (about 12 percent).[Footnote 25] HCFAC mandatory 
funds are available until expended, while discretionary HCFAC funds 
are available for 2 fiscal years. Other appropriations that agencies 
use for HCFAC activities vary in how long they are available. Because 
agencies reported in fiscal year 2012 obligating funds that were 
carried over from prior fiscal years, and because agencies obligated 
funds from other appropriations not specific to the HCFAC program, the 
obligations the agencies reported for HCFAC activities in fiscal year 
2012--$583.6 million--exceed the HCFAC funds appropriated to the 
agencies for that year. For example, HHS, HHS-OIG, and DOJ were 
appropriated $486.1 million in HCFAC mandatory and discretionary 
funding for fiscal year 2012. However, for fiscal year 2012, these 
agencies reported HCFAC obligations of $583.6 million, including over 
$67 million in obligations of other appropriations, as well as 
obligations of funds appropriated in prior fiscal years. 

In fiscal year 2012, DOJ incurred about 48 percent of the agencies' 
total HCFAC obligations (about $280.3 million),[Footnote 26] while HHS-
OIG incurred about 44 percent ($258.8 million), and HHS incurred the 
remaining 8 percent ($44.4 million). See figure 2 for the distribution 
of HCFAC obligations by appropriations type--HCFAC mandatory, HCFAC 
discretionary, and other appropriations--by HHS, HHS-OIG, and DOJ's 
components for fiscal year 2012. See table 3 in appendix II for the 
distribution of HCFAC obligations by appropriations type--HCFAC 
mandatory, HCFAC discretionary, and other appropriations--for HHS, HHS-
OIG, and DOJ's components for fiscal years 2008 through 2012. 

Figure 2: Fiscal Year 2012 Health Care Fraud and Abuse Control (HCFAC) 
Obligations (in Millions), by Agency Component and Type of 
Appropriations: 

[Refer to PDF for image: stacked vertical bar graph] 

Department of Health and Human Services (HHS)[A]: 
Agency total: $44.4 million. 

ACL; 
Mandatory: $10.63 million; 
Discretionary: $0; 
Obligators of other appropriations: $0. 

CMS; 
Mandatory: $14.53 million; 
Discretionary: $0.35 million; 
Obligators of other appropriations: $0. 

FDA; 
Mandatory: $2.77 million; 
Discretionary: $0; 
Obligators of other appropriations: $0 million. 

OGC; 
Mandatory: $8.85 million; 
Discretionary: $0; 
Obligators of other appropriations: $7.30 million. 

HHS-Office of Inspector General (HHS-OIG)[A,D]: 
Agency total: $258.8 million. 

OAS; 
Mandatory: $65.80 million; 
Discretionary: $0; 
Obligators of other appropriations: $4.67 million. 

OCIG; 
Mandatory: $9.82 million; 
Discretionary: $0; 
Obligators of other appropriations: $0.70 million. 

OEI; 
Mandatory: $15.41 million; 
Discretionary: $0; 
Obligators of other appropriations: $1.20 million. 

OI; 
Mandatory: $88.68 million; 
Discretionary: $0; 
Obligators of other appropriations: $6.34 million. 

OMP; 
Mandatory: $36.42 million; 
Discretionary: $23.82 million; 
Obligators of other appropriations: $5.96 million. 

Department of Justice (DOJ)[A]: 
Agency total: $280.3 million. 

Civil; 
Mandatory: $23.0 million; 
Discretionary: $4.99 million; 
Obligators of other appropriations: $1.95 million. 

Civil Rights; 
Mandatory: $3.82 million; 
Discretionary: $0.89 million; 
Obligators of other appropriations: $0.45 million. 

Criminal; 
Mandatory: $1.21 million; 
Discretionary: $8.08 million; 
Obligators of other appropriations: $0. 

FBI; 
Mandatory: $134.38; 
Discretionary: $3.81 million; 
Obligators of other appropriations: $7.47 million. 

JMD; 
Mandatory: $4.95 million; 
Discretionary: $10.80 million; 
Obligators of other appropriations: $0. 

USAO; 
Mandatory: $32.66 million; 
Discretionary: $10.76 million; 
Obligators of other appropriations: $31.12 million. 

Source: GAO analysis of HCFAC obligations that HHS, HHS-OIG, and DOJ 
reported for their components in fiscal year 2012. 

Notes: Agency total HCFAC obligations may not equal the sum of HCFAC 
obligations for the agency's components due to rounding. 

[A] The Department of Health and Human Services' (HHS) components that 
received HCFAC funding in fiscal year 2012 were: Administration for 
Community Living (ACL), Centers for Medicare & Medicaid Services 
(CMS), Food and Drug Administration (FDA), and Office of General 
Counsel (OGC). HHS's Office of Inspector General's (HHS-OIG) 
components that received HCFAC funding in fiscal year 2012 were: 
Office of Audit Services (OAS), Office of Counsel to the Inspector 
General (OCIG), Office of Evaluation and Inspections (OEI), Office of 
Investigations (OI), and Office of Management and Policy (OMP). The 
Department of Justice's (DOJ) components that received HCFAC funding 
were: DOJ's Civil Division, Civil Rights Division, Criminal Division, 
the 94 U.S. Attorneys' Offices (USAO), the Justice Management Division 
(JMD), and the Federal Bureau of Investigation (FBI). 

[B] For fiscal year 2012, CMS reported amounts in HCFAC mandatory 
appropriations, about $1.6 million, that the agency reserved to fund 
HCFAC activities in future years. These funds were allocated to CMS in 
fiscal year 2012, but were not obligated. 

[C] HHS's OGC reported estimated obligations of other appropriations, 
which included reimbursements for attorney services provided to OGC 
clients within HHS, that supported HCFAC activities. 

[D] HHS-OIG's reported obligations also include any funding the agency 
received as reimbursement for the costs of conducting investigations 
and audits and other activities when such costs are ordered by a 
court, voluntarily agreed to by the payor, or otherwise authorized 
under 42 U.S.C. §1320a-7c(b). 

[E] DOJ's Criminal Division stated that it uses some of its annual 
appropriation for health care fraud activities. However, Division 
officials indicated that the Division infrequently funds HCFAC 
activities with other appropriations and, as a result, the Division 
does not track its use of these appropriations for HCFAC activities. 

[F] For fiscal year 2012, DOJ reported allocations of HCFAC mandatory 
and discretionary appropriations that the department reserved for 
future use to fund HCFAC activities, about $4.7 million in mandatory 
HCFAC appropriations and about $10.8 million in discretionary HCFAC 
appropriations. These funds were allocated to JMD, but were not 
obligated. We have included these HCFAC allocations under the JMD, in 
addition to the $208,676 in mandatory HCFAC obligations JMD reported. 
However, in the return-on-investment included in the fiscal year 2012 
annual HCFAC report, only a portion of these allocations (about $13.2 
million) were included in the calculation. JMD may use these funds for 
unanticipated HCFAC costs. 

[End of figure] 

Mandatory HCFAC Funding: 

A portion of the mandatory HCFAC appropriation that supports HHS and 
DOJ's HCFAC activities--or wedge funds--is allocated to each agency. 
According to a HHS official, in fiscal year 2010, the departments 
reached a standing agreement for the following allocations: 
approximately 38 percent for HHS and 62 percent for DOJ.[Footnote 27] 
Prior to fiscal year 2010, HHS and DOJ negotiated each year how to 
divide the wedge funds between the two agencies, which a HHS official 
described as time-consuming. 

HHS distributes its wedge funds to HHS components based on their 
annual funding requests that the Secretary approves. In fiscal year 
2012, HHS distributed mandatory funding to ACL for the Senior Medicare 
Patrol programs, OGC to support program integrity work of its clients, 
FDA to support the Pharmaceutical Fraud Program, and CMS to support 
Medicaid and CHIP financial specialists and a pilot project related to 
fraud in community mental health center providers in Texas, Florida, 
and Louisiana.[Footnote 28] According to a DOJ official, DOJ 
distributes mandatory HCFAC funds--its portion of wedge funds--to its 
components to carry out their HCFAC activities, and the distribution 
of such funds has not varied much since the inception of the program. 
Separately, HHS-OIG receives a mandatory appropriation for its HCFAC 
activities. This appropriation is HHS-OIG's primary source of funding 
for Medicare and Medicaid fraud investigations, as well as for audits, 
evaluations, and inspections it conducts related to the Medicare and 
Medicaid programs. 

Discretionary HCFAC Funding: 

In fiscal year 2012, DOJ and HHS-OIG obligated discretionary HCFAC 
appropriations. According to the information each agency reported to 
us, each DOJ component received a share of DOJ's discretionary HCFAC 
appropriation for their HCFAC activities. A DOJ official told us that 
DOJ components generally received the same amount of funding from the 
agency's discretionary HCFAC appropriation for their HCFAC activities 
in fiscal year 2012 as they had in prior fiscal years. Additionally, 
the official indicated that a large portion of DOJ's HCFAC 
discretionary appropriation supports the Strike Force teams because 
DOJ believes that these teams reduce fraud. One component in HHS-OIG--
OMP-
-received discretionary HCFAC appropriations.[Footnote 29] OMP 
officials told us that most obligations of these funds are for 
overhead expenses for the HHS-OIG components that are handled by OMP 
(such as rent and utilities). 

Other Appropriations Supporting HCFAC Activities: 

HHS, HHS-OIG, and DOJ components obligated over $67 million in funds 
from other appropriations in addition to the mandatory and 
discretionary HCFAC appropriations they obligated for HCFAC activities 
in fiscal year 2012. Within HHS, one component--OGC--used other 
appropriations to supplement its HCFAC funding.[Footnote 30] To carry 
out its HCFAC activities, OGC obligated funds from the annual HHS 
General Department Management appropriation, which accounted for 
almost half of its overall obligations for HCFAC activities in fiscal 
year 2012. ACL, CMS, and FDA did not use other appropriations to 
support their HCFAC activities. 

Each of HHS-OIG's components obligated funds from other appropriations 
to support HCFAC activities in fiscal year 2012. From other 
appropriations, HHS-OIG obligated about $18.9 million of these 
appropriations for HCFAC activities in fiscal year 2012, which 
represented about 7 percent of its overall HCFAC obligations. HHS-OIG 
reported that the other appropriations used to support HCFAC 
activities included funds appropriated specifically to support HHS-
OIG's Medicare and Medicaid program integrity work. For example, in 
fiscal year 2012, each HHS-OIG component reported obligating funds 
appropriated in section 6034 of the Deficit Reduction Act (which, 
among other things, established the Medicaid Integrity Program and 
provided HHS-OIG with increased funding for Medicaid fraud and abuse 
control activities) to conduct HCFAC activities.[Footnote 31] 

Most of DOJ's components also used funding from other appropriations 
to support HCFAC activities, specifically the USAOs, the FBI, the 
Civil Division, and the Civil Rights Division.[Footnote 32] The USAOs 
obligated the most funding from other appropriations among all of the 
DOJ components, about $31.1 million in fiscal year 2012. This 
accounted for 42 percent of the USAOs' overall obligations for HCFAC 
activities in fiscal year 2012. Officials from the USAOs reported 
obligating funds from DOJ's annual appropriations and the DOJ's "Three 
Percent" funds to support HCFAC activities.[Footnote 33] According to 
USAO officials, a portion of the USAOs' annual appropriation is used 
to fund attorneys, paralegals, auditors and investigators, and 
litigation support for resource intensive health care fraud cases. 
Officials from the Civil Division told us that they also used "Three 
Percent" funds to continue the division's health care fraud litigation 
work, such as to investigate qui tam cases alleging false claims and 
to prepare cases for trial.[Footnote 34] The Civil Rights Division 
reported using DOJ's Salaries and Expenses, General Legal Activities 
appropriation to fund the rent for office space used by personnel, and 
the FBI reported using its annual appropriation to cover personnel 
expenses for investigators working health care fraud cases beyond 
those covered by HCFAC funds. 

Most HCFAC Obligations Were for Personnel in Fiscal Year 2012: 

HHS, HHS-OIG, and DOJ reported that most of their HCFAC obligations 
were for personnel costs in fiscal year 2012, with some exceptions 
based on the type of HCFAC activities each component performs (see 
table 3 of appendix II for HCFAC obligations for fiscal years 2008 
through 2012 for HHS, HHS-OIG, and DOJ's components).[Footnote 35] A 
large portion of most HHS components' HCFAC obligations were for 
personnel costs. The same was true for HHS-OIG and DOJ. Each agency 
relied on personnel to conduct HCFAC activities--HHS-OIG employed 
investigators to examine potential fraud cases and DOJ employed 
investigators, attorneys, and other support personnel to investigate 
and prosecute fraud cases. Additionally, HHS-OIG employed auditors and 
evaluators to study issues related to the Medicare and Medicaid 
programs, including issues related to fraud in these programs, as well 
as a variety of other issues. 

HHS, HHS-OIG, and DOJ components also reported that their next largest 
amount of HCFAC obligations was for contractual services and supplies. 
Components reported using these contractual services and supplies for 
transportation, rent, supplies, or other contractual services--such as 
for litigation consultants (for example, medical experts) and 
litigation support (for example, paralegals to review case 
documentation), among other things. Obligations for personnel and 
contracted services and supplies generally accounted for almost all of 
a component's HCFAC obligations. 

Specifically, for HHS's components, obligations for personnel costs 
represented the largest portion of FDA's, CMS's, and OGC's obligations 
for HCFAC activities for fiscal year 2012. In contrast, most of ACL's 
obligations in fiscal year 2012 were for expanding grants to the 
Senior Medicare Patrol programs. 

Each of HHS-OIG's components, with the exception of OMP, reported 
obligations for personnel costs as their largest HCFAC obligations for 
fiscal year 2012, devoting 87 percent or more of their obligations to 
personnel in fiscal year 2012. For OMP, over 70 percent of its 
obligations were devoted to rent, communication, utilities, equipment, 
printing, and other contractual services. OMP officials told us that 
certain overhead expenses incurred by the HHS-OIG components--for 
example, rent payments--are handled by OMP. 

About half or more of DOJ components' obligations for HCFAC activities 
were for personnel costs. In fiscal year 2012, the USAOs, Civil 
Division, Criminal Division, Civil Rights Division, and FBI reported 
that obligations for personnel costs ranged from 47 percent (Civil 
Division) to 84 percent (USAOs) of their obligations. For example, for 
the Civil Division, obligations for contractual services and supplies 
represented 53 percent of its HCFAC obligations; and officials told us 
that they use contracted services for litigation consultants (such as 
medical experts to review medical records or to prepare exhibits to be 
used at trial) and for litigation support (such as paralegals to 
review case documentation). 

Over $47 Million in Obligations in Fiscal Year 2012 Supported Strike 
Force Teams in Nine Cities: 

In fiscal year 2012, HHS-OIG and DOJ obligated over $47 million in 
HCFAC funds to support Strike Force teams. This represented about 8.1 
percent of the $583.6 million in obligations for HCFAC activities. DOJ 
officials told us that Strike Force teams are an important and 
valuable tool for identifying potential health care fraud schemes. 
(See table 1 for the HCFAC obligations by Strike Force location for 
fiscal year 2012, and see appendix II, table 4 for information on 
HCFAC obligations devoted to Strike Force teams for fiscal years 2008-
2012.) 

Table 1: Total Health Care Fraud and Abuse Control (HCFAC) Obligations 
By Agency Component and Strike Force Location, Fiscal Year 2012: 

Strike Force Location & Fiscal Year Launched: Miami, FL Launched FY 
2007; 
Department of Health and Human Services' Office of Inspector General 
(HHS-OIG)[A]: $6,276,735; 
Department of Justice's (DOJ) Criminal Division: $1,570,190; 
U.S. Attorneys' Offices (USAOs): $1,404,500; 
Federal Bureau of Investigation (FBI): $3,711,474; 
Total, by city: $12,962,899. 

Strike Force Location & Fiscal Year Launched: Detroit, MI Launched FY 
2009; 
Department of Health and Human Services' Office of Inspector General 
(HHS-OIG)[A]: $2,483,564; 
Department of Justice's (DOJ) Criminal Division: $913,940; 
U.S. Attorneys' Offices (USAOs): $623,000; 
Federal Bureau of Investigation (FBI): $1,078,020; 
Total, by city: $5,098,524. 

Strike Force Location & Fiscal Year Launched: Dallas, TX Launched FY 
2011; 
Department of Health and Human Services' Office of Inspector General 
(HHS-OIG)[A]: $3,013,496; 
Department of Justice's (DOJ) Criminal Division: $480,834; 
U.S. Attorneys' Offices (USAOs): $458,000; 
Federal Bureau of Investigation (FBI): $1,075,460; 
Total, by city: $5,027,790. 

Strike Force Location & Fiscal Year Launched: Los Angeles, CA Launched 
FY 2008; 
Department of Health and Human Services' Office of Inspector General 
(HHS-OIG)[A]: $2,360,294; 
Department of Justice's (DOJ) Criminal Division: $431,460; 
U.S. Attorneys' Offices (USAOs): $428,000; 
Federal Bureau of Investigation (FBI): $1,596,209; 
Total, by city: $4,815,963. 

Strike Force Location & Fiscal Year Launched: Brooklyn, NY Launched FY 
2010; 
Department of Health and Human Services' Office of Inspector General 
(HHS-OIG)[A]: $2,005,588; 
Department of Justice's (DOJ) Criminal Division: $855,329; 
U.S. Attorneys' Offices (USAOs): $553,000; 
Federal Bureau of Investigation (FBI): $978,934; 
Total, by city: $4,392,851. 

Strike Force Location & Fiscal Year Launched: Baton Rouge, LA Launched 
FY 2010; 
Department of Health and Human Services' Office of Inspector General 
(HHS-OIG)[A]: $1,612,787; 
Department of Justice's (DOJ) Criminal Division: $943,497; 
U.S. Attorneys' Offices (USAOs): $386,000; 
Federal Bureau of Investigation (FBI): $496,083; 
Total, by city: $3,438,367. 

Strike Force Location & Fiscal Year Launched: Chicago, IL Launched FY 
2011; 
Department of Health and Human Services' Office of Inspector General 
(HHS-OIG)[A]: $1,270,269; 
Department of Justice's (DOJ) Criminal Division: [Empty]; 
U.S. Attorneys' Offices (USAOs): $715,000; 
Federal Bureau of Investigation (FBI): $1,394,940; 
Total, by city: $3,380,209. 

Strike Force Location & Fiscal Year Launched: Houston, TX Launched FY 
2009; 
Department of Health and Human Services' Office of Inspector General 
(HHS-OIG)[A]: $783,021; 
Department of Justice's (DOJ) Criminal Division: $738,069; 
U.S. Attorneys' Offices (USAOs): $424,000; 
Federal Bureau of Investigation (FBI): $621,018; 
Total, by city: $2,566,108. 

Strike Force Location & Fiscal Year Launched: Tampa, FL Launched FY 
2010; 
Department of Health and Human Services' Office of Inspector General 
(HHS-OIG)[A]: $1,341,201; 
Department of Justice's (DOJ) Criminal Division: $94.901; 
U.S. Attorneys' Offices (USAOs): $578,000; 
Federal Bureau of Investigation (FBI): $535,100; 
Total, by city: $2,549,202. 

Strike Force Location & Fiscal Year Launched: Headquarters Support of 
Strike Forces; 
Department of Health and Human Services' Office of Inspector General 
(HHS-OIG)[A]: $187,840; 
Department of Justice's (DOJ) Criminal Division: $2,055,643; 
U.S. Attorneys' Offices (USAOs): $485,000; 
Federal Bureau of Investigation (FBI): $323,330; 
Total, by city: $3,051,813. 

Strike Force Location & Fiscal Year Launched: Total; 
Department of Health and Human Services' Office of Inspector General 
(HHS-OIG)[A]: $21,334,795; 
Department of Justice's (DOJ) Criminal Division: $8,083,863; 
U.S. Attorneys' Offices (USAOs): $6,054,500; 
Federal Bureau of Investigation (FBI): $11,810,568; 
Total, by city: $47,283,726. 

Source: GAO analysis of HCFAC obligations reported to GAO by HHS-OIG's 
Office of Investigations and DOJ's Criminal Division, USAOs, and FBI 
for fiscal year 2012. 

Notes: CMS also obligated $350,656 of its discretionary HCFAC 
appropriations for headquarters' support of the Strike Force teams. 
However, these obligations were not associated with any one of the 
nine Strike Force cities and this amount is not reflected in the table 
above. 

[A] HHS-OIG reported estimated HCFAC obligations to support the Strike 
Force teams including obligations of non-HCFAC appropriations. In 
fiscal year 2012, these other appropriations consisted of funds 
appropriated to HHS-OIG under section 6034 of the Deficit Reduction 
Act that remained available for obligation in fiscal year 2012. 
Deficit Reduction Act, Pub. L. No. 109-171, § 6034(c), 120 Stat. 4, 77 
(Feb. 8, 2006). 

[End of table] 

In fiscal year 2012, DOJ and HHS-OIG obligated over $12.9 million for 
the Strike Force team in Miami, which represented over 27 percent of 
funding for all Strike Force teams. The first Strike Force team was 
officially launched in Miami in fiscal year 2007, based in part on an 
HHS-OIG evaluation that found aberrant claims patterns for infusion 
therapy for Medicare beneficiaries with HIV/AIDs that differentiated 
South Florida Medicare providers and beneficiaries from the rest of 
the country.[Footnote 36] Additionally, obligations for Miami's Strike 
Force team were more than twice as much as in Detroit, the team with 
the second highest obligations for fiscal year 2012 ($5.1 million). 

Based on the obligations reported for fiscal year 2012, HHS-OIG's 
Office of Investigations accounted for 45 percent of the total 
obligations used for Strike Force teams. The FBI incurred 25 percent, 
DOJ's Criminal Division incurred 17 percent, and the USAOs incurred 13 
percent of obligations for the Strike Force teams. HHS-OIG's Office of 
Investigations and the FBI's agents conduct investigations and gather 
evidence, such as through surveillance for Strike Force cases, while 
DOJ's Criminal Division and the USAOs' attorneys are the primary 
prosecutors of Strike Force cases. Additionally, although not 
reflected in the table above, CMS obligated approximately $350,656 in 
discretionary HCFAC appropriations to support Strike Force Teams. 
CMS's HCFAC obligations were not associated with any one individual 
Strike Force city. 

Since fiscal year 2010, the USAOs have used some of their HCFAC 
discretionary appropriation for three Special Focus teams--in San 
Francisco, Boston, and Philadelphia. These Special Focus teams are 
similar to the Strike Force teams, but handle pharmaceutical civil 
cases rather than criminal cases. Approximately $2.8 million of the 
USAOs' HCFAC obligations in fiscal year 2012 were for these Special 
Focus teams. This amount was in addition to the HCFAC obligations they 
used for the Strike Force teams. 

Agencies Use Several Indicators to Assess HCFAC Activities, and Some 
Key Outputs Changed Over Time: 

HHS, HHS-OIG, and DOJ use several indicators to assess HCFAC 
activities as well as to inform decision-makers about how to allocate 
resources. These indicators include those listed in the annual HCFAC 
report as well as others outlined in agency reports. For example, FDA 
assesses the work of its Pharmaceutical Fraud Program by tracking the 
number of criminal investigations opened and the outcomes of criminal 
convictions obtained, among other indicators. Additionally, many of 
the indicators that HHS, HHS-OIG, and DOJ use reflect the collective 
work of multiple agencies since they work many health care fraud cases 
jointly. Outputs from some of these key indicators have changed in 
recent fiscal years. For example, the return-on-investment has 
increased from $4.90 returned for every $1.00 invested for fiscal 
years 2006-2008 to $7.90 returned for every $1.00 invested for fiscal 
years 2010-2012. 

HHS, HHS-OIG, and DOJ Use Several Indicators to Assess HCFAC 
Activities and Inform Decisions about Resource Allocation and 
Prioritization of Activities: 

HHS, HHS-OIG, and DOJ officials reported using several indicators to 
assess HCFAC activities and that those indicators serve multiple 
purposes. Several indicators are included in the annual HCFAC report, 
while other indicators are reported in agency documents or used 
internally. Additionally, some indicators are collective--in that they 
reflect the work of multiple agencies--and other indicators outline 
the activities conducted by a particular agency or component. Appendix 
III, tables 5 through 8, provides detailed information on indicators 
used to assess the activities conducted using HCFAC funding, including 
those outlined in the HCFAC report, as well as other indicators the 
agencies use, by agency and component. 

HHS Indicators: 

Each HHS component conducts unique activities related to health care 
fraud and abuse. As a result of these different types of activities, 
the indicators that each HHS component uses to highlight the 
accomplishments of its HCFAC activities vary. 

FDA uses indicators associated with its Pharmaceutical Fraud program--
which focuses on detecting, prosecuting, and preventing 
pharmaceutical, biologic, and medical device fraud--including the 
number of criminal investigations opened during a fiscal year and the 
outcomes of criminal convictions obtained (such as amount of jail 
time, probation, or amount of restitution). FDA officials told us that 
the indicators they use are outlined in the annual HCFAC report. For 
example, FDA reported in the fiscal year 2012 HCFAC report that it had 
opened 42 criminal investigations since the inception of the 
Pharmaceutical Fraud Program, and 17 investigations during fiscal year 
2012. 

ACL primarily uses indicators that track information related to the 
Senior Medicare Patrol (SMP) programs--which train senior volunteers 
to inform fellow beneficiaries on how to detect and prevent fraud, 
waste, and abuse in the Medicare program--such as indicators related 
to beneficiary education and training, outreach activities, and events 
the SMP programs conduct, and cases that were referred for 
investigation. For instance, ACL tracks the number of group education 
sessions the SMPs conduct and the estimated number of beneficiaries 
who attended the sessions. Many of the indicators ACL uses are 
outlined in an annual HHS-OIG report on the SMP programs, as well as 
the annual HCFAC report.[Footnote 37] According to ACL officials, ACL 
has hired a contractor to assess the adequacy of the current 
indicators used by ACL and to determine if the indicators are 
appropriate for evaluating the performance of the SMPs. 

HHS's OGC uses several indicators to assess the HCFAC activities it 
conducts. These indicators include amounts of recoveries for matters 
on which OGC has assisted--such as False Claims Act matters and civil 
monetary penalties--and the number of physician self-referral 
disclosures in which OGC advised.[Footnote 38] As with the other HHS 
agencies, OGC's indicators are outlined in the annual HCFAC report. 

CMS officials told us that CMS uses a variety of indicators to assess 
the HCFAC activities included in our review. For the Medicaid and CHIP 
financial management project, CMS tracks information related to the 
amount of the federal share of Medicaid funds that were recovered as a 
result of the project's monitoring and financial management reviews of 
Medicaid expenditures. For the community mental health centers study, 
CMS officials told us that they do not have indicators since the 
project is relatively new. For CMS's efforts associated with the 
Strike Force teams, officials told us that one indicator they use is 
the drop in number of claims for particular services, which they 
believe coincides with the efforts of the Strike Force teams to 
investigate and prosecute fraud. For example, according to information 
that CMS provided to us, payments for home health services dropped by 
nearly one-half from 2008 to 2011 in Miami-Dade County, which 
officials believe was, in part, due to the Strike Force team's efforts 
focused on reducing fraud in home health care. 

HHS-OIG Indicators: 

HHS-OIG uses a variety of indicators to assess the work it conducts 
using HCFAC funds. Some of these indicators reflect the collective 
work of HHS-OIG's components and some are unique to the activities 
conducted by a particular component. For example, HHS-OIG tracks the 
health care savings attributable to HHS-OIG investigations, audits, 
and evaluations. This indicator includes work from nearly all HHS-OIG 
components, including the Office of Investigations, the Office of 
Audit Services, and the Office of Evaluation and Inspections. Among 
many other indicators, HHS-OIG's Office of Counsel to the Inspector 
General tracks the number of corporate integrity agreements monitored 
for compliance, which is specific to the work of that office.[Footnote 
39] HHS-OIG officials told us that the indicators they use to assess 
HCFAC activities are reported in the annual HCFAC report and in other 
HHS-OIG reports (such as its semi-annual reports to Congress). 

DOJ Indicators: 

DOJ uses several indicators to assess the work it conducts with HCFAC 
funding. The indicators it uses relate to the activities that each DOJ 
component conducts to enforce health care fraud and abuse laws. For 
example, the USAOs use indicators related to criminal prosecutions, 
including the number of defendants charged and the number of 
convictions. In addition to those measures, the USAOs also track 
information related to civil matters, such as the number of pending 
civil investigations. 

In addition to the indicators listed in the annual HCFAC report, 
officials from DOJ's components told us that they use other indicators 
to assess the work they conduct related to health care fraud and 
abuse. Officials told us that these indicators are tracked at the 
departmental level and aggregate the work of multiple DOJ components. 
For example, DOJ tracks the percentage of criminal and civil cases 
resolved favorably. These indicators include health care fraud cases, 
as well as other cases that DOJ components handle. 

Indicators Inform Decisions about Resource Allocation and 
Prioritization of Activities: 

Officials from HHS, HHS-OIG, and DOJ told us that they use indicators 
to inform decision-makers about how to allocate resources. For 
example, officials from DOJ's Civil Rights Division told us that they 
use indicators to help determine what resources they need to handle 
their current caseload. The Civil Rights Division considers the number 
of cases the division is currently working along with the number of 
remedial agreements with facilities that the division needs to monitor 
in the upcoming year when developing requests for funding. 
Additionally, officials from FDA told us that they review the 
preceding year's number of investigations and the costs associated 
with those investigations, when requesting annual funding. 

Additionally, HHS, HHS-OIG, and DOJ officials indicated that they use 
data to inform their decisions about which activities to prioritize, 
including what cases or studies to undertake, as well as where to 
locate specific resources. For example, officials from HHS-OIG told us 
that they use Medicare claims data to identify which service areas to 
target for investigations, audits, or evaluations, as well as which 
geographic regions to focus their efforts. Officials said that they 
continually review whether HHS-OIG staff are located in the most 
appropriate geographic areas and have relocated staff to areas to 
enhance the efficiency of HHS-OIG resources. HHS-OIG officials also 
told us that the agency uses several indicators for internal 
management purposes. Additionally, officials from DOJ's Criminal 
Division told us that one factor they consider when deciding how to 
prioritize cases is to review data analyses to focus on cases with 
large amounts of alleged fraudulent billing. 

Some Key Outputs that Reflect Work of Multiple Agencies Have Changed 
in Recent Years: 

Since HHS-OIG and DOJ's components work many health care fraud cases 
jointly, many of the indicators included in the annual HCFAC report 
highlight the work of both HHS-OIG and DOJ, as well as various 
components within each agency. For example, the report includes 
information on the results of HCFAC activities, such as the dollar 
amount recovered as a result of fraud cases, which HHS-OIG and DOJ 
officials say reflects the investigative work done by HHS-OIG and FBI, 
as well as the work of DOJ's components in prosecuting the cases. 
Additionally, the report presents several indicators related to the 
work of the Strike Force teams, such as the number of indictments and 
complaints involving charges that were filed, the outcomes of the 
cases, and the total amount of alleged billing to Medicare as a result 
of these Strike Force cases. 

The return-on-investment is another indicator that reflects the work 
of multiple agencies and has changed in recent years. We have 
recognized that agencies can use a return-on-investment as a valuable 
tool for assessing a program's activities and for determining how best 
to target resources.[Footnote 40] The return-on-investment is included 
in the annual HCFAC report and compares the amount of funds that were 
returned to the Medicare Trust Funds, such as restitution and 
compensatory damages awarded, with the amount of appropriations for 
HCFAC activities. Specifically: 

* The total returns--the numerator--includes deposits to the Medicare 
Trust Funds. The calculation includes amounts that were deposited into 
the Medicare Trust Funds rather than amounts that were ordered or 
negotiated in health care fraud and abuse cases, but not yet 
transferred to the Medicare Trust Funds. Officials reported that 
although there may be large amounts of restitution ordered or agreed 
upon in health care fraud cases, the amounts actually returned to the 
Medicare Trust Funds may be lower.[Footnote 41],[Footnote 42] By 
including only those funds that have been returned to the Medicare 
Trust Funds, the return-on-investment is not artificially inflated. 

* The total investment--the denominator--includes mandatory and 
discretionary HCFAC funds that were appropriated to HHS, HHS-OIG, and 
DOJ (including the FBI's mandatory funds devoted to health care fraud 
and abuse reduction activities) and does not include funding from 
other appropriations. DOJ officials told us that the HCFAC funding 
that CMS receives through HHS's wedge fund is included in the return-
on-investment calculation, and a small portion of HCFAC discretionary 
funds that CMS uses to support the Strike Force teams.[Footnote 43] 

* Return-on-investment is calculated using a 3-year moving average. To 
account for differences in the amounts returned to the Medicare Trust 
Funds between years, the return-on-investment is calculated using a 3-
year average. For example, a case may have been investigated in fiscal 
year 2010 but not settled until fiscal year 2012, and thus the funds 
received from that case would not be deposited until 2012. Similarly, 
although agencies may carry over HCFAC appropriations into future 
fiscal years, the amount of appropriations included in the calculation 
is also based on a 3-year average with carry over amounts included in 
the year in which they were appropriated.[Footnote 44] 

According to the annual HCFAC report, the return-on-investment for 
fiscal years 2010-2012 was $7.90 returned to the Medicare Trust Funds 
for every $1.00 of HCFAC funds appropriated for HCFAC activities. The 
return-on-investment increased steadily from fiscal year 2008 to 2012. 
In fiscal years 2006-2008, the return-on-investment was $4.90 to 
$1.00, and in fiscal years 2010-2012, the return-on-investment was the 
highest at $7.90 to $1.00. See figure 3 for additional information on 
the return-on-investment for fiscal years 2008-2012. 

Figure 3: Health Care Fraud and Abuse Control (HCFAC) Program Return-
on-Investment, Fiscal Years 2008 through 2012: 

[Refer to PDF for image: line graph] 

Fiscal year: 2008; 
Return-on-investment: 4.9:1. 

Fiscal year: 2009; 
Return-on-investment: 5.1:1. 

Fiscal year: 2010; 
Return-on-investment: 5.8:1. 

Fiscal year: 2011; 
Return-on-investment: 7.2:1. 

Fiscal year: 2012; 
Return-on-investment: 7.9:1. 

Source: GAO analysis of information provided by DOJ for fiscal years 
2008-2012. 

Note: The return-on-investment is based on amounts recovered from 
HCFAC activities and deposited into the Medicare Trust Funds and 
amounts appropriated to Department of Health and Human Services (HHS), 
HHS Office of Inspector General, and the Department of Justice (DOJ) 
to conduct HCFAC activities. The information about the return-on-
investment was obtained from DOJ. The return-on-investment is 
calculated using a 3-year moving average and, as a result, the 
calculation for each fiscal year incorporates amounts that were 
deposited into the Medicare Trust Funds and appropriations from that 
fiscal year and the two prior fiscal years. For example, the return-on-
investment for fiscal year 2008 is calculated using the amounts from 
fiscal years 2006, 2007, and 2008. Additionally, because many fraud 
cases can take years to investigate and prosecute, the amounts 
deposited into the Medicare Trust Funds may have been the result of 
prior year's HCFAC activities. 

[End of figure] 

A review of other key outputs listed in the annual HCFAC reports from 
2008 through 2012 that reflect accomplishments or outputs of 
activities conducted by multiple agencies using HCFAC funding shows 
some key outputs have generally increased and some have remained 
stable. During the same time period, HCFAC obligations and funding 
from other appropriations used to support HCFAC activities increased 
about 38 percent. See figure 4 for data on selected key outputs for 
fiscal years 2008 to 2012, and see appendix IV, table 9 for additional 
detailed information on the key outputs for fiscal years 2008 to 2012. 

Figure 4: Selected Key Program Outputs and Total Obligations for 
Health Care Fraud and Abuse Control (HCFAC) Program Activities, Fiscal 
Years 2008 through 2012: 

[Refer to PDF for image: combined stacked vertical bar and line graph] 

Fiscal year: 2008; 
Obligations of HCFAC mandatory appropriations: $355.0 million; 
Obligations of HCFAC discretionary appropriations: $0; 
Obligations of other appropriations: $67.3 million; 
Number of new criminal health care fraud investigations opened: 957; 
Number of cases where criminal charges were filed: 502; 
Number of defendants convicted of health care fraud-related crimes: 
588; 
Number of new civil health care fraud investigations opened: 843. 

Fiscal year: 2009; 
Obligations of HCFAC mandatory appropriations: $366.1 million; 
Obligations of HCFAC discretionary appropriations: $39.1 million; 
Obligations of other appropriations: $80.8 million; 
Number of new criminal health care fraud investigations opened: 1,014; 
Number of cases where criminal charges were filed: 481; 
Number of defendants convicted of health care fraud-related crimes: 
583; 
Number of new civil health care fraud investigations opened: 886. 

Fiscal year: 2010; 
Obligations of HCFAC mandatory appropriations: $387.0 million; 
Obligations of HCFAC discretionary appropriations: $32.6 million; 
Obligations of other appropriations: $75.1 million; 
Number of new criminal health care fraud investigations opened: 1,116; 
Number of cases where criminal charges were filed: 488; 
Number of defendants convicted of health care fraud-related crimes: 
726; 
Number of new civil health care fraud investigations opened: 942. 

Fiscal year: 2011; 
Obligations of HCFAC mandatory appropriations: $395.9 million; 
Obligations of HCFAC discretionary appropriations: $78.4 million; 
Obligations of other appropriations: $91.5 million; 
Number of new criminal health care fraud investigations opened: 1,110; 
Number of cases where criminal charges were filed: 489; 
Number of defendants convicted of health care fraud-related crimes: 
743; 
Number of new civil health care fraud investigations opened: 977. 

Fiscal year: 2012; 
Obligations of HCFAC mandatory appropriations: $452.9 million; 
Obligations of HCFAC discretionary appropriations: $63.5 million; 
Obligations of other appropriations: $67.2 million; 
Number of new criminal health care fraud investigations opened: 1,131; 
Number of cases where criminal charges were filed: 452; 
Number of defendants convicted of health care fraud-related crimes: 
826; 
Number of new civil health care fraud investigations opened: 885. 

Source: GAO analysis of annual HCFAC reports for fiscal years 2008-
2012 and obligations for HCFAC activities reported to GAO by 
HHS, HHS Office of Inspector General, and Department of Justice. 

Note: Since many fraud cases can take years to investigate and 
prosecute, the number of investigations, cases, and defendants 
reported in the figure above may have been the result of a prior 
year's HCFAC activities. The obligations information included in the 
figure above reports obligations for HCFAC activities that Department 
of Justice, Department of Health and Human Services (HHS), and HHS 
Office of Inspector General reported to GAO for a single fiscal year. 

[End of figure] 

One key output that has increased since fiscal year 2008 is the number 
of defendants convicted of health care fraud. For example, the number 
of defendants convicted of health care fraud generally increased from 
around 588 in fiscal year 2008 to 826 in fiscal year 2012 (a 40 
percent increase). 

Some key outputs did not change between fiscal years 2008 and 2012. 
While funding has increased since 2008, there has not been a 
consistent pattern of increasing outputs. For example, the number of 
new criminal health care fraud investigations opened increased from 
fiscal year 2008 (957 investigations) to fiscal year 2012 (1,131 
investigations). Additionally, the number of new civil health care 
fraud investigations opened did not vary much between 2008 (843 cases) 
and 2012 (885 cases). 

HHS-OIG and DOJ officials indicated that there are a number of factors 
that might contribute to these trends. DOJ officials told us that the 
complexity of fraud cases has increased in recent years and requires 
more substantial resources to investigate and prosecute than other, 
less-complex cases. Officials stated that this limits the amount of 
resources they are able to commit to other cases. HHS-OIG and DOJ 
officials also cited other factors, including external factors (such 
as an increase in the number of defendants opting to go to trial) and 
significant changes to federal health care programs (such as the 
implementation of the Medicare Part D prescription drug program), 
which might influence these trends. 

Nonetheless, HHS-OIG and DOJ officials indicated that they consider 
the increase since 2008 in some of the key outputs to be significant. 
For example, HHS-OIG officials noted that there was an increase of 42 
civil fraud investigations from 2008 to 2012, and they consider the 
increase to be of significance given the complexity of fraud schemes 
and the resources needed to handle these civil cases. Additionally, 
DOJ officials told us that they consider increases to the number of 
new criminal fraud investigations opened (an increase of 18 percent) 
to be significant. DOJ officials also indicated that several key 
outputs related to the Strike Force teams have increased since 2008. 
See appendix IV for detailed information on key outputs related to 
HCFAC activities, including the Strike Force teams. 

Several Factors Contribute to Lack of Information about the 
Effectiveness of HCFAC Activities: 

The indicators used by agencies to track the outputs of HCFAC 
activities provide information on the accomplishments of HCFAC 
activities, not on the effectiveness of the activities in reducing 
health care fraud and abuse. HHS, HHS-OIG, and DOJ officials reported 
that they consider the indicators to be the outputs or accomplishments 
of the HCFAC activities they conduct and in that sense they provide a 
composite picture of the achievements of the HCFAC program. However, 
difficulty in establishing a causal link between HCFAC activities and 
output indicators, difficulty in determining the deterrent effect 
HCFAC activities may have on potential health care fraud and abuse, 
limited research on the effectiveness of health care fraud 
interventions, and the lack of a health care fraud baseline hinder a 
broader understanding of the effectiveness of the HCFAC program in 
reducing health care fraud and abuse. 

Indicators Agencies Use to Assess HCFAC Activities Provide Information 
on Accomplishments, but Not Effectiveness: 

The indicators that HHS, HHS-OIG, and DOJ use to track HCFAC 
activities offer insights on the accomplishments and outputs of HCFAC 
activities, but they do not measure the effectiveness of the HCFAC 
program in reducing health care fraud and abuse. HHS, HHS-OIG, and DOJ 
officials reported that they consider the indicators they use to be 
the accomplishments or outputs of the HCFAC activities they conduct. 
For example, the key program outputs discussed earlier in this report 
reflect accomplishments of activities agencies conduct using HCFAC 
funding. Officials from HHS, HHS-OIG, and DOJ told us that these 
indicators can be used to provide insights on program activities or 
the number of actions a component has been able to accomplish in a 
specific time frame (e.g., the number of defendants convicted in a 
fiscal year). However, several HHS and DOJ agency officials told us 
that they do not consider these indicators to be measures of the 
performance or the effectiveness of the HCFAC program in reducing 
health care fraud. The return-on-investment is an example of an 
indicator that describes program results but does not measure program 
effectiveness. We found that the return-on-investment provides 
information on the accomplishments of HCFAC activities in relationship 
to the amount of funds appropriated for these activities, but does not 
provide information on the extent to which the HCFAC program reduces 
health care fraud. 

Additionally, most of the indicators used to track HCFAC activities do 
not have targets or goals associated with them. Although standard 
practices for internal controls indicate that ongoing performance 
monitoring should include comparison of performance indicator data 
against planned targets, our previous work has recognized that 
establishing measures and setting specific targets in the law 
enforcement area can be challenging.[Footnote 45] Officials from HHS, 
HHS-OIG, and DOJ told us that they intentionally do not set 
performance targets for indicators such as the number of health care 
fraud investigations or prosecutions undertaken because such targets 
could cause the public to perceive law enforcement as engaging in 
"bounty hunting" or pursuing arbitrary targets merely to meet 
particular goals.[Footnote 46] The officials believe that it is 
important that agencies carry out law enforcement actions that are 
based on merit and avoid the appearance that they strive to achieve 
certain numerical quotas. 

Several Factors Make Assessing the Effectiveness of the HCFAC Program 
Challenging: 

HHS, HHS-OIG, and DOJ officials, as well as literature we reviewed, 
indicate that there are several factors that make assessing the 
effectiveness of the HCFAC program in reducing health care fraud and 
abuse challenging. 

Establishing a Causal Link: 

It is difficult to establish if the HCFAC program has a direct 
relationship to changes in the amount of health care fraud and abuse. 
HHS, HHS-OIG, and DOJ officials told us that HCFAC activities--as well 
as other efforts by federal agencies and others, including non-
government entities--may have helped reduce health care fraud; 
however, the effect that any of these actions may have had on health 
care fraud and abuse is difficult to isolate. For example, HHS-OIG 
officials stated that compliance training and guidance provided by the 
HHS-OIG to health care organization directors--an activity conducted 
with HCFAC funding--may have had an effect on health care fraud but 
that it is difficult to isolate how much of an effect the activity has 
had. However, according to HHS-OIG officials, a rise in the number of 
provider compliance programs established by hospital organizations in 
response to shareholder interest in improving compliance with federal 
and state health care program requirements may also contribute to 
reductions in health care fraud. Moreover, many efforts within CMS aim 
to reduce health care fraud and abuse, in addition to those identified 
as HCFAC activities, and it is difficult to know which CMS program or 
activity has had an effect on the incidence of fraud. For example, CMS 
has implemented a number of initiatives to prevent health care fraud 
and abuse that are not funded with HCFAC funds. One such effort is a 
change to the provider enrollment process, which is designed to better 
ensure that only legitimate providers and suppliers are allowed to 
bill Medicare. However, it is difficult to isolate the effect that 
either HCFAC activities or broader CMS efforts may have had in 
reducing health care fraud and abuse. 

Measuring Deterrence: 

Another factor that limits understanding of the effectiveness of the 
HCFAC program in reducing health care fraud and abuse is the 
difficulty in quantifying the HCFAC program's effect in deterring 
health care fraud and abuse. DOJ officials provided anecdotal evidence 
that HCFAC activities help to deter would-be offenders. For example, a 
Justice Management Division official asserted that DOJ prosecutions 
that result in doctors being sentenced to prison for health care fraud 
and abuse deter other doctors who are contemplating committing fraud. 
Other DOJ officials reported that cooperating witnesses in health care 
fraud investigations have told officials of instances where a provider 
committing potentially fraudulent acts had ceased operations because 
of the pressure brought on by Strike Force prosecutions. DOJ officials 
stated that they could recall about a dozen examples of specific 
individuals who have said they were deterred from committing fraud or 
ceased a fraudulent operation because they saw another individual get 
caught. However, these examples are anecdotal and DOJ and HHS-OIG 
officials stated that it is difficult to know how much health care 
fraud is deterred as a result of HCFAC activities. 

Limited Research: 

Research on the effectiveness of health care fraud and abuse 
interventions, and on ways to measure the effectiveness of health care 
fraud and abuse interventions has been limited. We found that none of 
the 49 articles we selected to review for this study evaluated the 
effectiveness of the HCFAC program specifically, and few studies 
examined the effectiveness of health care fraud and abuse 
interventions in general. A recent review of literature conducted by 
experts in the field found similar results.[Footnote 47] 

Establishing a Health Care Fraud Baseline: 

Another challenge that limits the ability to determine whether HCFAC 
activities are effective in reducing health care fraud and abuse is 
the lack of a baseline for the amount of health care fraud that exists 
at any point in time. Having such a baseline could provide information 
on the amount of health care fraud and how much it has changed in a 
given year or over time. We have previously reported that there 
currently is no reliable baseline estimate of the amount of health 
care fraud in the United States.[Footnote 48] Several experts told us 
or have written about the importance of establishing a baseline in 
assessing the effectiveness of law enforcement programs. A baseline 
estimate could provide an understanding of the extent of fraud and, 
with additional information on program activities, could help to 
inform decision-making related to allocation of resources to combat 
health care fraud. 

HHS and CMS have taken steps to try to establish a health care fraud 
baseline because, according to the fiscal year 2012 HCFAC report, they 
appreciate that a baseline would allow the agencies to evaluate the 
success of fraud prevention activities. HHS officials stated that the 
Assistant Secretary for Planning and Evaluation initiated work to 
establish a baseline measurement, and that work was subsequently 
transferred to CMS's Center for Program Integrity. According to the 
fiscal year 2012 HCFAC report, the project is designed to measure 
probable fraud in home health care agencies and will pilot test a 
measurement approach and calculate an estimate of probable fraud for 
specific home health care services. CMS and its contractor will 
collect information from home health care agencies, the referring 
physicians, and Medicare beneficiaries selected in a national random 
sample of home health care claims. The pilot will rely on the 
information collected along with a summary of the service history of 
the home health care agency, the referring provider, and the 
beneficiary to estimate the percentage of total payments that are 
associated with probable fraud, and the percentage of all claims that 
are associated with probable fraud for Medicare fee-for-service home 
health care. CMS reports that after completion of the pilot, it will 
determine whether the measurement approach should be expanded to other 
areas of health care. Officials from the Center for Program Integrity 
stated that as of May 2013, they were beginning the data collection 
phase of the fraud baseline measurement pilot, which they expect will 
last two years. 

Some HCFAC-funded agencies have attempted to determine the effect of 
HCFAC activities on specific types of fraud in certain locations. DOJ 
officials provided examples of reductions in billings for certain 
services in specific locations and told us that they believe these 
reductions are associated with the work of the Strike Force teams. For 
example, DOJ officials reported assessing the amount of home health 
care billings in certain Strike Force cities before the Strike Force 
began operations and then again after the Strike Force had begun 
operations.[Footnote 49] Since the amount of home health care billing 
was measured before and after the Strike Force was implemented, HHS, 
HHS-OIG, and DOJ officials are able to estimate some effect that the 
Strike Force team had on the amount of billing in that area. For 
example, in a May 14, 2013 press conference, the Attorney General 
noted that after the Detroit Strike Force began investigating cases of 
potential group-psychotherapy fraud, claims for this type of treatment 
in Detroit dropped by more than 70 percent since January 2011. 
[Footnote 50] 

Concluding Observations: 

Making progress in preventing and reducing health care fraud and abuse 
is an essential yet challenging task. HHS and DOJ use a number of 
indicators to assess the activities they conduct to reduce health care 
fraud and abuse. However, the indicators do not provide information 
about the effectiveness of the program, and little is known about 
whether and how well the HCFAC program reduces health care fraud. 
While positive results on the program's return-on-investment can be 
seen as an indication of program success, the return-on-investment 
does not indicate the extent to which the program is reducing fraud. 
For example, the increasing returns from the fraud that is being 
investigated and prosecuted may indicate that HCFAC programming is 
effective in detecting or deterring potentially fraudulent schemes or 
indicate that there is simply an increase in potentially fraudulent 
activity. CMS's recent efforts to establish a home health care fraud 
baseline is a good first step to understanding the extent of the 
problem and, if implemented as planned, could provide policymakers 
with information on how much fraud exists and in coming years, how 
potentially fraudulent activity has increased or decreased over time. 
However, CMS has not yet determined whether the methodology used to 
establish a baseline of probable fraud in home health care could be 
used to assess the amount of fraud in other health care services. 
Additionally, even with a baseline estimate of the total amount of 
probable fraud, there will likely be continuing challenges in 
understanding the effectiveness of the HCFAC program, such as 
isolating the program's ability to reduce or prevent fraud and abuse. 
Despite these inherent challenges, if a health care fraud baseline is 
established more broadly, it may become feasible to study how 
individual HCFAC activities, and possibly the program as a whole, 
affects changes in health care fraud. Results from these studies could 
provide HHS and DOJ with additional information regarding which 
activities are the most effective in reducing health care fraud and 
abuse, and could potentially inform agency decisions about how best to 
allocate limited resources. 

Agency Comments: 

GAO provided a draft of the report to HHS and DOJ. In its written 
comments reproduced in appendix V, HHS discussed its program integrity 
efforts to reduce fraud, waste, and abuse. HHS also provided examples 
of CMS's efforts to reduce fraud, waste, and abuse in Medicare. The 
examples provided were not included in our review because they were 
not included in the funding used to calculate the return-on-investment 
for the HCFAC program. While not commenting specifically on our 
report, DOJ sent us examples of reductions in Medicare billings for 
specific services (such as durable medical equipment, home health 
services, and community mental health center services) in certain 
Strike Force cities. In their comments, DOJ officials stated that 
based on their examples, the Strike Force efforts have had a lasting 
effect on savings to Medicare payments. In addition, HHS and DOJ 
provided technical comments, which we have incorporated as appropriate. 

As agreed with your offices, unless you publicly announce the contents 
of this report earlier, we plan no further distribution until 30 days 
from the report date. At that time, we will send copies to the 
Secretary of HHS, the Attorney General, the Inspector General of HHS, 
and other interested parties. In addition, the report will be 
available at no charge on GAO's website at [hyperlink, 
http://www.gao.gov]. If you or your staff have any questions about 
this report, please contact Kathleen M. King at (202) 512-7114 or 
kingk@gao.gov or Eileen R. Larence at (202) 512-8777 or 
larencee@gao.gov. Contact points for our Offices of Congressional 
Relations and Public Affairs may be found on the last page of this 
report. Key contributors to this report are listed in appendix VI. 

Signed by: 

Kathleen M. King: 
Director, Health Care: 

Signed by: 

Eileen R. Larence: 
Director, Homeland Security and Justice: 

[End of section] 

Appendix I: Health Care Fraud and Abuse Control (HCFAC) Program 
Activities Conducted by Agencies in Fiscal Year 2012: 

The activities listed in table 2 below represent only activities that 
are supported with HCFAC funds (as reported in agency documents or 
interviews with agency officials). The table does not include other 
activities conducted by the agencies that are not related to health 
care fraud and abuse control. 

Table 2: Agencies, Components, and Health Care Fraud and Abuse Control 
(HCFAC) Program Activities: 

Agency: Department of Health and Human Services (HHS); 

Component: Office of General Counsel (OGC); 
HCFAC Activities: Supports program integrity work of its clients (such 
as the Centers for Medicare & Medicaid Services) through a variety of 
activities. Among other activities, OGC works to recover payments by 
Medicare that are the primary responsibility of other payers under the 
Medicare Secondary Payer provisions, which preclude Medicare payment 
for services and items that certain other health insurance or coverage 
is primarily responsible for paying; to protect Medicare funds when 
providers seek bankruptcy protections; and to defend CMS and its 
contractors in cases seeking damages for the alleged wrongful denial 
of claims and other actions. In addition, OGC assists CMS in 
implementing provisions of the Patient Protection and Affordable Care 
Act; and provides legal advice to CMS regarding the development and 
imposition of Civil Monetary Penalties and defends CMS in 
administrative appeals and judicial litigation resulting from these 
cases. OGC also participates in the Health Care Fraud Prevention and 
Enforcement Action Team (HEAT) initiative; and assists the Department 
of Justice (DOJ) with cases filed under the False Claims Act. 

Component: Administration for Community Living (ACL); 
HCFAC Activities: Agency: Provides infrastructure, technical 
assistance, and program support for the Senior Medicare Patrol (SMP) 
programs. Additionally, in fiscal year 2012, ACL used HCFAC funding to 
expand SMP programs and funded two technical assistance grantees. 

Component: Centers for Medicare & Medicaid Services (CMS); 
HCFAC Activities: Agency: Supports, among many other program integrity 
activities, the Medicaid and Children's Health Insurance Program 
(CHIP) financial oversight project, which conducts a variety of 
financial oversight activities, including monitoring of Medicaid 
expenditures and financial management reviews of Medicaid. Project 
activities include reviews of proposed Medicaid state plan 
methodologies and associated financing sources, to ensure their 
compliance with federal requirements. Additionally, CMS conducts a 
pilot project designed to use predictive modeling and data analytics 
to detect fraud and abuse in community mental health centers in 
Florida, Texas, and Louisiana. The pilot is related to funding 
received by community mental health centers for partial 
hospitalization services, where CMS has seen high levels of fraud and 
abuse and will identify high risk providers, conduct targeted site 
visits, and apply appropriate corrective actions, such as revocations, 
suspensions, and referrals to law enforcement. Finally, CMS uses some 
of its HCFAC appropriations for its contributions to the Strike Force 
teams--which are comprised of staff from federal, state, and local 
investigation agencies, designed to combat Medicare fraud by using 
technology, such as data analysis techniques--located in nine cities 
nationwide. 

Component: Food and Drug Administration (FDA); 
HCFAC Activities: Conducts Pharmaceutical Fraud Program to detect, 
investigate, prosecute, and prevent pharmaceutical, biologic, and 
medical device fraud. 

Agency: Department of Health and Human Services' Office of Inspector 
General (HHS-OIG); 

Component: Office of Audit Services (OAS); 
HCFAC Activities: Conducts independent audits of HHS programs, 
grantees, and contractors. These audits review CMS operations and 
external entities that play a role in providing Medicare and Medicaid 
services, including Medicare contractors, state Medicaid agencies, and 
providers of healthcare services. These audits review program 
performance, identify opportunities for reducing costs, assess 
compliance with federal laws and HHS regulations, recommend recovery 
of improper payments, and identify vulnerabilities in systems controls 
and operations. OAS also responds to health care-related complaints 
received by the OIG Hotline; reviews proposed regulations and laws 
relating to Medicare and Medicaid; and responds to congressional 
requests. 

Component: Office of Evaluation and Inspections (OEI); 
HCFAC Activities: Agency: Conducts national evaluations to provide 
HHS, Congress, and the public with information on issues related to 
preventing fraud, waste, and abuse; and promoting economy, efficiency, 
and effectiveness of HHS programs. OEI reports also include 
recommendations for improving HHS program operations. OEI issues 
referrals (both internally and externally) to identify specific 
entities--such as providers and suppliers--that merit further study or 
investigation. 

Component: Office of Investigations (OI); 
HCFAC Activities: Agency: Coordinates and conducts investigations of 
allegations of fraud, waste, and abuse in HHS programs, including 
Medicare, Medicaid, and CHIP. OI is also responsible for excluding 
certain individuals and entities, such as physicians and 
pharmaceutical or device manufacturers, from participating in federal 
health care programs for certain types of conduct. OI investigators 
also play an active role in the Strike Force teams. OI also oversees 
the operations of the OIG Hotline, which receives complaints of fraud, 
waste, abuse, and mismanagement related to all HHS programs, and 
serves as the primary point of contact to report fraud. 

Component: Office of Counsel to the Inspector General (OCIG); 
HCFAC Activities: Agency: Exercises the authority to impose civil and 
administrative penalties related to health care fraud, including civil 
monetary penalties. OCIG also litigates appeals of exclusions, and 
assists on civil False Claims Act cases and settlements. Additionally, 
OCIG operates the voluntary disclosure program for providers--a 
program whereby providers can voluntarily report their fraudulent 
conduct affecting Medicare, Medicaid, and other federal health care 
programs; monitors compliance with Corporate Integrity Agreements; 
and provides industry guidance, such as through advisory opinions, 
fraud alerts, and public outreach/training. According to OCIG 
officials, OCIG also provides legal support for HHS-OIG's evaluations 
and audits and legal clearance on issuance of all HHS-OIG subpoenas 
and uses of electronic surveillance by OI. 

Component: Office of Management and Policy (OMP); 
HCFAC Activities: Provides management, guidance, and resources in 
support of HHS-OIG's other components, including budget formulation 
and execution, human capital planning, information technology 
solutions, and administrative services (such as space management, 
travel, and policies). 

Agency: Department of Justice (DOJ); 

Component: Criminal Division; 
HCFAC Activities: Initiates and coordinates health care fraud 
prosecutions and supports the United States Attorney's Offices (USAO) 
with legal and investigative guidance and training and attorneys to 
prosecute violations of criminal health care fraud. DOJ's Criminal 
Division plays an active role in the Strike Force teams, as well as 
provides legal guidance, such as through annual health care fraud 
training conferences and review of qui tam, or whistleblower, lawsuits 
under the False Claims Act to assess whether the defendants in such 
lawsuits have engaged in criminal activity. DOJ's Criminal Division 
also supports investigations and prosecutions of fraud and abuse 
targeting private sector health plans sponsored by employers and/or 
unions, as well as investigations and prosecutions of health care 
frauds perpetrated by domestic and international organized crime 
groups. 

Component: Civil Division; 
HCFAC Activities: Agency: Investigates and resolves matters against a 
wide array of health care providers and suppliers, often in response 
to qui tam, or whistleblower, lawsuits filed under the False Claims 
Act. For example, the Civil Division represents the U.S. government in 
civil matters, such as cases alleging that a pharmaceutical 
manufacturer has illegally marketed a prescription drug for an 
unapproved use and cases alleging that a provider improperly billed 
Medicare. The Elder Justice and Nursing Home Initiative, within the 
Civil Division, coordinates and supports law enforcement efforts to 
combat elder abuse, neglect, and financial exploitation, by hosting 
quarterly conference calls with DOJ attorneys to discuss issues or 
developments in connection with nursing home or failure of care cases. 
DOJ's Civil Division also has the authority to bring criminal charges 
against pharmaceutical and medical device manufacturers under the 
Federal Food, Drug, and Cosmetic Act. 

Component: Civil Rights Division; 
HCFAC Activities: Agency: Investigates cases of abuse and grossly 
substandard care in Medicare and Medicaid-funded long-term care 
facilities. The Civil Rights Division is the DOJ component responsible 
for enforcement of the Civil Rights of Institutionalized Persons Act, 
which authorizes investigation of conditions of confinement at state 
and local residential institutions (including facilities for persons 
with developmental disabilities or mental illness, and nursing homes) 
and initiates civil actions to remedy practices in violation of an 
individual's rights. The Civil Rights Division also has primary 
enforcement authority for the Americans with Disabilities Act and 
investigates allegations of discrimination by public entities against 
individuals with disabilities, including discrimination in the form of 
needless institutionalization of persons who require health care 
services. 

Component: U.S. Attorney's Offices; 
HCFAC Activities: Agency: Prosecute both civil and criminal health 
care fraud cases in their districts--94 USAOs throughout the country--
that involve a wide variety of health care fraud matters, including 
false billings by providers; kickbacks to induce referrals of Medicare 
or Medicaid patients; and failure of care allegations against nursing 
homes. The USAOs often partner with the Criminal and Civil divisions 
to prosecute health care fraud cases. The USAOs and support personnel 
in the nine cities where Strike Force teams are located participate in 
those teams. 

Component: Federal Bureau of Investigation (FBI); 
HCFAC Activities: Serves as the primary investigative agency of health 
care fraud, with jurisdiction to investigate fraud under both federal 
health care programs and private health insurance plans. The FBI 
investigates health care fraud through coordinated initiatives with 
federal, state, and local agencies. Additionally, the FBI participates 
in task forces and undercover operations to pursue investigations for 
health care fraud and participates in the Strike Force teams. The FBI 
also provides training and guidance on health care investigative 
matters--such as innovative methods of employing advanced 
investigative techniques--to health care investigators and analysts. 

Source: Information from fiscal year 2012 annual HCFAC report, in 
agency reports, on agency websites, and from interviews with agency 
officials. 

[End of table] 

[End of section] 

Appendix II: Health Care Fraud and Abuse Control (HCFAC) Program 
Obligations for Fiscal Years 2008 through 2012: 

Table 3 summarizes the HCFAC obligations for the Department of Health 
and Human Services (HHS), including the HHS Office of Inspector 
General, and Department of Justice components for fiscal years 2008 
through 2012 by type of appropriations. An obligation is a definite 
commitment that creates a legal liability of the government for 
payment of goods and services ordered or received. The table includes 
obligations of mandatory HCFAC appropriations, discretionary HCFAC 
appropriations, and other appropriations used to support HCFAC 
activities. Mandatory HCFAC appropriations refer to the HCFAC 
budgetary resources controlled by a law, principally the Health 
Insurance Portability and Accountability Act of 1996, rather than 
appropriations acts. Discretionary HCFAC appropriations refer to 
budgetary resources provided in annual appropriation acts, other than 
those that fund mandatory programs. Congress appropriated mandatory 
funding for HCFAC activities beginning in fiscal year 1997, and 
appropriated discretionary funding for HCFAC activities beginning in 
fiscal year 2009. Other appropriations include funding from other 
appropriations not specific to the HCFAC program that the agencies 
used, in addition to the HCFAC funds, to carry out activities related 
to health care fraud and abuse. In addition, the table shows the 
percentage of HCFAC obligations for personnel services and contracted 
services and supplies. 

Table 3: Obligations For Health Care Fraud and Abuse Control (HCFAC) 
Program Activities, Fiscal Years 2008-2012, By Agency and Component 
and Type of Appropriations: 

Department of Health and Human Services (HHS)[A]: 

Administration for Community Living: 

Obligations of Mandatory HCFAC Appropriations; 
Fiscal Year 2008: $2,972,070; 
Fiscal Year 2009: $3,180,221; 
Fiscal Year 2010: $3,364,520; 
Fiscal Year 2011: $3,702,737; 
Fiscal Year 2012: $10,631,727. 

Obligations of Discretionary HCFAC Appropriations; 
Fiscal Year 2008: N/A; 
Fiscal Year 2009: $0; 
Fiscal Year 2010: $0; 
Fiscal Year 2011: $0; 
Fiscal Year 2012: $0. 

Obligations of Other Appropriations; 
Fiscal Year 2008: $0; 
Fiscal Year 2009: $0; 
Fiscal Year 2010: $0; 
Fiscal Year 2011: $0; 
Fiscal Year 2012: $0. 

Total HCFAC Obligations; 
Fiscal Year 2008: $2,972,070; 
Fiscal Year 2009: $3,180,221; 
Fiscal Year 2010: $3,364,520; 
Fiscal Year 2011: $3,702,737; 
Fiscal Year 2012: $10,631,727. 

Percentage for Personnel; 
Fiscal Year 2008: 30%; 
Fiscal Year 2009: 29%; 
Fiscal Year 2010: 27%; 
Fiscal Year 2011: 24%; 
Fiscal Year 2012: 11%. 

Percentage for Contracted Services/Supplies; 
Fiscal Year 2008: 15%; 
Fiscal Year 2009: 22%; 
Fiscal Year 2010: 39%; 
Fiscal Year 2011: 27%; 
Fiscal Year 2012: 10%. 

Centers for Medicare & Medicaid Services: 

Obligations of Mandatory HCFAC Appropriations; 
Fiscal Year 2008: Administration for Community Living: [B]; 
Fiscal Year 2009: [B]; 
Fiscal Year 2010: [B]; 
Fiscal Year 2011: [B]; 
Fiscal Year 2012: $14,530,000. 

Obligations of Discretionary HCFAC Appropriations; 
Fiscal Year 2008: N/A; 
Fiscal Year 2009: [B]; 
Fiscal Year 2010: [B]; 
Fiscal Year 2011: [B]; 
Fiscal Year 2012: $350,656. 

Obligations of Other Appropriations; 
Fiscal Year 2008: [B]; 
Fiscal Year 2009: [B]; 
Fiscal Year 2010: [B]; 
Fiscal Year 2011: [B]; 
Fiscal Year 2012: $0. 

Total HCFAC Obligations; 
Fiscal Year 2008: [B]; 
Fiscal Year 2009: [B]; 
Fiscal Year 2010: [B]; 
Fiscal Year 2011: [B]; 
Fiscal Year 2012: $14,880,656. 

Percentage for Personnel; 
Fiscal Year 2008: [B]; 
Fiscal Year 2009: [B]; 
Fiscal Year 2010: [B]; 
Fiscal Year 2011: [B]; 
Fiscal Year 2012: 73%. 

Percentage for Contracted Services/Supplies; 
Fiscal Year 2008: [B]; 
Fiscal Year 2009: [B]; 
Fiscal Year 2010: [B]; 
Fiscal Year 2011: [B]; 
Fiscal Year 2012: 16%. 

Food and Drug Administration: 

Obligations of Mandatory HCFAC Appropriations; 
Fiscal Year 2008: $0; 
Fiscal Year 2009: $0; 
Fiscal Year 2010: $699,691; 
Fiscal Year 2011: $1,988,451; 
Fiscal Year 2012: $2,768,273. 

Obligations of Discretionary HCFAC Appropriations; 
Fiscal Year 2008: N/A; 
Fiscal Year 2009: $0; 
Fiscal Year 2010: $0; 
Fiscal Year 2011: $0; 
Fiscal Year 2012: $0. 

Obligations of Other Appropriations; 
Fiscal Year 2008: $0; 
Fiscal Year 2009: $0; 
Fiscal Year 2010: $0; 
Fiscal Year 2011: $0; 
Fiscal Year 2012: $0. 

Total HCFAC Obligations; 
Fiscal Year 2008: $0; 
Fiscal Year 2009: $0; 
Fiscal Year 2010: $699,691; 
Fiscal Year 2011: $1,988,451; 
Fiscal Year 2012: $2,768,273. 

Percentage for Personnel; 
Fiscal Year 2008: [Empty]; 
Fiscal Year 2009: [Empty]; 
Fiscal Year 2010: 88%; 
Fiscal Year 2011: 100%; 
Fiscal Year 2012: 63%. 

Percentage for Contracted Services/Supplies; 
Fiscal Year 2008: [Empty]; 
Fiscal Year 2009: [Empty]; 
Fiscal Year 2010: 1%; 
Fiscal Year 2011: 0%; 
Fiscal Year 2012: 35%. 

Office of General Counsel: 

Obligations of Mandatory HCFAC Appropriations; 
Fiscal Year 2008: $5,745,975; 
Fiscal Year 2009: $5,712,705; 
Fiscal Year 2010: $8,711,228; 
Fiscal Year 2011: $8,873,169; 
Fiscal Year 2012: $8,854,695. 

Obligations of Discretionary HCFAC Appropriations; 
Fiscal Year 2008: N/A; 
Fiscal Year 2009: $0; 
Fiscal Year 2010: $0; 
Fiscal Year 2011: $0; 
Fiscal Year 2012: $0. 

Obligations of Other Appropriations[C]; 
Fiscal Year 2008: $8,080,155; 
Fiscal Year 2009: $9,113,745; 
Fiscal Year 2010: $6,553,380; 
Fiscal Year 2011: $6,680,831; 
Fiscal Year 2012: $7,295,487. 

Total HCFAC Obligations; 
Fiscal Year 2008: $13,826,130; 
Fiscal Year 2009: $14,826,450; 
Fiscal Year 2010: $15,264,608; 
Fiscal Year 2011: $15,554,000; 
Fiscal Year 2012: $16,150,182. 

Percentage for Personnel; 
Fiscal Year 2008: 74%; 
Fiscal Year 2009: 85%; 
Fiscal Year 2010: 86%; 
Fiscal Year 2011: 84%; 
Fiscal Year 2012: 84%. 

Percentage for Contracted Services/Supplies; 
Fiscal Year 2008: 26%; 
Fiscal Year 2009: 15%; 
Fiscal Year 2010: 14%; 
Fiscal Year 2011: 14%; 
Fiscal Year 2012: 16%. 

Department of Health and Human Services' Office of Inspector General 
(HHS-OIG)[D]: 

Office of Audit Services: 

Obligations of Mandatory HCFAC Appropriations; 
Fiscal Year 2008: $53,638,586; 
Fiscal Year 2009: $45,534,873; 
Fiscal Year 2010: $55,134,402; 
Fiscal Year 2011: $52,261,218; 
Fiscal Year 2012: $65,804,004. 

Obligations of Discretionary HCFAC Appropriations; 
Fiscal Year 2008: N/A; 
Fiscal Year 2009: $14,314,348; 
Fiscal Year 2010: $34,004; 
Fiscal Year 2011: $0; 
Fiscal Year 2012: $0. 

Obligations of Other Appropriations; 
Fiscal Year 2008: 9,866,186; 
Fiscal Year 2009: $6,904,396; 
Fiscal Year 2010: $16,859,544; 
Fiscal Year 2011: $24,863,597; 
Fiscal Year 2012: $4,671,102. 

Total HCFAC Obligations; 
Fiscal Year 2008: $63,504,772; 
Fiscal Year 2009: $66,753,617; 
Fiscal Year 2010: $72,027,950; 
Fiscal Year 2011: $77,124,815; 
Fiscal Year 2012: $70,475,106. 

Percentage for Personnel; 
Fiscal Year 2008: 91%; 
Fiscal Year 2009: 90%; 
Fiscal Year 2010: 91%; 
Fiscal Year 2011: 91%; 
Fiscal Year 2012: 92%. 

Percentage for Contracted Services/Supplies; 
Fiscal Year 2008: 9%; 
Fiscal Year 2009: 10%; 
Fiscal Year 2010: 9%; 
Fiscal Year 2011: 9%; 
Fiscal Year 2012: 8%. 

Office of Evaluation and Inspections: 

Obligations of Mandatory HCFAC Appropriations; 
Fiscal Year 2008: $11,373,838; 
Fiscal Year 2009: $10,344,700; 
Fiscal Year 2010: $14,919,144; 
Fiscal Year 2011: $15,860,518; 
Fiscal Year 2012: $15,410,246. 

Obligations of Discretionary HCFAC Appropriations; 
Fiscal Year 2008: N/A; 
Fiscal Year 2009: $0; 
Fiscal Year 2010: $0; 
Fiscal Year 2011: $0; 
Fiscal Year 2012: $0. 

Obligations of Other Appropriations; 
Fiscal Year 2008: $3,136,893; 
Fiscal Year 2009: $5,365,036; 
Fiscal Year 2010: $1,821,373; 
Fiscal Year 2011: $1,297,694; 
Fiscal Year 2012: $1,196,973. 

Total HCFAC Obligations; 
Fiscal Year 2008: $14,510,732; 
Fiscal Year 2009: $15,709,735; 
Fiscal Year 2010: $16,740,517; 
Fiscal Year 2011: $17,158,212; 
Fiscal Year 2012: $16,607,219. 

Percentage for Personnel; 
Fiscal Year 2008: 88%; 
Fiscal Year 2009: 87%; 
Fiscal Year 2010: 90%; 
Fiscal Year 2011: 90%; 
Fiscal Year 2012: 92%. 

Percentage for Contracted Services/Supplies; 
Fiscal Year 2008: 11%; 
Fiscal Year 2009: 13%; 
Fiscal Year 2010: 10%; 
Fiscal Year 2011: 10%; 
Fiscal Year 2012: 8%. 

Office of Investigations: 

Obligations of Mandatory HCFAC Appropriations; 
Fiscal Year 2008: $59,181,222; 
Fiscal Year 2009: $68,339,359; 
Fiscal Year 2010: $71,854,447; 
Fiscal Year 2011: $70,876,633; 
Fiscal Year 2012: $88,675,409. 

Obligations of Discretionary HCFAC Appropriations; 
Fiscal Year 2008: N/A; 
Fiscal Year 2009: $4,600,019; 
Fiscal Year 2010: $0; 
Fiscal Year 2011: $19,103,354; 
Fiscal Year 2012: $0. 

Obligations of Other Appropriations; 
Fiscal Year 2008: $10,345,534; 
Fiscal Year 2009: $5,038,277; 
Fiscal Year 2010: $8,242,560; 
Fiscal Year 2011: $6,961,168; 
Fiscal Year 2012: $6,343,658. 

Total HCFAC Obligations; 
Fiscal Year 2008: $69,526,755; 
Fiscal Year 2009: $77,977,656; 
Fiscal Year 2010: $80,097,007; 
Fiscal Year 2011: $96,941,156; 
Fiscal Year 2012: $95,019,067. 

Percentage for Personnel; 
Fiscal Year 2008: 89%; 
Fiscal Year 2009: 87%; 
Fiscal Year 2010: 84%; 
Fiscal Year 2011: 82%; 
Fiscal Year 2012: 87%. 

Percentage for Contracted Services/Supplies; 
Fiscal Year 2008: 10%; 
Fiscal Year 2009: 10%; 
Fiscal Year 2010: 12%; 
Fiscal Year 2011: 14%; 
Fiscal Year 2012: 11%. 

Office of Counsel to the Inspector General: 

Obligations of Mandatory HCFAC Appropriations; 
Fiscal Year 2008: $7,363,903; 
Fiscal Year 2009: $9,342,140; 
Fiscal Year 2010: $8,699,671; 
Fiscal Year 2011: $9,879,173; 
Fiscal Year 2012: $9,822,896. 

Obligations of Discretionary HCFAC Appropriations; 
Fiscal Year 2008: N/A; 
Fiscal Year 2009: $0; 
Fiscal Year 2010: $0; 
Fiscal Year 2011: $0; 
Fiscal Year 2012: $0. 

Obligations of Other Appropriations; 
Fiscal Year 2008: $1,023,655; 
Fiscal Year 2009: $511,664; 
Fiscal Year 2010: $1,008,637; 
Fiscal Year 2011: $741,009; 
Fiscal Year 2012: $702,226. 

Total HCFAC Obligations; 
Fiscal Year 2008: $8,387,557; 
Fiscal Year 2009: $9,853,804; 
Fiscal Year 2010: $9,708,308; 
Fiscal Year 2011: $10,620,183; 
Fiscal Year 2012: $10,525,122. 

Percentage for Personnel; 
Fiscal Year 2008: 96%; 
Fiscal Year 2009: 96%; 
Fiscal Year 2010: 95%; 
Fiscal Year 2011: 94%; 
Fiscal Year 2012: 97%. 

Percentage for Contracted Services/Supplies; 
Fiscal Year 2008: 4%; 
Fiscal Year 2009: 4%; 
Fiscal Year 2010: 5%; 
Fiscal Year 2011: 6%; 
Fiscal Year 2012: 3%. 

Office of Management and Policy: 

Obligations of Mandatory HCFAC Appropriations; 
Fiscal Year 2008: $44,335,892; 
Fiscal Year 2009: $43,945,152; 
Fiscal Year 2010: $37,639,506; 
Fiscal Year 2011: $46,779,355; 
Fiscal Year 2012: $36,421,764. 

Obligations of Discretionary HCFAC Appropriations; 
Fiscal Year 2008: N/A; 
Fiscal Year 2009: $29,927; 
Fiscal Year 2010: $18,393,657; 
Fiscal Year 2011: $17,113,762; 
Fiscal Year 2012: $23,817,566. 

Obligations of Other Appropriations; 
Fiscal Year 2008: $6,493,865; 
Fiscal Year 2009: $13,754,488; 
Fiscal Year 2010: $6,318,229; 
Fiscal Year 2011: $4,782,107; 
Fiscal Year 2012: $5,958,176. 

Total HCFAC Obligations; 
Fiscal Year 2008: $50,829,757; 
Fiscal Year 2009: $57,729,567; 
Fiscal Year 2010: $62,351,393; 
Fiscal Year 2011: $68,675,224; 
Fiscal Year 2012: $66,197,506. 

Percentage for Personnel; 
Fiscal Year 2008: 21%; 
Fiscal Year 2009: 20%; 
Fiscal Year 2010: 20%; 
Fiscal Year 2011: 22%; 
Fiscal Year 2012: 25%. 

Percentage for Contracted Services/Supplies; 
Fiscal Year 2008: 71%; 
Fiscal Year 2009: 67%; 
Fiscal Year 2010: 60%; 
Fiscal Year 2011: 68%; 
Fiscal Year 2012: 70%. 

Department of Justice (DOJ): 

Civil Division: 

Obligations of Mandatory HCFAC Appropriations; 
Fiscal Year 2008: $15,396,015; 
Fiscal Year 2009: $16,041,913; 
Fiscal Year 2010: $19,874,046; 
Fiscal Year 2011: $19,735,915; 
Fiscal Year 2012: $22,977,000. 

Obligations of Discretionary HCFAC Appropriations; 
Fiscal Year 2008: N/A; 
Fiscal Year 2009: $8,236,767; 
Fiscal Year 2010: $2,783,651; 
Fiscal Year 2011: $6,405,988; 
Fiscal Year 2012: $4,991,000. 

Obligations of Other Appropriations; 
Fiscal Year 2008: $1,636,524; 
Fiscal Year 2009: $4,059,000; 
Fiscal Year 2010: $2,246,099; 
Fiscal Year 2011: $10,211,184; 
Fiscal Year 2012: $1,948,000. 

Total HCFAC Obligations; 
Fiscal Year 2008: $17,032,539; 
Fiscal Year 2009: $28,337,680; 
Fiscal Year 2010: $24,903,796; 
Fiscal Year 2011: $36,353,087; 
Fiscal Year 2012: $29,916,000. 

Percentage for Personnel; 
Fiscal Year 2008: 56%; 
Fiscal Year 2009: 39%; 
Fiscal Year 2010: 47%; 
Fiscal Year 2011: 40%; 
Fiscal Year 2012: 47%. 

Percentage for Contracted Services/Supplies; 
Fiscal Year 2008: 44%; 
Fiscal Year 2009: 61%; 
Fiscal Year 2010: 52%; 
Fiscal Year 2011: 60%; 
Fiscal Year 2012: 53%. 

Civil Rights Division: 

Obligations of Mandatory HCFAC Appropriations; 
Fiscal Year 2008: $2,375,999; 
Fiscal Year 2009: $2,476,000; 
Fiscal Year 2010: $2,376,000; 
Fiscal Year 2011: $3,432,688; 
Fiscal Year 2012: $3,823,868. 

Obligations of Discretionary HCFAC Appropriations; 
Fiscal Year 2008: N/A; 
Fiscal Year 2009: $0; 
Fiscal Year 2010: $1,769,255; 
Fiscal Year 2011: $1,942,057; 
Fiscal Year 2012: $892,606. 

Obligations of Other Appropriations; 
Fiscal Year 2008: $629,995; 
Fiscal Year 2009: $1,016,944; 
Fiscal Year 2010: $373,283; 
Fiscal Year 2011: $468,911; 
Fiscal Year 2012: $453,209. 

Total HCFAC Obligations; 
Fiscal Year 2008: $3,005,995; 
Fiscal Year 2009: $3,492,944; 
Fiscal Year 2010: $4,518,538; 
Fiscal Year 2011: $5,843,656; 
Fiscal Year 2012: $5,169,683. 

Percentage for Personnel; 
Fiscal Year 2008: 59%; 
Fiscal Year 2009: 70%; 
Fiscal Year 2010: 67%; 
Fiscal Year 2011: 67%; 
Fiscal Year 2012: 68%. 

Percentage for Contracted Services/Supplies; 
Fiscal Year 2008: 41%; 
Fiscal Year 2009: 30%; 
Fiscal Year 2010: 32%; 
Fiscal Year 2011: 32%; 
Fiscal Year 2012: 32%. 

Criminal Division: 

Obligations of Mandatory HCFAC Appropriations; 
Fiscal Year 2008: $3,080,000; 
Fiscal Year 2009: $948,746; 
Fiscal Year 2010: $1,541,998; 
Fiscal Year 2011: $1,482,273; 
Fiscal Year 2012: $1,212,507. 

Obligations of Discretionary HCFAC Appropriations; 
Fiscal Year 2008: N/A; 
Fiscal Year 2009: $2,881,619; 
Fiscal Year 2010: $3,389,957; 
Fiscal Year 2011: $5,286,118; 
Fiscal Year 2012: $8,083,863. 

Obligations of Other Appropriations[E]; 
Fiscal Year 2008: $0; 
Fiscal Year 2009: $0; 
Fiscal Year 2010: $0; 
Fiscal Year 2011: $0; 
Fiscal Year 2012: $0. 

Total HCFAC Obligations; 
Fiscal Year 2008: $3,080,000; 
Fiscal Year 2009: $3,830,365; 
Fiscal Year 2010: $4,931,955; 
Fiscal Year 2011: $6,768,390; 
Fiscal Year 2012: $9,296,370. 

Percentage for Personnel; 
Fiscal Year 2008: 50%; 
Fiscal Year 2009: 47%; 
Fiscal Year 2010: 56%; 
Fiscal Year 2011: 65%; 
Fiscal Year 2012: 52%. 

Percentage for Contracted Services/Supplies; 
Fiscal Year 2008: 33%; 
Fiscal Year 2009: 28%; 
Fiscal Year 2010: 38%; 
Fiscal Year 2011: 35%; 
Fiscal Year 2012: 47%. 

Federal Bureau of Investigation: 

Obligations of Mandatory HCFAC Appropriations; 
Fiscal Year 2008: $118,085,122; 
Fiscal Year 2009: $126,953,586; 
Fiscal Year 2010: $129,171,234; 
Fiscal Year 2011: $125,166,278; 
Fiscal Year 2012: $134,381,774. 

Obligations of Discretionary HCFAC Appropriations; 
Fiscal Year 2008: N/A; 
Fiscal Year 2009: $0; 
Fiscal Year 2010: $0; 
Fiscal Year 2011: $5,902,130; 
Fiscal Year 2012: $3,806,330. 

Obligations of Other Appropriations; 
Fiscal Year 2008: $0; 
Fiscal Year 2009: $0; 
Fiscal Year 2010: $0; 
Fiscal Year 2011: $3,570,676; 
Fiscal Year 2012: $7,473,799. 

Total HCFAC Obligations; 
Fiscal Year 2008: $118,085,122; 
Fiscal Year 2009: $126,953,586; 
Fiscal Year 2010: $129,171,234; 
Fiscal Year 2011: $134,639,084; 
Fiscal Year 2012: $145,661,903. 

Percentage for Personnel; 
Fiscal Year 2008: 78%; 
Fiscal Year 2009: 78%; 
Fiscal Year 2010: 80%; 
Fiscal Year 2011: 82%; 
Fiscal Year 2012: 81%. 

Percentage for Contracted Services/Supplies; 
Fiscal Year 2008: 22%; 
Fiscal Year 2009: 20%; 
Fiscal Year 2010: 18%; 
Fiscal Year 2011: 16%; 
Fiscal Year 2012: 17%. 

Justice Management Division[F]: 

Obligations of Mandatory HCFAC Appropriations; 
Fiscal Year 2008: $0; 
Fiscal Year 2009: $0; 
Fiscal Year 2010: $157,621; 
Fiscal Year 2011: $5,416,098; 
Fiscal Year 2012: $4,951,367. 

Obligations of Discretionary HCFAC Appropriations; 
Fiscal Year 2008: N/A; 
Fiscal Year 2009: $0; 
Fiscal Year 2010: $0; 
Fiscal Year 2011: $7,266,1530; 
Fiscal Year 2012: $10,799,404. 

Obligations of Other Appropriations; 
Fiscal Year 2008: $0; 
Fiscal Year 2009: $0; 
Fiscal Year 2010: $0; 
Fiscal Year 2011: $0; 
Fiscal Year 2012: $0. 

Total HCFAC Obligations; 
Fiscal Year 2008: $0; 
Fiscal Year 2009: $0; 
Fiscal Year 2010: $157,621; 
Fiscal Year 2011: $12,682,251; 
Fiscal Year 2012: $15,750,771. 

Percentage for Personnel; 
Fiscal Year 2008: [Empty]; 
Fiscal Year 2009: [Empty]; 
Fiscal Year 2010: 100%; 
Fiscal Year 2011: 3.3%; 
Fiscal Year 2012: 3.75%. 

Percentage for Contracted Services/Supplies; 
Fiscal Year 2008: [Empty]; 
Fiscal Year 2009: [Empty]; 
Fiscal Year 2010: 0%; 
Fiscal Year 2011: 0%; 
Fiscal Year 2012: 0.46%. 

U.S. Attorney's Offices: 

Obligations of Mandatory HCFAC Appropriations; 
Fiscal Year 2008: $31,421,769; 
Fiscal Year 2009: $33,255,655; 
Fiscal Year 2010: $32,893,926; 
Fiscal Year 2011: $29,723,423; 
Fiscal Year 2012: $32,659,037. 

Obligations of Discretionary HCFAC Appropriations; 
Fiscal Year 2008: N/A; 
Fiscal Year 2009: $9,023,000; 
Fiscal Year 2010: $6,227,568; 
Fiscal Year 2011: $15,338,747; 
Fiscal Year 2012: $10,760,057. 

Obligations of Other Appropriations; 
Fiscal Year 2008: $26,061,218; 
Fiscal Year 2009: $35,035,966; 
Fiscal Year 2010: $31,652,106; 
Fiscal Year 2011: $31,896,207; 
Fiscal Year 2012: $31,122,465. 

Total HCFAC Obligations; 
Fiscal Year 2008: $57,482,987; 
Fiscal Year 2009: $77,314,620; 
Fiscal Year 2010: $70,773,600; 
Fiscal Year 2011: $76,958,377; 
Fiscal Year 2012: $74,541,560. 

Percentage for Personnel; 
Fiscal Year 2008: 84%; 
Fiscal Year 2009: 78%; 
Fiscal Year 2010: 83%; 
Fiscal Year 2011: 83%; 
Fiscal Year 2012: 84%. 

Percentage for Contracted Services/Supplies; 
Fiscal Year 2008: 15%; 
Fiscal Year 2009: 20%; 
Fiscal Year 2010: 16%; 
Fiscal Year 2011: 17%; 
Fiscal Year 2012: 16%. 

Legend: N/A = Not Applicable; $0 means no funds obligated in that 
fiscal year for the type of appropriation; and [Empty] means no 
percentage in that fiscal year for the type of appropriation. 

Source: GAO analysis of HCFAC obligations reported to GAO by HHS, HHS-
OIG, and DOJ. 

Notes: 

[A] Two HHS components, the Office of the Assistant Secretary for 
Planning and Evaluation (ASPE) and the Office of the Assistant 
Secretary for Public Affairs (ASPA), had HCFAC obligations for fiscal 
year 2011 only--$45,000 for ASPE and $690,894 for ASPA. These amounts 
are not reflected in the table. 

[B] We chose to report on the activities that CMS conducted in fiscal 
year 2012 because those activities were included in that year's HCFAC 
return-on-investment calculation. In total for fiscal year 2012, CMS 
reported about $14.9 million in HCFAC appropriations, about $1.6 
million of which was allocated in fiscal year 2012 but not obligated, 
which CMS reserved to fund HCFAC activities in future years. We did 
not request fiscal years 2008 through 2011 HCFAC obligations from CMS 
because the agency conducted activities other than those that were 
funded with HHS's mandatory HCFAC appropriations in fiscal year 2012. 
For example, in fiscal year 2010, CMS used its HCFAC mandatory 
appropriations for the One Program Integrity database, a centralized 
web-based portal that enables users, such as law enforcement, to 
access claims, provider, and beneficiary data from a centralized 
source. 

[C] HHS's OGC reported estimated obligations of other appropriations, 
which included reimbursements for attorney services provided to OGC 
clients within HHS, that supported HCFAC activities. 

[D] HHS-OIG's reported obligations also include any obligations of 
funds the agency received as reimbursement for the costs of conducting 
investigations and audits and other activities when such costs are 
ordered by a court, voluntarily agreed to by the payor, or otherwise 
authorized under 42 U.S.C. §1320a-7c(b). 

[E] DOJ's Criminal Division stated that it uses some other 
appropriations for health care fraud activities. However, officials 
indicated that the division infrequently funds HCFAC activities with 
other appropriations and, as a result, the division does not track the 
amount of other appropriations used specifically for the HCFAC program. 

[F] For fiscal years 2011 and 2012, DOJ reported amounts in HCFAC 
mandatory and discretionary appropriations that the department 
reserved for future use to fund HCFAC activities. In fiscal year 2011, 
DOJ reported about $5.2 million in mandatory HCFAC appropriations and 
about $7.3 million in discretionary HCFAC appropriations; in fiscal 
year 2012, DOJ reported about $4.7 million in mandatory HCFAC 
appropriations and about $10.8 million in discretionary 
appropriations. These funds were allocated to the Justice Management 
Division, but were not obligated. We have included these HCFAC funds 
under the Justice Management Division, in addition to the $180,494 (in 
fiscal year 2011) and $208,676 (in fiscal year 2012) in mandatory 
HCFAC obligations the division reported. 

[End of table] 

Table 4 summarizes HCFAC obligations for Strike Force teams for fiscal 
years 2008 through 2012 by the geographic location of the Strike Force 
teams. Strike Force teams consist of investigators and prosecutors who 
use data analysis techniques to identify, investigate, and prosecute 
potentially fraudulent activities in geographic areas with high rates 
of fraud. 

Table 4: Total Health Care Fraud and Abuse Control (HCFAC) Program 
Obligations by Strike Force Location and Fiscal Year, 2008 through 
2012: 

Strike Force Location & Fiscal Year Launched: Miami, FL; Launched FY 
2007; 
Fiscal Year: 2008: $5,335,321; 
Fiscal Year: 2009: $7,504,704; 
Fiscal Year: 2010: $8,344,504; 
Fiscal Year: 2011: $10,020,003; 
Fiscal Year: 2012: $12,962,899. 

Strike Force Location & Fiscal Year Launched: Detroit, MI; Launched FY 
2009; 
Fiscal Year: 2008: $524,578[A]; 
Fiscal Year: 2009: $2,687,385; 
Fiscal Year: 2010: $3,963,202; 
Fiscal Year: 2011: $4,930,594; 
Fiscal Year: 2012: $5,098,524. 

Strike Force Location & Fiscal Year Launched: Dallas, TX; Launched FY 
2011; 
Fiscal Year: 2008: $6,838[A]; 
Fiscal Year: 2009: $28,247[A]; 
Fiscal Year: 2010: $40,070[A]; 
Fiscal Year: 2011: $3,696,685; 
Fiscal Year: 2012: $5,027,790. 

Strike Force Location & Fiscal Year Launched: Los Angeles, CA; 
Launched FY 2008; 
Fiscal Year: 2008: $4,197,914; 
Fiscal Year: 2009: $4,488,269; 
Fiscal Year: 2010: $4,861,523; 
Fiscal Year: 2011: $6,487,639; 
Fiscal Year: 2012: $4,815,963. 

Strike Force Location & Fiscal Year Launched: Brooklyn, NY; Launched 
FY 2010; 
Fiscal Year: 2008: $43,782[A]; 
Fiscal Year: 2009: $308,666[A]; 
Fiscal Year: 2010: $4,785,975; 
Fiscal Year: 2011: $4,915,032; 
Fiscal Year: 2012: $4,392,851. 

Strike Force Location & Fiscal Year Launched: Baton Rouge, LA; 
Launched FY 2010; 
Fiscal Year: 2008: $71,757[A]; 
Fiscal Year: 2009: $253,915[A]; 
Fiscal Year: 2010: $1,806,066; 
Fiscal Year: 2011: $3,422,416; 
Fiscal Year: 2012: $3,438,367. 

Strike Force Location & Fiscal Year Launched: Chicago, IL; Launched in 
FY 2011; 
Fiscal Year: 2008: $39,334[A]; 
Fiscal Year: 2009: $145,841[A]; 
Fiscal Year: 2010: $434,390[A]; 
Fiscal Year: 2011: $2,954,041; 
Fiscal Year: 2012: $3,380,209. 

Strike Force Location & Fiscal Year Launched: Houston, TX; Launched in 
FY 2009; 
Fiscal Year: 2008: [Empty]; 
Fiscal Year: 2009: $2,611,054; 
Fiscal Year: 2010: $2,801,064; 
Fiscal Year: 2011: $3,038,569; 
Fiscal Year: 2012: $2,566,108. 

Strike Force Location & Fiscal Year Launched: Tampa, FL; Launched FY 
2010; 
Fiscal Year: 2008: $251,702[A]; 
Fiscal Year: 2009: $566,604[A]; 
Fiscal Year: 2010: $1,450,824; 
Fiscal Year: 2011: $2,613,618; 
Fiscal Year: 2012: $2,549,202. 

Strike Force Location & Fiscal Year Launched: Headquarters Support of 
Strike Forces; 
Fiscal Year: 2008: [Empty]; 
Fiscal Year: 2009: [Empty]; 
Fiscal Year: 2010: $1,618,348; 
Fiscal Year: 2011: $5,985,725; 
Fiscal Year: 2012: $3,051,813. 

Strike Force Location & Fiscal Year Launched: Total HCFAC Obligations; 
Fiscal Year: 2008: $10,471,226; 
Fiscal Year: 2009: $18,594,685; 
Fiscal Year: 2010: $30,105,966; 
Fiscal Year: 2011: $48,064,322; 
Fiscal Year: 2012: $47,283,726. 

Source: GAO analysis of HCFAC obligations reported to GAO by the 
Department of Health and Human Services' Office of Inspector General's 
(HHS-OIG) Office of Investigations and the Department of Justice's 
Criminal Division, the U.S. Attorneys' Offices, and the Federal Bureau 
of Investigation for fiscal years 2008 through 2012. 

Notes: CMS also obligated $350,656 of its discretionary HCFAC 
appropriations for headquarters' support of the Strike Force teams. 
However, these obligations were not associated with any one of the 
nine Strike Force cities and the this amount is not reflected in the 
table above. 

[A] HHS-OIG reported obligations for the Strike Forces in these cities 
prior to their official launch, because HHS-OIG investigators worked 
to gather evidence on cases in those cities. 

[End of table] 

[End of section] 

Appendix III: Indicators Used by Agencies to Assess Health Care Fraud 
and Abuse Control (HCFAC) Program Activities: 

Table 5: Collective Indicators Reported in the Annual Health Care 
Fraud and Abuse Control (HCFAC) Program Report, and Outcomes/Outputs 
for Associated Indicator, for Fiscal Year 2012: 

Collective indicators, in which multiple agencies contribute 
(including Department of Health and Human Services' Office of 
Inspector General (HHS-OIG) and Department of Justice (DOJ)): 

Indicators reported in HCFAC report by agencies to assess activities: 
Amount won or negotiated through health care fraud judgments and 
settlements; 
Outcomes/outputs of indicators for Fiscal Year 2012: Over $3.0 billion 
in judgments and settlements. 

Indicators reported in HCFAC report by agencies to assess activities: 
Amount deposited with the Department of Treasury and the Center for 
Medicare &Medicaid Services, transferred to other Federal agencies, or 
paid to private persons (result of fiscal year's HCFAC efforts as well 
as efforts from previous fiscal years); 
Outcomes/outputs of indicators for Fiscal Year 2012: Approximately 
$4.2 billion deposited. 

Indicators reported in HCFAC report by agencies to assess activities: 
Number of new criminal health care fraud investigations opened; 
Outcomes/outputs of indicators for Fiscal Year 2012: 1,131 new 
criminal investigations involving 2,148 potential defendants. 

Indicators reported in HCFAC report by agencies to assess activities: 
Number of cases where criminal charges were filed; 
Outcomes/outputs of indicators for Fiscal Year 2012: 452 cases 
involving 892 defendants. 

Indicators reported in HCFAC report by agencies to assess activities: 
Number of defendants convicted of health care fraud-related crimes; 
Outcomes/outputs of indicators for Fiscal Year 2012: 826 defendants 
convicted. 

Indicators reported in HCFAC report by agencies to assess activities: 
Number of new civil health care fraud investigations opened; 
Outcomes/outputs of indicators for Fiscal Year 2012: 885 new civil 
investigations opened. 

Indicators reported in HCFAC report by agencies to assess activities: 
Number of individuals and entities excluded from participation in 
federal health care programs by HHS-OIG; 
Outcomes/outputs of indicators for Fiscal Year 2012: 3,131 individuals 
and entities excluded. 

Indicators reported in HCFAC report by agencies to assess activities: 
Return-on-investment; 
Outcomes/outputs of indicators for Fiscal Year 2012: $7.90 returned 
for every $1.00 expended for fiscal years 2010-2012. 

Indicators related to the Strike Force Teams located in 9 cities 
nationwide: 

Number of indictments, informations (an accusation of a criminal 
offense made by a public officer rather than a grand jury), and 
complaints involving charges filed against number of defendants; 
Outcomes/outputs of indicators for Fiscal Year 2012: 117 indictments, 
informations, and complaints filed against 278 defendants. 

Amount of alleged billing to Medicare from defendants; 
Outcomes/outputs of indicators for Fiscal Year 2012: Over $1.5 billion 
in alleged collective billings to Medicare. 

Number of defendants that pled guilty; 
Outcomes/outputs of indicators for Fiscal Year 2012: 251 guilty pleas 
negotiated. 

Number of defendants convicted in jury trials; 
Outcomes/outputs of indicators for Fiscal Year 2012: Guilty verdicts 
obtained for 29 defendants in 13 jury trials. 

Number of individuals that were sentenced to imprisonment and amount 
of average term; 
Outcomes/outputs of indicators for Fiscal Year 2012: Outcomes/outputs 
of indicators for Fiscal Year 2012: 201 defendants sentenced with 
average prison term of 48 months. 

Source: Fiscal year 2012 annual HCFAC report and interviews with HHS-
OIG and DOJ officials. 

[End of table] 

Table 6: Indicators That Are Used by the HHS Components to Assess 
Health Care Fraud and Abuse Control Program Activities, Source of 
Indicators, and Outcomes/Outputs for Associated Indicator, for Fiscal 
Year 2012: 

HHS Component: Administration for Community Living (ACL) -Senior 
Medicare Patrol programs[B]: 

Indicators used by agencies to assess activities: Total number of 
active volunteers, number of volunteer training hours, and number of 
volunteer work hours; 
Source of indicator: FY 2012 HCFAC report: [Check]; 
Source of indicator: Other: [CheckPlus]; 
Outcomes/outputs of indicator for Fiscal Year 2012[A]: 5,137 active 
volunteers, 39,257 training hours, and 120,953 work hours in calendar 
year 2012. 

Indicators used by agencies to assess activities: Number of media 
airings; 
Source of indicator: FY 2012 HCFAC report: [Check]; 
Source of indicator: Other: [CheckPlus]; 
Outcomes/outputs of indicator for Fiscal Year 2012[A]: 188,199 media 
airings in calendar year 2012. 

Indicators used by agencies to assess activities: Number of community 
outreach education events conducted and estimated number of people 
reached by events; 
Source of indicator: FY 2012 HCFAC report: [Check]; 
Source of indicator: Other: [CheckPlus]; 
Outcomes/outputs of indicator for Fiscal Year 2012[A]: 10,032 
education events in which 996,040 people were reached in calendar year 
2012. 

Indicators used by agencies to assess activities: Number of group 
education sessions for beneficiaries and number of beneficiaries who 
attended; 
Source of indicator: FY 2012 HCFAC report: [Check]; 
Source of indicator: Other: [CheckPlus]; 
Outcomes/outputs of indicator for Fiscal Year 2012[A]: 14,748 sessions 
attended by 449,509 beneficiaries in calendar year 2012. 

Indicators used by agencies to assess activities: Number of one-on-one 
counseling sessions held with or on behalf of a beneficiary; 
Source of indicator: FY 2012 HCFAC report: [Check]; 
Source of indicator: Other: [CheckPlus]; 
Outcomes/outputs of indicator for Fiscal Year 2012[A]: 113,457 
sessions in calendar year 2012. 

Indicators used by agencies to assess activities: Total number of 
simple inquiries received and number of simple inquiries resolved; 
Source of indicator: FY 2012 HCFAC report: [Empty]; 
Source of indicator: Other: [CheckPlus]; 
Outcomes/outputs of indicator for Fiscal Year 2012[A]: 84,061 
inquiries received and 83,856 inquiries resolved in calendar year 2012. 

Indicators used by agencies to assess activities: Number of inquiries 
involving complex issues received and number of complex issue 
inquiries referred for further action; 
Source of indicator: FY 2012 HCFAC report: [Check]; 
Source of indicator: Other: [CheckPlus]; 
Outcomes/outputs of indicator for Fiscal Year 2012[A]: 2,270 inquiries 
received and 908 inquiries referred for further action in calendar 
year 2012. 

Indicators used by agencies to assess activities: Total dollar amount 
referred for further action; 
Source of indicator: FY 2012 HCFAC report: [Check]; 
Source of indicator: Other: [CheckPlus]; 
Outcomes/outputs of indicator for Fiscal Year 2012[A]: $27,529,968 in 
calendar year 2012. 

Indicators used by agencies to assess activities: Number of complex 
issues resolved and number of complex issues pending further action; 
Source of indicator: FY 2012 HCFAC report: [Check]; 
Source of indicator: Other: [CheckPlus]; 
Outcomes/outputs of indicator for Fiscal Year 2012[A]: 1,748 issues 
resolved and 2,585 issues pending in calendar year 2012. 

Indicators used by agencies to assess activities: Centers for Medicare 
& Medicaid Services (CMS): Cost avoidance on behalf of Medicare, 
Medicaid, beneficiaries, or others; 
Additionally, expected recoveries or savings, including: 
* Expected Medicare funds recovered attributable to the projects; 
* Expected Medicaid funds recovered attributable to the projects; 
* Savings to beneficiaries attributable to the projects; 
* Other savings attributable to the projects; 
* (e.g., Supplemental Insurance), and; 
* Total savings attributable to the projects (which is the sum of 
expected Medicare funds, expected Medicaid funds, savings to 
beneficiaries, and other savings attributable to the projects); 
Source of indicator: FY 2012 HCFAC report: Centers for Medicare & 
Medicaid Services (CMS): [Check][C]; 
Source of indicator: Other: Centers for Medicare & Medicaid Services 
(CMS): [CheckPlus]; 
Outcomes/outputs of indicator for Fiscal Year 2012[A]: Centers for 
Medicare & Medicaid Services (CMS): In calendar year 2012: 
* $113,692 in cost avoidance; 
Additionally: 
* $5,957,910 in expected Medicare funds; 
* $102,000 in expected Medicaid funds; 
* $130,796 in savings to beneficiaries; 
* $3,175 in other savings; 
* $6,193,881 in total savings. 

HHS Component: Centers for Medicare & Medicaid Services (CMS): 

Indicators used by agencies to assess activities: Estimated amount of 
the federal share of Medicaid funds that were removed as a result of 
CMS's financial oversight of Medicaid and Children's Health Insurance 
Program (CHIP), including approximate amount recovered and approximate 
amount resolved; 
Source of indicator: FY 2012 HCFAC report: [Check]; 
Source of indicator: Other: [Empty]; 
Outcomes/outputs of indicator for Fiscal Year 2012[A]: Estimated $895 
million removed, including $451 million recovered and $444 million 
resolved. 

Indicators used by agencies to assess activities: Estimated amount of 
the federal share of Medicaid funds (in questionable reimbursement) 
that were averted due to preventive work with states from Medicaid and 
CHIP financial management project; 
Source of indicator: FY 2012 HCFAC report: [Check]; 
Source of indicator: Other: [Empty]; 
Outcomes/outputs of indicator for Fiscal Year 2012[A]: Estimated $128 
million averted. 

Indicators used by agencies to assess activities: For the community 
mental health centers project, which uses data analytics to identify 
fraud in community mental health centers in 3 states; 
Source of indicator: FY 2012 HCFAC report: [Empty]; 
Source of indicator: Other: [Empty]; 
Outcomes/outputs of indicator for Fiscal Year 2012[A]: CMS officials 
indicated that because the project has recently started, CMS does not 
yet have indicators to assess it. CMS officials reported that they may 
consider using indicators similar to those used to assess the Fraud 
Prevention System, such as cost avoided as a result of the project. 

HHS Component: Food and Drug Administration (FDA) - Pharmaceutical 
Fraud Program: 

Indicators used by agencies to assess activities: Number of criminal 
investigations opened since the inception of the Pharmaceutical Fraud 
Program; 
Source of indicator: FY 2012 HCFAC report: [Check]; 
Source of indicator: Other: [Empty]; 
Outcomes/outputs of indicator for Fiscal Year 2012[A]: 42 criminal 
investigations. 

Indicators used by agencies to assess activities: Number of criminal 
investigations opened during fiscal year, including a description of 
the types of cases opened; 
Source of indicator: FY 2012 HCFAC report: [Check]; 
Source of indicator: Other: [Empty]; 
Outcomes/outputs of indicator for Fiscal Year 2012[A]: 17 criminal 
investigations. 

Indicators used by agencies to assess activities: Type of judicial 
actions related to the investigations (such as number of individuals 
convicted from investigations) and outcomes (including amount of jail 
time, probation, or amount of restitution); 
Source of indicator: FY 2012 HCFAC report: [Check]; 
Source of indicator: Other: [Empty]; 
Outcomes/outputs of indicator for Fiscal Year 2012[A]: 1 investigation 
resulted in conviction of 2 individuals, who received 12 months 
probation and were ordered to pay $36,040 in restitution. 

HHS Component: Office of General Counsel (OGC): 

Indicators used by agencies to assess activities: Amount of recoveries 
for the government from: 
* False Claims Act and related matters in which OGC participated; 
* Civil Monetary Penalties that OGC established the right to recover, 
and; 
* Money that OGC petitioned law enforcement agencies to seize as a 
result of criminal and civil litigation matters; 
Source of indicator: FY 2012 HCFAC report: [Check]; 
Source of indicator: Other: [Empty]; 
Outcomes/outputs of indicator for Fiscal Year 2012[A]: 
* Over $2.6 billion in recoveries under False Claims Act and related 
matters; 
* Over $4.5 million in Civil Monetary Penalties; 
* About $5.4 million in seizures. 

Indicators used by agencies to assess activities: Number of physician 
self-referral disclosures in which OGC advised CMS on how to resolve; 
Source of indicator: FY 2012 HCFAC report: [Check]; 
Source of indicator: Other: [Empty]; 
Outcomes/outputs of indicator for Fiscal Year 2012[A]: Over 100 
disclosures. 

Indicators used by agencies to assess activities: Indicators used by 
agencies to assess activities: Amount of money that OGC established 
the right to recover under the Medicare Secondary Payer provisions and 
amount involving bankrupt providers that OGC established the right to 
collect; 
Source of indicator: FY 2012 HCFAC report: [Check]; 
Source of indicator: Other: [Empty]; 
Outcomes/outputs of indicator for Fiscal Year 2012[A]: Over $17 
million recovered under Medicare Secondary Payer provisions and over 
$4.9 million collected from bankrupt providers. 

Legend: 

[Check] indicates that measure is included in Fiscal Year 2012 annual 
HCFAC report: 

[CheckPlus] indicates that measure is included in Department of Health 
and Human Services' Office of Inspector General (HHS-OIG) July 2013 
report on Senior Medicare Patrol programs. 

Source: Agency reports, including fiscal year 2012 annual HCFAC 
report, and interviews with HHS officials. 

[A] Unless otherwise noted, the information on outcomes/output for 
each measure is for fiscal year 2012. 

[B] For the outcomes and outputs for indicators associated with ACL's 
Senior Medicare Patrol program, we used the most currently available 
data, which was calendar year 2012 data obtained from the July 2013 
HHS-OIG report on the Senior Medicare Patrol program. The outcomes and 
output for these indicators is also included in the fiscal year 2012 
HCFAC report; however, the outcomes and output is calendar year 2011 
data. 

[C] In HHS-OIG's July 2013 report on Senior Medicare Patrol program, 
this indicator for Medicare and Medicaid funds recovered attributable 
to the programs was expanded to account for both expected and actual 
funds recovered. However, in the fiscal year 2012 report, the 
indicator included only actual funds recovered. 

[End of table] 

Table 7: Indicators That Are Used by the Department of Health and 
Human Services Office of Inspector General (HHS-OIG) to Assess Health 
Care Fraud and Abuse Control (HCFAC) Program Activities, Source of 
Indicators, Associated Target (if any), and Outcomes/Outputs for 
Associated Indicator, for Fiscal Year 2012: 

HHS-OIG Component: Collective indicators in which more than one HHS-
OIG component contributes: 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of prosecutions or settlements that resulted 
from investigations or other inquiries conducted by HHS-OIG; 
Source of indicator: FY 2012 HCFAC report: [Check]; 
Source of indicator: Other: [Empty]; 
Outcomes/outputs of indicators for Fiscal Year 2012: 1,145 
prosecutions or settlements of which 1,047 were health care cases. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Amount of health care savings attributable to 
statutory changes enacted and administrative actions taken in response 
to HHS-OIG investigations, audits, and evaluations, including: amount 
of savings to Medicare and Medicaid; 
Source of indicator: FY 2012 HCFAC report: [Check]; 
Source of indicator: Other: [CheckPlus1]; 
Outcomes/outputs of indicators for Fiscal Year 2012: $8.5 billion in 
total; $8 billion in Medicare savings and $525 million in savings to 
the federal share of Medicaid. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Examples of audits and evaluations by topic area; 
Source of indicator: FY 2012 HCFAC report: [Check]; 
Source of indicator: Other: [Empty]; 
Outcomes/outputs of indicators for Fiscal Year 2012: Audits and 
evaluations covering a number of topics, including Medicaid drugs, 
Medicaid managed care, Medicare physician services, community mental 
health centers, and Medicare Advantage organizations. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Amount of HHS-OIG Audit Disallowances recovered in 
Medicare and Medicaid; 
Source of indicator: FY 2012 HCFAC report: [Check]; 
Source of indicator: Other: [Empty]; 
Outcomes/outputs of indicators for Fiscal Year 2012: $89,667,376 in 
Medicare and $275,559,307 in Medicaid recovered audit disallowances. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Amount of expected recoveries, including audit 
receivables and investigative receivables and non-HHS investigative 
receivables resulting from work in areas such as states' shares of 
Medicaid restitution; 
Source of indicator: FY 2012 HCFAC report: [Empty]; 
Source of indicator: Other: [CheckPlus1]; 
Outcomes/outputs of indicators for Fiscal Year 2012: $6.9 billion 
consisting of $923.8 million in audit receivables and $6 billion in 
investigative receivables (which includes $1.7 billion in non-HHS 
investigative receivables resulting from work in areas such as the 
states' shares of Medicaid restitution). 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Ratio of expected return on investment measuring the 
efficiency of HHS-OIG's health care oversight efforts; 
(Target: $12.0); 
Source of indicator: FY 2012 HCFAC report: [Empty]; 
Source of indicator: Other: [CheckPlus2]; 
Outcomes/outputs of indicators for Fiscal Year 2012: $17.9. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of quality and management improvement 
recommendations that HHS program managers accepted; 
Source of indicator: FY 2012 HCFAC report: [Empty]; 
Source of indicator: Other: [CheckPlus2]; 
Outcomes/outputs of indicators for Fiscal Year 2012: 190 
recommendations. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of audit reports with funds to be put to better 
use; 
Source of indicator: FY 2012 HCFAC report: [Empty]; 
Source of indicator: Other: [CheckPlus1]; 
Outcomes/outputs of indicators for Fiscal Year 2012: 19 reports. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Examples of recently completed cases and settlements 
by specific types; 
Source of indicator: FY 2012 HCFAC report: [Empty]; 
Source of indicator: Other: [CheckPlus1]; 
Outcomes/outputs of indicators for Fiscal Year 2012: Examples cover 
many types, including medical equipment and supplies, pharmaceutical 
companies, laboratories, hospitals, and hospice care. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of sanctions administered in the form of 
program exclusions or administrative actions; 
Source of indicator: FY 2012 HCFAC report: [Empty]; 
Source of indicator: Other: [CheckPlus1]; 
Outcomes/outputs of indicators for Fiscal Year 2012: 1,911 sanctions 
administered in the form of program exclusions or administrative 
actions for alleged fraud or abuse or other activities that posed a 
risk to federal health care programs and their beneficiaries. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Amount of civil monetary penalties and assessments 
from cases in which OIG was involved; 
Source of indicator: FY 2012 HCFAC report: [Empty]; 
Source of indicator: Other: [CheckPlus1]; 
Outcomes/outputs of indicators for Fiscal Year 2012: $6.7 million. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Office of Audit Services (OAS): Amount of HHS 
receivables from self-disclosure cases in which HHS-OIG was involved; 
Source of indicator: FY 2012 HCFAC report: Office of Audit Services 
(OAS): [Empty]; 
Source of indicator: Other: Office of Audit Services (OAS): 
[CheckPlus1]; 
Outcomes/outputs of indicators for Fiscal Year 2012: Office of Audit 
Services (OAS): $53.3 million in HHS receivables. 

HHS-OIG Component: Office of Audit Services (OAS): 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of audit starts by program area; 
Source of indicator: FY 2012 HCFAC report: [Empty]; 
Source of indicator: Other: [CheckPlus2]; 
Outcomes/outputs of indicators for Fiscal Year 2012: 472 reports 
started, 337 of which were health care-related. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of final reports issued by program area; 
Source of indicator: FY 2012 HCFAC report: [Empty]; 
Source of indicator: Other: [CheckPlus2]; 
Outcomes/outputs of indicators for Fiscal Year 2012: 438 reports 
issued, 303 of which were health care-related. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Questioned cost recommendations (dollar value); 
Source of indicator: FY 2012 HCFAC report: [Empty]; 
Source of indicator: Other: [CheckPlus1]; 
Outcomes/outputs of indicators for Fiscal Year 2012: $860.6 million. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Funds put to better use recommendations; 
Source of indicator: FY 2012 HCFAC report: [Empty]; 
Source of indicator: Other: [CheckPlus1]; 
Outcomes/outputs of indicators for Fiscal Year 2012: $1,659.2 billion. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Timeliness of draft reports (or final reports if 
issued without a draft); (Target: 63 percent); 
Source of indicator: FY 2012 HCFAC report: [Empty]; 
Source of indicator: Other: [CheckPlus2]; 
Outcomes/outputs of indicators for Fiscal Year 2012: 72 percent. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Single Audits (A-133 audits) reviewed and transmitted 
to agencies for resolution; 
Source of indicator: FY 2012 HCFAC report: [Empty]; 
Source of indicator: Other: [CheckPlus1]; 
Outcomes/outputs of indicators for Fiscal Year 2012: 3,280 audits, 
which included 8,276 recommendations. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Audit receivables (disallowed questioned cost 
recommendations); 
Source of indicator: FY 2012 HCFAC report: [Empty]; 
Source of indicator: Other: v[CheckPlus2]; 
Outcomes/outputs of indicators for Fiscal Year 2012: $923.8 million. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Office of Counsel to the Inspector General (OCIG): 
Accepted management and quality improvement recommendations; 
Source of indicator: FY 2012 HCFAC report: Office of Counsel to the 
Inspector General (OCIG): [Empty]; 
Source of indicator: Other: Office of Counsel to the Inspector General 
(OCIG): [CheckPlus2]; 
Outcomes/outputs of indicators for Fiscal Year 2012: Office of Counsel 
to the Inspector General (OCIG): 83 recommendations, 18 of which were 
implemented. 

HHS-OIG Component: Office of Counsel to the Inspector General (OCIG): 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of compliance roundtable meetings held and 
number of companies represented; 
Source of indicator: FY 2012 HCFAC report: [Check]; 
Source of indicator: Other: [Empty]; 
Outcomes/outputs of indicators for Fiscal Year 2012: 2 roundtables 
held with officials representing 55 companies. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Indicators involving Civil Monetary Penalties (CMP), 
including dollar value of penalties and assessments for CMPs; 
Source of indicator: FY 2012 HCFAC report: [Empty]; 
Source of indicator: Other: [CheckPlus2]; 
Outcomes/outputs of indicators for Fiscal Year 2012: $20,980,462.53. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Indicators related to Corporate Integrity Agreements 
(CIA) or other similar agreements, including: 
Number of Corporate Integrity Agreements, Integrity Agreements, or 
other similar agreements monitored for compliance in fiscal year; 
Source of indicator: FY 2012 HCFAC report: [Check]; 
Source of indicator: Other: [CheckPlus2]; 
Outcomes/outputs of indicators for Fiscal Year 2012: 214 agreements 
monitored; 
Number of Corporate Integrity Agreements entered; 
Source of indicator: FY 2012 HCFAC report: [Empty]; 
Source of indicator: Other: [CheckPlus2]; 
Outcomes/outputs of indicators for Fiscal Year 2012: 35 agreements. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Indicators related to advisory opinions, including: 
Number of advisory opinions issued and number modified, including the 
number issued since inception of HCFAC program; 
Source of indicator: FY 2012 HCFAC report: [Check]; 
Source of indicator: Other: [CheckPlus2]; 
Outcomes/outputs of indicators for Fiscal Year 2012: 19 advisory 
opinions issued and 2 modifications of advisory opinions in fiscal 
year 2012; 276 opinions have been issued since inception of HCFAC 
program. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Office of Evaluation and Inspections (OEI): Advisory 
opinion requests received; 
Source of indicator: FY 2012 HCFAC report: Office of Evaluation and 
Inspections (OEI): [Empty]; 
Source of indicator: Other: Office of Evaluation and Inspections 
(OEI): [Empty]; 
Outcomes/outputs of indicators for Fiscal Year 2012: Office of 
Evaluation and Inspections (OEI): 61 opinions received. 

HHS-OIG Component: Office of Evaluation and Inspections (OEI): 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of evaluations started; (Target: 57 
evaluations); 
Source of indicator: FY 2012 HCFAC report: [Empty]; 
Source of indicator: Other: [CheckPlus2]; 
Outcomes/outputs of indicators for Fiscal Year 2012: 83 evaluations. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of reports issued; 
Source of indicator: FY 2012 HCFAC report: [Empty]; 
Source of indicator: Other: [CheckPlus2]; 
Outcomes/outputs of indicators for Fiscal Year 2012: 59 reports. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Percentage of final reports completed within a year; 
(Target: 55 percent); 
Source of indicator: FY 2012 HCFAC report: [Empty]; 
Source of indicator: Other: [CheckPlus2]; 
Outcomes/outputs of indicators for Fiscal Year 2012: 51 percent. 

HHS-OIG Component: Office of Investigations (OI): 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of individuals and entities excluded from 
participation in federal health care programs, including by the top 
reasons for exclusion; 
Source of indicator: FY 2012 HCFAC report: [Check]; 
Source of indicator: Other: [CheckPlus1]; 
Outcomes/outputs of indicators for Fiscal Year 2012: 3,131 individuals 
and entities excluded. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Complaints received; 
(Target: 6,290 complaints); 
Source of indicator: FY 2012 HCFAC report: [Empty]; 
Source of indicator: Other: [CheckPlus2]; 
Outcomes/outputs of indicators for Fiscal Year 2012: 4,827 complaints 
received. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Cases opened; 
Source of indicator: FY 2012 HCFAC report: [Empty]; 
Source of indicator: Other: [CheckPlus2]; 
Outcomes/outputs of indicators for Fiscal Year 2012: 2,369 cases. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Indicators used by agencies to assess activities 
(Associated target, if applicable): Cases closed; 
Source of indicator: FY 2012 HCFAC report: [Empty]; 
Source of indicator: Other: [CheckPlus2]; 
Outcomes/outputs of indicators for Fiscal Year 2012: 2,105 cases. 

Legend: 

[Check] indicates that the indicator is included in Fiscal Year 2012 
annual HCFAC report. 

[CheckPlus1] indicates that the indicator is included in at least one 
of the two HHS-OIG's Semiannual Report to Congress for fiscal year 
2012. 

[CheckPlus2] indicates that the indicator is included in HHS-OIG's 
Fiscal Year 2014 Justification of Estimates for Appropriations 
Committees, which includes outcomes/output of indicators for fiscal 
year 2012. 

Source: Agency reports, including fiscal year 2012 annual HCFAC 
report, and information from HHS-OIG officials. 

Notes: In addition to the indicators listed in the annual HCFAC 
reports and other HHS-OIG reports, officials indicated that they use 
additional indicators internally to manage and assess the work they 
conduct related to identifying and reducing health care fraud and 
abuse. 

[End of table] 

Table 8: Indicators That Are Used by the Department of Justice (DOJ) 
Components to Assess Health Care Fraud and Abuse Control (HCFAC) 
Program Activities, Source of Indicators, Associated Targets (if any), 
and Outcomes/Outputs for Associated Indicator, for Fiscal Year 2012: 

DOJ Component: Civil Division: 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Amount obtained through settlements and judgments; 
Source of indicator: 
FY 2012 HCFAC report: [Check]; 
Other: [Empty]; 
Outcomes/outputs of indicators for fiscal year 2012[A]: Over $3 
billion in settlements and judgments. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of new civil health care fraud investigations 
opened; 
Source of indicator: FY 2012 HCFAC report: [Check]; 
Other: [Empty]; 
Outcomes/outputs of indicators for fiscal year 2012[A]: 885 new civil 
investigations[B]. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of civil health care fraud matters pending at 
the end of the fiscal year; 
Source of indicator: 
FY 2012 HCFAC report: [Check]; 
Other: [Empty]; 
Outcomes/outputs of indicators for fiscal year 2012[A]: 1,023 civil 
investigations pending[B]. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of investigations completed per Department of 
Justice attorney working on financial fraud and health care fraud 
cases[C]; (Target: 11.92 investigations per attorney); 
Source of indicator: 
FY 2012 HCFAC report: [Empty]; 
Other: [CheckPlus1]; 
Outcomes/outputs of indicators for fiscal year 2012[A]: 10.28 
investigations per attorney for fiscal year 2012. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Percentage of civil cases favorably resolved for 
litigating divisions[C]; (Target: 80 percent of civil cases favorably 
resolved); 
Source of indicator: 
FY 2012 HCFAC report: [Empty]; 
Other: [CheckPlus1]; 
Outcomes/outputs of indicators for fiscal year 2012[A]: 81 percent of 
civil cases favorably resolved. 

DOJ Component: Civil Rights Division: 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of health care facilities reviewed (regarding 
conditions and services), including: 
* Number of health care facilities for persons with intellectual and 
developmental disabilities and/or mental illness found to violate 
residents' statutory rights; 
* Number of investigations continued for residential facilities for 
persons with intellectual and developmental disabilities; 
* Number of investigations continued for residential facilities for 
persons with mental illness; 
* Number of investigations continued for nursing facilities; 
Source of indicator: FY 2012 HCFAC report: [Empty]; 
Other: [Empty]; 
Outcomes/outputs of indicators for fiscal year 2012[A]: 
* Conditions and practices at 12 state facilities for persons with 
intellectual and developmental disabilities and/or mental illness were 
found to violate residents' rights; 
* Investigations of 10 residential facilities for persons with 
intellectual and developmental disabilities that were continued; 
* Investigations of 3 facilities for persons with mental illness that 
were continued; 
* Investigations of 2 nursing facilities that were continued. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of states where reviewed health care facilities 
are located; 
Source of indicator: 
FY 2012 HCFAC report: [Check]; 
Other: [Empty]; 
Outcomes/outputs of indicators for fiscal year 2012[A]: Reviewed 
conditions and services at 19 health care facilities in 16 states. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of formal investigations opened or continued 
and remedial agreements entered or monitored at facilities; 
Source of indicator: 
FY 2012 HCFAC report: [Check]; 
Other: [Empty]; 
Outcomes/outputs of indicators for fiscal year 2012[A]: 62 health care 
facilities in 19 states, the District of Columbia, and the 
Commonwealth of Puerto Rico. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of existing remedial agreements monitored, 
including: 
* Number of remedial agreements monitored for facilities for persons 
with intellectual and developmental disabilities; 
* Number of remedial agreements monitored for state-operated 
residential facilities for persons with mental illness; 
* Number of remedial agreements monitored for nursing facilities; 
Source of indicator: 
FY 2012 HCFAC report: [Check]; 
Other: [Empty]; 
Outcomes/outputs of indicators for fiscal year 2012[A]: Remedial 
agreements for 17 facilities for persons with intellectual and 
developmental disabilities monitored; 
Remedial agreements regarding 18 state-operated residential facilities 
for persons with mental illness monitored; 
Remedial agreements at 2 nursing facilities monitored. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of actions involving unjustified 
institutionalization of a disabled individual in which the Civil 
Rights Division intervened; 
Source of indicator: 
FY 2012 HCFAC report: [Check]; 
Other: [Empty]; 
Outcomes/outputs of indicators for fiscal year 2012[A]: 2 actions 
involving unjustified institutionalization of a disabled individual 
where the division moved to intervene. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of statements of interest or amicus briefs in 
litigation filed; 
Source of indicator: 
FY 2012 HCFAC report: [Check]; 
Other: [Empty]; 
Outcomes/outputs of indicators for fiscal year 2012[A]: 10 statements 
of interest or amicus briefs filed. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of cases favorably resolved for litigating 
components[C]; 
(Target: 80 percent of civil cases favorably resolved); 
Source of indicator: FY 2012 HCFAC report: [Empty]; 
Other: [CheckPlus1]; 
Outcomes/outputs of indicators for fiscal year 2012[A]: Criminal 
Division: 81 percent of civil cases favorably resolved. 

DOJ Component: Criminal Division: 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of new health care fraud cases; 
Source of indicator: 
FY 2012 HCFAC report: [Check]; 
Other: [Empty]; 
Outcomes/outputs of indicators for fiscal year 2012[A]: 136 health 
care fraud cases. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of defendants charged and amount that was 
collectively billed to Medicare and Medicaid; 
Source of indicator: 
FY 2012 HCFAC report: [Check]; 
Other: [Empty]; 
Outcomes/outputs of indicators for fiscal year 2012[A]: 110 defendants 
charged who collectively billed Medicare and Medicaid for more than 
$1.3 billion. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of guilty pleas obtained; 
Source of indicator: 
FY 2012 HCFAC report: [Check]; 
Other: [Empty]; 
Outcomes/outputs of indicators for fiscal year 2012[A]: 99 guilty 
pleas. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of jury trials litigated; 
Source of indicator: 
FY 2012 HCFAC report: [Check]; 
Other: [Empty]; 
Outcomes/outputs of indicators for fiscal year 2012[A]: 10 jury trials 
litigated. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of guilty verdicts obtained against number of 
defendants; 
Source of indicator: 
FY 2012 HCFAC report: [Check]; 
Other: [Empty]; 
Outcomes/outputs of indicators for fiscal year 2012[A]: Guilty 
verdicts for 21 defendants. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Average number of months of prison sentences in health 
care fraud cases; 
Source of indicator: 
FY 2012 HCFAC report: [Check]; 
Other: [Empty]; 
Outcomes/outputs of indicators for fiscal year 2012[A]: 56 months. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Amount secured through court-ordered restitution, 
forfeiture, and fines; 
Source of indicator: 
FY 2012 HCFAC report: [Check]; 
Other: [Empty]; 
Outcomes/outputs of indicators for fiscal year 2012[A]: $373 million. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of investigations completed per Department of 
Justice attorney working on financial fraud and health care fraud 
cases[C]; (Target: 11.92 investigations per attorney); 
Source of indicator: 
FY 2012 HCFAC report: [Empty]; 
Other: [CheckPlus1]; 
Outcomes/outputs of indicators for fiscal year 2012[A]: 10.28 
investigations per attorney for fiscal year 2012. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Percentage of criminal cases favorably resolved for 
litigating divisions[C]; (Target: 90 percent of criminal cases 
favorably resolved); 
Source of indicator: 
FY 2012 HCFAC report: [Empty]; 
Other: [CheckPlus1]; 
Outcomes/outputs of indicators for fiscal year 2012[A]: 92 percent of 
criminal cases favorably resolved. 

DOJ Component: Federal Bureau of Investigation (FBI): 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of operational disruptions of criminal fraud 
organizations; 
Source of indicator: 
FY 2012 HCFAC report: [Check]; 
Other: [Empty]; 
Outcomes/outputs of indicators for fiscal year 2012[A]: 329 criminal 
enterprises disrupted. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of dismantlements of criminal hierarchy of 
health care fraud enterprises; 
Source of indicator: 
FY 2012 HCFAC report: [Check]; 
Other: [Empty]; 
Outcomes/outputs of indicators for fiscal year 2012[A]: More than 83 
criminal enterprises dismantled. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of new health care fraud investigations 
initiated by the FBI; (Targets vary by field office); 
Source of indicator: 
FY 2012 HCFAC report: [Check]; 
Other: [Empty]; 
Outcomes/outputs of indicators for fiscal year 2012[A]: 817 new 
investigations. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of pending health care fraud investigations; 
(Targets vary by field office); 
Source of indicator: 
FY 2012 HCFAC report: [Check]; 
Other: [Empty]; 
Outcomes/outputs of indicators for fiscal year 2012[A]: 2,835 pending 
investigations. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of criminal health care fraud convictions; 
Source of indicator: 
FY 2012 HCFAC report: [Check]; 
Other: [Empty]; 
Outcomes/outputs of indicators for fiscal year 2012[A]: 1,096 criminal 
convictions. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of indictments and informations filed; 
Source of indicator: 
FY 2012 HCFAC report: [Check]; 
Other: [Empty]; 
Outcomes/outputs of indicators for fiscal year 2012[A]: 909 
indictments and informations filed. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of FBI health care fraud investigators and 
analysts that received training; (Targets vary by field office); 
Source of indicator: 
FY 2012 HCFAC report: [Check]; 
Other: [Empty]; 
Outcomes/outputs of indicators for fiscal year 2012[A]: More than 400 
FBI health care fraud investigators and analysts received training. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of dismantled criminal enterprises engaging in 
white-collar crime; (Target: 360 criminal enterprises); 
Source of indicator: 
FY 2012 HCFAC report: [Empty]; 
Other: [CheckPlus1]; 
Outcomes/outputs of indicators for fiscal year 2012[A]: 409 criminal 
enterprises. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): United States Attorneys' Offices (USAOs): Amounts 
received for restitutions, fines, seizures, civil restitution, and 
civil settlements; 
Source of indicator: 
FY 2012 HCFAC report: [Empty]; 
Other: [CheckPlus2]; 
Outcomes/outputs of indicators for fiscal year 2012[A]: In fiscal year 
2011: 
$1.2 billion in restitutions; $1 billion in fines; $96 million in 
seizures; $320 million in civil restitution; and over $1 billion in 
civil settlements. 

DOJ Component: United States Attorneys' Offices (USAOs): 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of new criminal matters received and defendants 
involved with those new matters; 
Source of indicator: 
FY 2012 HCFAC report: [Check]; 
Other: [Empty]; 
Outcomes/outputs of indicators for fiscal year 2012[A]: 1,131 new 
criminal matters involving 2,148 defendants. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of health care fraud criminal matters pending 
and defendants involved; 
Source of indicator: 
FY 2012 HCFAC report: [Check]; 
Other: [Empty]; 
Outcomes/outputs of indicators for fiscal year 2012[A]: 2,032 criminal 
matters pending involving 3,410 defendants. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of criminal charges filed and defendants 
involved; 
Source of indicator: 
FY 2012 HCFAC report: [Check]; 
Other: [Empty]; 
Outcomes/outputs of indicators for fiscal year 2012[A]: Charges filed 
in 452 cases involving 892 defendants. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of Federal health care fraud related 
convictions; 
Source of indicator: 
FY 2012 HCFAC report: [Check]; 
Other: [Empty]; 
Outcomes/outputs of indicators for fiscal year 2012[A]: 826 
convictions. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of new civil health care fraud investigations 
opened; 
Source of indicator: 
FY 2012 HCFAC report: [Check]; 
Other: [Empty]; 
Outcomes/outputs of indicators for fiscal year 2012[A]: 885 new civil 
investigations[B]. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of civil health care fraud investigations 
pending; 
Source of indicator: 
FY 2012 HCFAC report: [Check]; 
Other: [Empty]; 
Outcomes/outputs of indicators for fiscal year 2012[A]: 1,023 civil 
investigations pending[B]. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Number of investigations completed per Department of 
Justice attorney working on financial fraud and health care fraud 
cases[C]; (Target: 11.92 investigations per attorney); 
Source of indicator: 
FY 2012 HCFAC report: [Empty]; 
Other: [CheckPlus2]; 
Outcomes/outputs of indicators for fiscal year 2012[A]: 10.28 
investigations per attorney. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Percentage of criminal cases favorably resolved for 
litigating divisions[C]; (Target: 90 percent of criminal cases 
favorably resolved; 80 percent of civil cases favorably resolved); 
Source of indicator: 
FY 2012 HCFAC report: [Empty]; 
Other: [CheckPlus2]; 
Outcomes/outputs of indicators for fiscal year 2012[A]: 92 percent of 
criminal cases favorably resolved; 81 percent of civil cases favorably 
resolved. 

Indicators used by agencies to assess activities (Associated target, 
if applicable): Indicators used by agencies to assess activities 
(Associated target, if applicable): Percent of white collar crimes 
cases concerning mortgage fraud, health care fraud, and official 
corruption favorably resolved[C]; (Target: 90 percent of white collar 
cases favorably resolved); 
Source of indicator: 
FY 2012 HCFAC report: [Empty]; 
Other: [CheckPlus3]; 
Outcomes/outputs of indicators for fiscal year 2012[A]: 92.2 percent 
of white collar crime cases favorably resolved in fiscal year 2010. 

Legend: 

[Check] indicates that measure is included in Fiscal Year 2012 annual 
HCFAC report: 

[CheckPlus1] indicates that measure is in DOJ's Performance and 
Accountability report: 

[CheckPlus2] indicates that the measure is in FBI's Financial Crimes 
Report to the Public for Fiscal Years 2010--2011. 

[CheckPlus3] indicates that the measure is in DOJ's Performance Plan 
for Fiscal Year 2012: 

Source: Agency reports, including fiscal year 2012 annual HCFAC 
report, and interviews with DOJ officials. 

[A] Unless otherwise noted, the information on outcomes/output for 
each measure is for fiscal year 2012. 

[B] The outputs for these indicators are included in the summary of 
the HCFAC report and in the section regarding USAO activities. We 
report the outputs in the Civil Division section and USAO section of 
this table because the outputs include civil matters handled by the 
USAOs and/or Civil Division. 

[C] These measures are reported at the departmental level for DOJ, in 
which several DOJ components contribute, and include health care fraud 
cases in addition to other cases. 

[End of table] 

[End of section] 

Appendix IV: Key Outcomes and Outputs of Health Care Fraud and Abuse 
Control (HCFAC) Program Activities: 

Table 9: Key Program Outcomes/Outputs of Health Care Fraud and Abuse 
Control (HCFAC) Program Activities, Fiscal Years 2008 through 2012: 

HCFAC Key Program Outcomes/Outputs in Selected Years: 

Program outcome/output: Approximate amount won or negotiated through 
health care fraud judgments and settlements; 
Fiscal year 2008: $1 billion; 
Fiscal year 2009: $1.63 billion; 
Fiscal year 2010: $2.5 billion; 
Fiscal year 2011: $2.4 billion; 
Fiscal year 2012: $3 billion. 

Program outcome/output: Approximate amount deposited with the 
Department of Treasury and Centers for Medicare & Medicaid Services, 
transferred to other federal agencies or paid to private persons 
(result of fiscal year efforts as well as efforts from previous fiscal 
years); 
Fiscal year 2008: $2.14 billion; 
Fiscal year 2009: $2.576 billion; 
Fiscal year 2010: $4.02 billion; 
Fiscal year 2011: $4.1billion; 
Fiscal year 2012: $4.2 billion. 

Program outcome/output: Estimated amount in health care savings 
attributed to legislative or administrative actions to make funds 
available for better use (taken in response to HHS-OIG investigations, 
audits, and evaluations); 
Fiscal year 2008: $16.7 billion; 
Fiscal year 2009: $16.47 billion; 
Fiscal year 2010: $21.0 billion; 
Fiscal year 2011: $19.8 billion; 
Fiscal year 2012: $8.5 billion. 

Program outcome/output: Number of new criminal health care fraud 
investigations opened; 
Fiscal year 2008: 957; 
Fiscal year 2009: 1,014; 
Fiscal year 2010: 1,116; 
Fiscal year 2011: 1,110; 
Fiscal year 2012: 1,131. 

Program outcome/output: Number of cases where criminal charges were 
filed; 
Fiscal year 2008: 502; 
Fiscal year 2009: 481; 
Fiscal year 2010: 488; 
Fiscal year 2011: 489; 
Fiscal year 2012: 452. 

Number of defendants in cases where criminal charges were filed; 
Program outcome/output: Fiscal year 2008: 797; 
Fiscal year 2009: 803; 
Fiscal year 2010: 931; 
Fiscal year 2011: 1,430; 
Fiscal year 2012: 892. 

Program outcome/output: Number of defendants convicted of health care 
fraud-related crimes; 
Fiscal year 2008: 588; 
Fiscal year 2009: 583; 
Fiscal year 2010: 726; 
Fiscal year 2011: 743; 
Fiscal year 2012: 826. 

Program outcome/output: Number of new civil health care fraud 
investigations opened; 
Fiscal year 2008: 843; 
Fiscal year 2009: 886; 
Fiscal year 2010: 942; 
Fiscal year 2011: 977; 
Fiscal year 2012: 885. 

Outcomes/outputs associated with Strike Force teams[A]: 

Program outcome/output: Number of defendants charged; 
Fiscal year 2008: 65; 
Fiscal year 2009: 209; 
Fiscal year 2010: 284; 
Fiscal year 2011: 323; 
Fiscal year 2012: 278. 

Program outcome/output: Number of defendants convicted; 
Fiscal year 2008: 75; 
Fiscal year 2009: 104; 
Fiscal year 2010: 240; 
Fiscal year 2011: 198; 
Fiscal year 2012: 280. 

Program outcome/output: Number of defendants sentenced to prison; 
Fiscal year 2008: 71; 
Fiscal year 2009: 77; 
Fiscal year 2010: 146; 
Fiscal year 2011: 175; 
Fiscal year 2012: 201. 

Program outcome/output: Estimated total amount billed to Medicare in 
alleged Strike Force cases; 
Fiscal year 2008: $140 million; 
Fiscal year 2009: $253 million; 
Fiscal year 2010: $590 million; 
Fiscal year 2011: $1 billion; 
Fiscal year 2012: $1.5 billion. 

Program outcome/output: Number of individuals and entities excluded by 
HHS-OIG; 
Fiscal year 2008: 3,129; 
Fiscal year 2009: 2,556; 
Fiscal year 2010: 3,340; 
Fiscal year 2011: 2,662; 
Fiscal year 2012: 3,131. 

Program outcome/output: Return-on-investment (3-year moving average); 
Fiscal year 2008: $4.9:1; 
Fiscal year 2009: $5.1:1; 
Fiscal year 2010: $6.8:1; 
Fiscal year 2011: $7.2:1; 
Fiscal year 2012: $7.9:1. 

Program outcome/output: HCFAC mandatory obligations; 
Fiscal year 2008: $354,970,390; 
Fiscal year 2009: $366,075,050; 
Fiscal year 2010: $387,037,433; 
Fiscal year 2011: $395,868,822; 
Fiscal year 2012: $452,924,566. 

Program outcome/output: HCFAC discretionary obligations; 
Fiscal year 2008: [Empty]; 
Fiscal year 2009: $39,085,681; 
Fiscal year 2010: $32,598,092; 
Fiscal year 2011: $78,403,309; 
Fiscal year 2012: $63,501,482. 

Program outcome/output: Obligations of other appropriations; 
Fiscal year 2008: $67,274,025; 
Fiscal year 2009: $80,799,515; 
Fiscal year 2010: $75,075,212; 
Fiscal year 2011: $91,473,384; 
Fiscal year 2012: $67,165,097. 

Total obligations: 
Fiscal year 2008: $422,244,416; 
Fiscal year 2009: $485,960,246; 
Fiscal year 2010: $494,710,737; 
Fiscal year 2011: $565,745,516; 
Fiscal year 2012: $583,591,144. 

Source: GAO analysis of annual HCFAC reports for fiscal years 2008 
through 2012, return-on-investment data for fiscal years 2008-2012 
reported to GAO by the Department of Justice, and HCFAC obligations 
reported to GAO by Department of Justice, Department of Health and 
Human Services (HHS), and HHS Office of Inspector General (HHS-OIG) 
for fiscal years 2008 through 2012. 

[A] Some of the outcomes/outputs associated with the Strike Force 
teams are subsets of outcomes/outputs reported for the HCFAC program 
as a whole. For example, the number of defendants charged in Strike 
Force cases is a subset of the total number of defendants in health 
care fraud-related cases where criminal charges were filed. As a 
result, the outcomes/outputs reported in this table may be duplicative. 

[End of table] 

[End of section] 

Appendix V: Comments from the Department of Health and Human Services: 

Department of Health and Human Services: 
Office of the Secretary: 
Assistant Secretary for Legislation: 
Washington, DC 20201: 

September 13, 2013: 

Kathleen King, Director: 
Health Care
Government Accountability Office: 
441 G Street, NW: 
Washington, DC 20548: 

Dear Ms. King: 

Attached are comments on the U.S. Government Accountability Office's 
(GAO} report entitled, "Health Care Fraud and Abuse Control Program: 
Indicators Provide Information on Program Accomplishments, but 
Assessing Program Effectiveness is Difficult" (GAO-13-746). 

The Department appreciates the opportunity to review this report prior 
to publication. 

Sincerely, 

Signed by: 

Jim R. Esquea: 
Assistant Secretary for Legislation: 

Attachment: 

General Comments Of Health and Human Services (HHS) on the Government 
Accountability Office's (GAO Draft Report Entitled, "Health Care Fraud 
and Abuse Control Program: Indicators Provide Information on Program 
Accomplishments, But Assessing Program Effectiveness is Difficult" 
(Gao-13-746): 

The Department appreciates the opportunity to review and comment on 
this draft report. 

HHS uses a comprehensive program integrity strategy to reduce fraud, 
waste, and abuse, and our activities are designed to be coordinated 
throughout the Department, as well as with the Office of Inspector 
General and DOJ. We believe that the comprehensive approach permits us 
to be more effective in the allocation of our resources, even though 
it may be difficult to assess the impact of each activity in 
isolation. For example, CMS is currently revalidating the enrollment
information of all currently enrolled Medicare providers. CMS used 
information from the Automated Provider Screening system to identify 
providers and suppliers as top priorities for revalidation. As a 
result, CMS was able to revoke or deactivate the billing privileges of 
tens of thousands of providers that do not meet Medicare requirements. 
While we are unable to quantify the savings that may result from these 
actions at this time, we know that improper payments, including 
potential fraud, have been prevented due to the removal of these 
providers and suppliers. 

HHS is committed to reducing fraud, waste, and abuse in federal health 
care programs. Through a collaborative effort with DOJ, HHS works to 
fulfill the HCFAC Program's goals, and support efforts related to the 
Medicare Strike Force teams. In conjunction with national takedowns, 
CMS, in particular, is using its expanded authority to suspend 
payments pending the investigation of a credible allegation of fraud 
for those providers involved. This immediately stops improper payments 
to potentially fraudulent providers and helps to shift our program 
integrity strategy beyond "pay and chase." In addition, CMS recently 
announced its first temporary provider enrollment moratoria using the 
authority provided by Section 6401(a} of the Affordable Care Act. The 
moratoria prevents the enrollment of new home health provider and 
ambulance suppliers in Medicare, Medicaid and the Children's Health 
Insurance Program (CHIP) in three Medicare strike force cities. The 
goal of the temporary moratoria is to fight fraud and safeguard 
taxpayer dollars, while ensuring patient access to care. 

Under the moratoria, existing providers and suppliers can continue to 
deliver and bill for services, but no new provider and supplier 
applications will be approved in these areas for all three programs. 
The temporary enrollment moratoria apply to newly-enrolling home 
health agencies in the Miami and Chicago metropolitan areas; and newly-
enrolling ground ambulance suppliers in the Houston metropolitan area. 

[End of section] 

Appendix VI: GAO Contacts and Staff Acknowledgments: 

GAO Contacts: 

Kathleen M. King, (202) 512-7114 or kingk@gao.gov: 

Eileen R. Larence, (202) 512-8777 or larencee@gao.gov: 

Staff Acknowledgments: 

In addition to the contacts named above, Martin T. Gahart, Assistant 
Director; Tom Jessor, Assistant Director; Christie Enders; Sandra 
George; Drew Long; Lisa Rogers; and Meghan Squires made significant 
contributions to the work. 

[End of section] 

Footnotes: 

[1] GAO, High-Risk Series: An Update, [hyperlink, 
http://www.gao.gov/products/GAO-11-278] (Washington, D.C.: February 
2011). Fraud represents intentional acts of deception with knowledge 
that the action or representation could result in an inappropriate 
gain. Abuse represents actions inconsistent with acceptable business 
or medical practices. 

[2] Pub. L. No. 104-191, § 201, 110 Stat. 1936, 1992 (Aug. 21, 1996) 
(codified at 42 U.S.C. §§ 1320a-7c, 1395i(k)). 

[3] Medicare is the federal health insurance program for persons aged 
65 and over, certain disabled individuals, and individuals with end-
stage renal disease. Medicaid and CHIP are joint federal-state 
programs that finance health insurance coverage for certain categories 
of low-income adults and children. 

[4] In this report, we refer to the agencies, divisions, and offices 
within HHS and DOJ as components. 

[5] In addition to HCFAC mandatory and discretionary funding 
appropriated to HHS, HHS-OIG, and DOJ, over $250 million in 
discretionary HCFAC funding was appropriated to CMS to support program 
integrity activities in Medicare and Medicaid for fiscal year 2012. 

[6] See GAO, Medicare: Progress Made to Deter Fraud, but More Could Be 
Done, [hyperlink, http://www.gao.gov/products/GAO-12-801T] 
(Washington, D.C.: June 8, 2012). 

[7] Mandatory funding refers to budgetary resources controlled by laws 
other than appropriations acts. Discretionary funding refers to 
budgetary resources provided in annual appropriations acts, other than 
those that fund mandatory programs. HHS and DOJ receive mandatory 
funding as well as discretionary funding for the HCFAC program. The 
FBI receives mandatory funding to support HCFAC activities. 

[8] HHS's components that received HCFAC funding in fiscal year 2012 
were: Administration for Community Living (ACL), CMS, Food and Drug 
Administration (FDA), and Office of General Counsel (HHS-OGC). HHS-
OIG's components that received HCFAC funding in fiscal year 2012 were: 
Office of Audit Services (OAS), Office of Counsel to the Inspector 
General (OCIG), Office of Evaluation and Inspections (OEI), Office of 
Investigations (OI), and Office of Management and Policy (OMP). DOJ's 
components that received HCFAC funding were: DOJ's Civil Division, 
Civil Rights Division, Criminal Division, Executive Office for United 
States Attorneys (EOUSA)--which provides administrative support for 
the 94 USAOs--the Justice Management Division (JMD), and the FBI. 

[9] The Medicare Trust Funds refer to the Hospital Insurance Trust 
Fund and the Supplementary Medical Insurance Trust Fund, which finance 
Medicare. 

[10] The HCFAC funding appropriated to CMS that we included in our 
review supports a Medicaid and CHIP financial management oversight 
project, a pilot project using data analytics to identify fraud in 
community mental health centers in 3 states, and some of CMS's 
contributions to the Medicare Strike Force teams, which provide 
additional investigative and prosecutorial resources in high fraud 
cities. The funding included in our review is a small portion of the 
HCFAC funding that CMS receives. In fiscal year 2012, CMS received 
over $250 million in discretionary HCFAC funding, and CMS officials 
told us that most of this funding was used to support program 
integrity activities in Medicare Parts C and D. 

[11] In July 2011, we issued a report on how CMS used its Medicare 
Integrity Program (MIP) funding to support the program's activities in 
fiscal years 2006 through 2010, how CMS assessed the effectiveness of 
MIP, and the factors CMS considered when allocating MIP funding. See 
GAO, Medicare Integrity Program: CMS Used Increased Funding for New 
Activities but Could Improve Measurement of Program Effectiveness, 
[hyperlink, http://www.gao.gov/products/GAO-11-592] (Washington, D.C.: 
July 29, 2011). CMS concurred with our recommendations that CMS update 
the return-on-investment calculation when program expenditure data are 
updated and implement data system changes that will permit CMS to 
capture accurate spending data. 

[12] An obligation is a definite commitment that creates a legal 
liability of the government for payment of goods and services ordered 
or received. Obligations can be paid immediately or in the future. 

[13] We requested that HHS, HHS-OIG, and DOJ report their information 
within five categories of expenses: (1) personnel compensation and 
benefits; (2) contractual services and supplies (including rent, 
transportation, printing, and supplies); (3) acquisition of assets; 
(4) grants; and (5) other expenses. In addition to fiscal year 2012, 
we obtained information for fiscal years 2008 through 2011, which is 
included in appendix II. 

[14] Two HHS components, the Office of the Assistant Secretary for 
Public Affairs and the Office of the Assistant Secretary for Planning 
and Evaluation, had HCFAC obligations for fiscal year 2011 only. 

[15] For the purposes of our report, we refer to HHS-OIG and its 
components separately from HHS and its agencies. Several HHS and DOJ 
components obligated funds not specifically appropriated for the HCFAC 
program in addition to HCFAC appropriations to carry out activities 
related to health care fraud and abuse. For example, DOJ's USAOs used 
other appropriations, including direct appropriations, to support 
HCFAC activities. 

[16] The return-on-investment calculation compares the amount of 
funding returned as a result of HCFAC activities with the funding 
appropriated to conduct those activities. 

[17] We selected these experts through our literature review. 

[18] Safe harbors identify payment or business practices that are 
protected from enforcement under federal laws that prohibit such 
payment or business practices. 

[19] See, e.g., Omnibus Appropriations Act, 2009, Pub. L. No. 111-8, 
123 Stat. 524, 773 (Mar. 11, 2009). In addition to appropriating 
discretionary HCFAC funds, this law and subsequent annual 
appropriations laws have required that the annual HCFAC report include 
measures of operational efficiency and impact on fraud, waste, and 
abuse in Medicare, Medicaid, and CHIP for the funds provided by these 
appropriations. Starting in fiscal year 2010, the annual HCFAC report 
has included a return-on-investment calculation. The calculation is 
estimated by dividing the monetary results (such as deposits and 
transfers to the Medicare Trust Funds) by the annual HCFAC 
appropriation in a given year. 

[20] The Patient Protection and Affordable Care Act and the Health 
Care and Education Reconciliation Act of 2010 provided additional 
mandatory appropriations from the Medicare Trust Funds for the HCFAC 
program for fiscal years 2011 through 2020. The additional fiscal year 
2012 mandatory appropriation is reflected in figure 1. Patient 
Protection and Affordable Care Act, Pub. L. No. 111-148, § 6402(i), 
124 Stat. 119, 760 (Mar. 23, 2010); Health Care Education and 
Reconciliation Act of 2010, Pub. L. No. 111-152, § 1303(a), 124 Stat. 
1029, 1057 (Mar. 30, 2010). 

[21] In fiscal year 2012, CMS was appropriated over $250 million in 
discretionary HCFAC funding and CMS officials told us that most of 
this funding was used to support program integrity activities in 
Medicare Parts C and D. In addition to HCFAC funding, CMS also 
received about $863 million in funding for the Medicare Integrity 
Program in fiscal year 2012. 

[22] The False Claims Act prohibits certain actions, including the 
knowing presentation of a false claim for payment by the federal 
government. Such claims may be brought by the United States or a 
private person--known as a relator or whistleblower--on behalf of him 
or herself and the United States, alleging the submission of false 
claims for payments by the federal government. DOJ may intervene in 
such an action, known as a "qui tam" action, and litigate the case 
along with the private party. 31 U.S.C. §§ 3729-3733. 

[23] Percentages do not add to 100 due to rounding. 

[24] An obligation is a definite commitment that creates a legal 
liability of the government for payment of goods and services ordered 
or received. Obligations can be paid immediately or in the future. 

[25] In addition to mandatory and discretionary HCFAC funding, we 
requested that HHS, HHS-OIG, and DOJ components identify other 
appropriations used to support HCFAC activities. For the purposes of 
this report, we define "HCFAC obligations" to be obligations used to 
support HCFAC activities, which includes obligations of HCFAC 
mandatory and discretionary appropriations, obligations of FBI 
mandatory appropriations provided under HIPAA for health care fraud 
and abuse activities, and obligations of other appropriations not 
specific to the HCFAC program. 

[26] As a component of DOJ, the FBI's obligations are included with 
DOJ HCFAC obligations, even though it receives its mandatory funding 
for health care fraud and abuse activities from the U.S. Treasury's 
general fund and not the Medicare Trust Funds. The FBI includes a 
description of its activities in an appendix to the annual HCFAC 
report and its funding is included in the HCFAC return-on-investment 
calculation. 

[27] The Patient Protection and Affordable Care Act and the Health 
Care and Education Reconciliation Act of 2010, which provide 
additional mandatory HCFAC appropriations for fiscal years 2011 
through 2020, require that these additional appropriations be 
allocated in the same proportion as the wedge fund was allocated in 
fiscal year 2010. The agencies have applied this allocation to the 
entire wedge appropriation since fiscal year 2010. 

[28] CMS's efforts related to the Strike Force teams were funded with 
HCFAC discretionary appropriations. 

[29] OMP provides management, guidance, and resources in support of 
the other HHS-OIG components. 

[30] HHS-OGC's reported estimated obligations of other appropriations, 
which also included reimbursements for attorney services provided to 
OGC clients within HHS that supported HCFAC activities. 

[31] Deficit Reduction Act of 2005, Pub. L. No. 109-171, § 6034(c), 
120 Stat. 4, 77 (Feb. 8, 2006). 

[32] Although some DOJ components reported obligating funds from other 
appropriations for HCFAC activities, they also reported carrying over 
some of their HCFAC funding into other fiscal years. A DOJ official 
told us that funds are often carried over to a new fiscal year, such 
as in the situation of a continuing resolution, which may shorten the 
number of months in which they are able to obligate the appropriated 
funds. 

[33] Section 11013 of the 21STCentury Department of Justice 
Appropriations Authorization Act authorized the Attorney General to 
credit, as an offsetting collection, to the Department of Justice 
Working Capital Fund--a revolving fund that is authorized by Congress, 
as a form of permanent appropriation, to maintain moneys from certain 
sources for specific purposes--up to 3 percent of all amounts 
collected pursuant to DOJ's civil debt collection litigation 
activities. DOJ refers to this appropriation as "Three Percent Funds." 
Pub. L. No. 107-273, § 11013, 116 Stat. 1758, 1823 (Nov. 2, 2002). 

[34] A qui tam case is a civil action brought under the False Claims 
Act by an individual--known as a relator or whistleblower--on behalf 
of him or herself and the United States, alleging the submission of 
false claims for payment by the federal government. In these qui tam 
cases, the relator may be eligible to receive a portion of the 
proceeds of the action or settlement, and reasonable expenses and 
attorneys' fees and costs. 31 U.S.C. § 3730(b),(d). 

[35] We requested that HHS, HHS-OIG, and DOJ report their HCFAC 
obligations within five categories of expenses. These categories were 
personnel compensation and benefits; contractual services and supplies 
(including rent, transportation, printing, supplies); acquisition of 
assets; grants; and other expenses. 

[36] HHS-OIG found that three South Florida counties (Miami-Dade, 
Broward, and Palm Beach) accounted for half of the submitted charges 
totaling $976 million, and 79 percent of the amount for drugs, billed 
nationally for Medicare beneficiaries with HIV/AIDs in the last half 
of 2006. In addition, HHS-OIG found that CMS and its contractors' 
efforts to control these inappropriate payments through multiple 
approaches--such as payment suspensions, provider revocations, and 
claims-processing edits--resulted in limited success in controlling 
the aberrant billing. See HHS-OIG, Aberrant Billing in South Florida 
For Beneficiaries with HIV/AIDs, OEI-09-07-0030 (Washington, D.C., 
Sept. 2007). 

[37] HHS-OIG's report on the Senior Medicare Patrol (SMP) programs 
presents performance data for each SMP program. HHS-OIG collects the 
data every 6 months, reports annually, and has done so since 1997. 

[38] According to the fiscal year 2012 HCFAC report, OGC advised CMS 
on the new voluntary Self Referral Disclosure Protocol established by 
the Patient Protection and Affordable Care Act. Pub. L. No. 111-148, § 
6409(a), 124 Stat. at 772. Under this protocol, providers of services 
and supplies may self-disclose actual or potential violations of the 
physician self-referral law, commonly known as the Stark law. The 
Stark law prohibits physicians from making certain referrals for 
"designated health services" paid for by Medicare to entities with 
which the physician (or immediate family members) has a financial 
relationship, unless the arrangement complies with a specified 
exception, such as in-office ancillary services. 42 U.S.C. § 
1395nn(a)(1), (b)(2). 

[39] Corporate integrity agreements outline conditions or requirements 
an entity agrees to as a part of a civil settlement. An entity agrees 
to the corporate integrity agreement's requirements in exchange for 
HHS-OIG's agreement that it will not seek to exclude the entity from 
participation in federal health care programs. HHS-OIG's Office of 
Counsel to the Inspector General monitors the compliance with these 
agreements. 

[40] GAO, 2013 Annual Report: Actions Needed to Reduce Fragmentation, 
Overlap, and Duplication and Achieve Other Financial Benefits, 
[hyperlink, http://www.gao.gov/products/GAO-13-279SP], (Washington, 
D.C.: April 2013); Medicare Integrity Program: CMS Used Increased 
Funding for New Activities but Could Improve Measurement of Program 
Effectiveness, [hyperlink, http://www.gao.gov/products/GAO-11-592] 
(Washington, D.C.: July 2011); and Opportunities to Reduce Potential 
Duplication in Government Programs, Save Tax Dollars, and Enhance 
Revenue, [hyperlink, http://www.gao.gov/products/GAO-11-318SP] 
(Washington, D.C.: March 2011). 

[41] For example, officials told us that although a defendant 
convicted of health care fraud may be ordered to pay restitution and 
penalties in a specific amount, the defendant may pay less than what 
is ordered as the ability to pay often affects how much is actually 
received. 

[42] Many cases discussed in the annual HCFAC report include 
settlements reached with pharmaceutical and device manufacturers for 
criminal and civil liabilities. For example, the fiscal year 2012 
HCFAC report describes many settlements reached with pharmaceutical 
and device manufacturers and the settlements ranged from about 
$200,000 to $3 billion. 

[43] The CMS activities for which funding is included are financial 
management oversight of the Medicaid program and CHIP; a pilot project 
related to payments for partial hospitalization programs made to 
community mental health centers (which is designed to use predictive 
modeling to prevent fraud in community mental health centers in 
Florida, Texas, and Louisiana); and for CMS support for the Medicare 
Strike Force teams. The return-on-investment calculation does not 
include the remaining HCFAC funding that CMS receives because it 
generally supports program integrity activities in Medicare Parts C 
and D. 

[44] Mandatory HCFAC appropriations are available until expended. 
Discretionary HCFAC appropriations are available for two years. 

[45] GAO, Intellectual Property: Federal Enforcement Has Generally 
Increased, but Assessing Performance Could Strengthen Law Enforcement 
Efforts, [hyperlink, http://www.gao.gov/products/GAO-08-157] 
(Washington, D.C.: Mar. 11, 2008). 

[46] According to one DOJ official, some of the department's 
indicators have targets that focus on the quality or efficiency of its 
work, rather than focusing on the number of cases opened or criminal 
charges filed. For example, DOJ has department-wide measures for the 
percentage of cases favorably resolved, that is, a judgment in favor 
of the U.S. government or a settlement. The target rate of cases 
favorably resolved is 90 percent for criminal cases and 80 percent for 
civil cases, which incorporate all of DOJ's cases (including health 
care fraud cases as well as other cases). 

[47] A. Rashidian, H. Joudaki, and T. Vian, "No Evidence of the Effect 
of the Interventions to Combat Health Care Fraud and Abuse: A 
Systematic Review of Literature," PLoS ONE, vol. 7, no. 8 (2012). 

[48] See GAO, Medicare: Progress Made to Deter Fraud, but More Could 
Be Done, [hyperlink, http://www.gao.gov/products/GAO-12-801T] 
(Washington, D.C.: June 8, 2012). 

[49] For example, DOJ Criminal Division officials reported that home 
health billings in Florida dropped from $3.4 billion in 2009 to $2.3 
billion in 2011. 

[50] DOJ officials reported that they compared claims submitted to 
Medicare for group psychotherapy during the six-month period between 
January 1, 2011 and June 30, 2011 to claims submitted to Medicare for 
those same services during the six-month period between July 1, 2012 
and December 31, 2012. 

[End of section] 

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