Health Care Fraud:

Characteristics, Sanctions, and Prevention

AFMD-87-29BR: Published: Jul 15, 1987. Publicly Released: Aug 18, 1987.

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In response to a congressional request, GAO conducted a review of health care fraud investigations that agency inspectors general referred to the Department of Justice (DOJ) for prosecution, to identify: (1) the characteristics of the alleged fraud; (2) actions DOJ took against those defrauding the government; and (3) whether the Department of Health and Human Services Office of Inspector General's (OIG) process to identify fraudulent activities was adequate.

GAO reviewed 279 Medicaid and Medicare cases that OIG referred to DOJ between 1984 and 1985 and found that: (1) 89 percent involved submission of false claims; (2) about 85 percent involved health care providers; (3) about 50 percent involved allegations of Medicare fraud; (4) 30 percent involved Medicaid; and (5) 9 percent involved more than one program. GAO identified three types of possible actions available against providers that commit Medicare or Medicaid fraud, including: (1) DOJ criminal or civil actions; (2) OIG assessments of monetary penalties; and (3) OIG suspensions from program participation. GAO also reviewed 351 cases in which DOJ found that fraud had occurred and found that: (1) OIG imposed 150 fines or settlements and 114 suspensions; and (2) DOJ effected 114 criminal convictions and deferred adjudications and 11 pretrial diversions. GAO also found that: (1) although OIG has established a Management Implication Reports (MIR) system to notify health care program managers of the causes of fraud and to recommend ways to prevent future fraud, managers did not always receive that information; and (2) OIG plans to implement new procedures that will ensure that program managers receive MIR.

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