12 Healthcare Fraud, Waste, & Abuse Facts

by | Apr 29, 2015 | FWA, Healthcare | 0 comments

  1. Fraud accounts for 19% of the $600 to $800B in waste in the U.S. healthcare system annually, including everything from bogus Medicare claims to kickbacks for worthless treatments and other services.
  2. 57% of insurers expect to see an increase in fraud losses this year on personal insurance lines (mainly auto and home insurance), while only 5% of insurers expect to see a decline in dollar fraud losses on personal lines.
  3. Each family in the U.S. pays more than an extra $800 in health care costs each year due to healthcare fraud.
  4. In 2013, the U.S. Department of Health and Human Services estimated that it improperly spent about $65B in taxpayer funds through waste, errors and fraud – with $60 billion attributed to overpayments to Medicare and Medicaid.
  5. The US Government Accountability Office estimates that $1 out of every $7 spent on Medicare is lost to fraud and abuse.
  6. Abuse cannot always be easily identified, because what “abuse” versus “fraud” is depends on specific facts and circumstances, intent and prior knowledge, and available evidence – among other factors.
  7. Private-sector payers have less success in combating fraud and abuse because they lack the legal and administrative tools available to the federal government.
  8. The Office of Inspector General reported savings and expected recoveries of more than $20B in 2008.
  9. The Congressional Budget Office estimates that increased enforcement would save Medicare and Medicaid about $2B over 10 years.
  10. In Oct. 2012, Medicare Strike Force operations in 7 cities led to charges against 91 individuals (doctors, nurses and other licensed medical professionals) for their alleged participation in Medicare fraud schemes involving approximately $432M in false billing.
  11. Due to the Affordable Care Act, criminals convicted of fraud now face tougher sentences and more jail time. Criminals will receive 20-50% longer sentences for crimes that involve more than $1 million in losses.

Sources:

  1. National Health Care Anti-Fraud Association, 2008
  2. Thomson Reuters, 2009
  3. Insurance Information Institute, 2015
  4. Blue Cross Blue Shield Assoc., 2013
  5. U.S. Department of Health and Human Services, 2013
  6. US  Government Accountability Office
  7. Humana, 2014
  8. AARP, 2009
  9. Office of Inspector General
  10. Congressional Budget Office
  11. U.S. Department of Health and Human Services, 2013
  12. U.S. Department of Health and Human Services, 2013

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