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Health Care Fraud and Abuse Control Program: Indicators Provide Information on Program Accomplishments, but Assessing Program Effectiveness is Difficult

NCJ Number
Date Published
September 2013
70 pages
This Government Accountability Office (GAO) study examined how the Department of Health and Human Services (HHS) and the Department of Justice (DOJ) are using funds to achieve the goals of the Health Care Fraud and Abuse Control (HCFAC) program, and also reviewed performance assessments and other metrics that HHS and DOJ use to determine HCFAC's effectiveness.
After reporting on HCFAC funding amounts and sources for fiscal year 2012, the GAO study determined how the funds ($583.6 million) were used to support a variety of HCFAC 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. HHS and DOJ use several performance indicators to assess HCFAC activities, as well as to inform decisionmakers on how to allocate resources; e.g., U.S. Attorneys' Offices use indicators related to criminal prosecutions. In addition, many of the indicators reflect the collective work of multiple agencies, since many agencies collaborate in building health care fraud cases. Still, the GAO study found there was insufficient information about the effectiveness of HCFAC activities in reducing health care fraud and abuse. Information is collected on outputs, but not on the effectiveness of the outputs in reducing health care fraud and abuse. A baseline measure of the extent of healthcare fraud is needed in order to then measure reductions over time that can be attributed to HCFAC activities. Such an effort is underway in HHS's estimation of a baseline of probable fraud in home health care. Successes in this effort may lead to its expansion to the measurement of baseline fraud and abuse in other areas of federally funded health care. Appended information on HCFAC activities in fiscal years 2008 through 2012