DOJ Healthcare Audits Charged $5 Billion In 2021

Excerpts, notes and quotes from the DOJ 2021 Fiscal Year Report


The DOJ DOJ Healthcare Audits Charged $5 Billion In 2021, according to a recent report. The Department of Justice released an analysis of all False Claims Act settlements and judgments in fiscal year 2021, revealing $5 Billion against healthcare, out of a $5.6B total. Healthcare represented 89% of all DOJ FCA judgments and settlements for the year.


The False Claims Act is the government’s primary civil tool to redress false claims involving other government operations and functions. 


“The Justice Department obtained more than $5.6 billion in settlements and judgments from civil cases involving fraud and false claims against the government in the fiscal year ending Sept. 30, 2021”

 — Acting Assistant Attorney General Brian M. Boynton of the DOJ’s Civil Division



In the False Claims Act history, this is the second largest annual total, and the largest since 2014. Settlement and judgments now total north of $70 billion since 1986, when Congress substantially strengthened the civil False Claims Act by boosting incentives up to 30% for whistleblowers. In 2021, whistleblowers filed 598 qui tam suits.


DOJ Healthcare Audits account for nearly 90% of all DOJ charges


Of the more than $5.6 billion in settlements and judgments reported by the Department of Justice this past fiscal year, over $5 billion relates to matters that involved the healthcare industry, including drug and medical device manufacturers, managed care providers, hospitals, pharmacies, hospice organizations, laboratories and physicians. The amounts included in the $5 billion reflect recoveries arising from only federal losses, and, in many of these cases, the department was instrumental in recovering additional amounts for state Medicaid programs.


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“Ensuring that citizens’ tax dollars are protected from fraud and abuse is among the department’s top priorities…  The False Claims Act is one of the most important tools available to the department both to deter and to hold accountable those who seek to misuse public funds.”

 — Acting Assistant Attorney General Brian M. Boynton of the DOJ’s Civil Division


First Place:  Health Care Fraud


Healthcare fraud was once again in the lead as the top source of the department’s False Claims Act settlements and judgments. The department’s efforts restore funds to federal programs such as Medicare, Medicaid and TRICARE and prevent billions in losses by acting as a deterrent. Often, also protecting patients from medically unnecessary or potentially harmful actions.


Second Place: Medicare Advantage

Prosecuting Plans AND Providers for Over-Coding, Up-Coding


In 2021, more than 26 million Medicare beneficiaries were enrolled in Medicare Advantage plans, and the Congressional Budget Office projected that CMS would pay more than $343 billion for those plans.


The department has pursued plans and healthcare providers that manipulated the risk adjustment process by submitting unsupported diagnosis codes to make their patients appear sicker than they actually were. This year, Sutter Health, a California-based health care services provider, paid $90 million to resolve allegations that it knowingly submitted unsupported diagnosis codes for certain patient encounters, resulting in inflated payments to be made to the Medicare Advantage Plans and Sutter Health. In addition, Kaiser Foundation Health Plan of Washington, formerly known as Group Health Cooperative (GHC), paid $6.3 million to resolve allegations that it submitted invalid diagnoses and received inflated payments as a result. In addition, the department intervened and filed complaints in separate lawsuits against Independent Health Corporation and members of the Kaiser Permanente consortium alleging that those Medicare Advantage organizations submitted or caused the submission of inaccurate information about the health status of beneficiaries enrolled in their plans to increase reimbursement from Medicare.


Other areas of Settlements and Judgments:

  • Unnecessary Medical Services
  • Combating the Opioid Epidemic
  • ​​Unlawful Kickbacks
  • Procurement Fraud
  • COVID-Related Fraud
  • Holding Individuals Accountable
  • Cybersecurity Initiative
  • Recoveries in Whistleblower Suits


Justice Department’s False Claims Act Settlements and Judgments Against Healthcare Exceed $5 Billion in Fiscal Year 2021

Source: DOJ

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