Whistleblower-Initiated Enforcement Actions against Health Care Fraud and Abuse in the United States, 1996 to 2005

摘要

Federal regulators have aggressively prosecuted health care fraud since the early 1990s, leading to billions of dollars in financial recoveries. Nearly all major cases today are qui tam actions, involving whistleblowers with inside knowledge of the allegedly illegal schemes. This article documents the outcomes of major enforcement actions and describe the schemes, defendants, and whistleblowers involved. The authors obtained an inventory of unsealed federal qui tam litigation targeting health care fraud that was resolved between 1996 and 2005 from the U.S. Department of Justice and gathered further information from publicly available sources. Among 379 cases, $9.3 billion was recovered, with more than $1.0 billion paid to whistleblowers. Case frequency peaked in 2001, but annual recoveries increased sharply from 2002 to 2005. Whistleblowers were frequently executives or physicians, and 75% were employees of defendant organizations. The 13 (4%) cases against pharmaceutical companies accounted for $3.6 billion (39%) of total recoveries. This study illuminates the scope and characteristics of qui tam fraud litigation and the whistleblowers who animate this important tool for addressing waste in the health care sector. nnIncreasing health care costs and financial strains on public insurance programs have highlighted the need to improve efficiency (1, 2) and reduce waste (3, 4) in health care delivery. One direct way to achieve these goals is by combating fraud and abuse, which encompasses financial misconduct associated with payment for health care services (5). The government has estimated that fraud may account for 10% of health care expenditures (6), although the empirical foundations of this figure are weak (7). Some commentators contend that losses are greater (8). nnIn the 1990s, the U.S. Department of Justice (DOJ) ramped up efforts to combat health care fraud (9, 10), focusing on false claims to the Medicare and Medicaid programs in particular (11). The volume of litigation and financial recoveries related to health care grew quickly (12). Much of this growth occurred among qui tam actions—enforcement actions initiated by whistleblowers who are private citizens with inside knowledge of the alleged fraud (13). By 2005, 90% of new health care fraud enforcement actions were initiated by whistleblowers (14, 15). nnThe illicit nature of health care fraud impedes research into its prevalence and cost. Few studies are available beyond descriptions of individual cases (16–19), analysis of the legal issues (20, 21), and investigations of specific organizational patterns of behavior (22). Summary statistics available in government reports aggregate recoveries by year, rather than linking them to particular cases (23). We compiled and analyzed information on the major U.S. health care fraud enforcement actions from 1996 to 2005, focusing on federal qui tam cases. Our objectives were to describe the case outcomes, as well as the fraudulent activities, defendants, and whistleblowers involved.