DOJ Fraud Division Streamlines Health Care Fraud Self-Disclosure to One Agency

Companies reporting criminal health care fraud now only need to contact the DOJ's Fraud Division. The new joint policy eliminates the need for multiple agency disclosures.

Single Disclosure Point for Health Care Fraud: DOJ and HHS-OIG Align Policies

The Justice Department's National Fraud Enforcement Division and the Department of Health and Human Services Office of Inspector General (HHS-OIG) have jointly issued a policy reducing the number of agencies companies must contact when voluntarily self-disclosing criminal health care fraud, DOJ Justice News reports. Under the new arrangement, a single disclosure to the Fraud Division's Health Care Fraud Section is sufficient to unlock the benefits of both the Department's Corporate Enforcement Policy and HHS-OIG's Health Care Fraud Self-Disclosure Protocol (SDP).

"Companies that discover fraud within their own operations should not have to navigate a maze of agencies before reporting it," said Assistant Attorney General Colin M. McDonald of the National Fraud Enforcement Division. "There is now one clear point of contact: DOJ's Fraud Division. If a company comes forward, cooperates fully, and remedies the misconduct, the benefits are clear and predictable. If a company conceals what it knows, it should expect a very different conversation."

Why the Change Was Needed

A single health care fraud arrangement — an illegal kickback, a scheme to bill Medicare for medically unnecessary services, a scheme concealing an excluded provider — can routinely carry potential criminal, civil, and administrative consequences simultaneously. Companies facing that overlap previously had to determine not only whether to come forward, but also which agency to approach and whether multiple disclosures were required.

The new policy resolves that ambiguity. A company that voluntarily self-discloses criminal conduct affecting a federal health care program to the Fraud Division will receive the benefits of HHS-OIG's SDP automatically, with no additional submission required through the HHS-OIG portal.

HHS-OIG separately updated the SDP to address the reverse scenario. The SDP covers conduct that may violate civil or administrative law, and the update clarifies that criminal conduct should be directed to the Department of Justice. A company disclosing only to HHS-OIG will generally not be considered to have made a voluntary self-disclosure to the Department and will generally not qualify for a declination on that basis. Companies seeking the full benefit of both programs should bring potentially criminal conduct to the Fraud Division first.

HHS-OIG's Position

"We encourage companies to come forward and disclose criminal conduct to the Justice Department, and we are committed to extending the benefits of the HHS-OIG Self-Disclosure Protocol to those who do," said HHS Inspector General T. March Bell. "The OIG Self-Disclosure Protocol is a critical tool for promoting accountability, transparency, and integrity across the health care system, providing organizations with a clear pathway to voluntarily report potential misconduct and address compliance concerns."

Bell added that the process helps strengthen trust in federally funded health care programs by encouraging timely corrective action, reducing future risk, and demonstrating a commitment to ethical conduct.

Background: The Fraud Division and Its Track Record

The Fraud Division was established on April 7, when the Department of Justice announced its creation with a focus on investigating and prosecuting fraud against the American people. Its work supports President Trump's Task Force to Eliminate Fraud, a whole-of-government effort chaired by Vice President J.D. Vance targeting fraud, waste, and abuse within federal benefit programs.

The Fraud Division's Health Care Fraud Section currently operates nine strike forces across federal districts nationwide. Since 2007, the section has charged more than 6,200 defendants who collectively billed federal health care programs and private insurers more than $45 billion. The Centers for Medicare & Medicaid Services, working alongside HHS-OIG, are also taking steps to hold providers accountable for involvement in health care fraud schemes.

Companies wishing to self-disclose may contact the Fraud Division directly at [email protected].

Source: DOJ Justice News