Kusserow on Compliance: OIG Reports $5B Return as Result of Its Efforts

The HHS Office of Inspector General (OIG) is required to issue semi-annual reports to Congress regarding the results of its efforts. On December 10, 2014, it released its second half of fiscal year (FY) 2014 report that included a summary of accomplishments for the entire year. The report included a lengthy list of achievements by the OIG. One of the major accomplishments claims was $4.9 billion improperly spent federal health care dollars having been returned to the government as result of the OIG’s oversight and investigation efforts conducted during the year. This was broken down to $834.7 million in program audits and about $4.1 billion in investigative work that included $1.1 billion as states’ shares of Medicaid restitution. The OIG also reported $15.7 billion in estimated savings resulting from legislative, regulatory, or administrative actions that were supported by report recommendations. Some other statistical accomplishments noted included a number of enforcement actions:

  • 4,017 individuals and entities were excluded from federal health care programs
  • 971 criminal actions against individuals or entities that engaged in crimes against HHS programs
  • 533 civil and administrative cases, including false claims and unjust-enrichment lawsuits filed in federal district court and civil monetary penalties administrative matters, which included both OIG-initiated actions and provider self-disclosures.
  • Participation in Department of Justice (DOJ) Strike Force efforts resulting in the filing of charges against 228 individuals or entities, 232 criminal actions, and $441 million in investigative receivables

Other highlights from the report included findings that:

  • The OIG conducted congressionally mandated reviews of the implementation of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) that include the Health Insurance Exchanges, also called Marketplaces, and found that not all internal controls implemented by the federal, California, and Connecticut Marketplaces were effective in ensuring that individuals were enrolled in qualified health plans (QHPs) according to federal requirements.
  • The Exchanges were unable to resolve 2.6 million of 2.9 million inconsistencies from October through December 2013, most commonly as citizenship and income issues.
  • Medicare inappropriately paid $6.7 billion for claims for evaluation and management (E/M) services in 2010 that were incorrectly coded and/or lacked documentation, representing 21 percent of Medicare payments for E/M services that year. A further note on this was that E/M services are 50 percent more likely to be paid for in error than other Part B services.
  • Medicare and beneficiaries could save $12 billion during calendar years (CYs) 2012 through 2017 if CMS reduces hospital outpatient department payment rates for ambulatory surgical center (ASC)-approved procedures to the same level as ASC payment rates. When outpatient surgical procedures that do not pose significant risk to patients are performed in an ASC instead of an outpatient department, the payment rates are generally lower.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2014 Strategic Management Services, LLC. Published with permission.