Kusserow on Compliance: OIG reports investigative results for first half of 2015

The Office of Inspector General (OIG) mission is to provide independent and objective oversight that promotes economy, efficiency, and effectiveness in the programs and operations of HHS. It investigates allegations of fraud, waste, and abuse in all of the Department’s programs and is mandated to report to Congress semi-annually on the progress of meeting these mission goals. On June 1, 2015, the OIG released its first half of fiscal year (FY) 2015’s report, which included the following statistical results from investigations:

• Expected recoveries of over $1.8 billion ($544.7 million in audit receivables and $1.26 billion in investigative receivables that includes $142 million in areas such as the states’ shares of Medicaid restitution);
• 486 criminal actions against individuals/entities engaged in crimes against HHS programs;
• 326 civil actions, civil monetary penalties settlements, and administrative recoveries related to provider self-disclosure matters;
• 1,735 individuals and entities excluded from participation in federal health care programs.

The largest body of work in the report involved the investigation of matters related to the Medicare and Medicaid programs, such as: (1) patient harm; (2) billing for services not rendered, medically unnecessary services, or services more extensive than those actually provided; (3) illegal billing, sale, diversion, and off-label marketing of prescription drugs; and (4) solicitation and receipt of kickbacks, including illegal payments to patients for involvement in fraud schemes and illegal referral arrangements between physicians and medical companies. The OIG also investigated cases involving organized criminal activity, medical identity theft, and fraudulent medical schemes that are established for the sole purpose of stealing Medicare dollars. Those who participate in these schemes may face heavy fines, jail time, and exclusion from participating in federal health care programs. The OIG took special note to highlight common criminal fraud scheme case types that occurred in the following areas:

• controlled and non-controlled prescription drugs;
• home health agencies and personal care services;
• ambulance transportation;
• durable medical equipment (DME); and
• diagnostic radiology and laboratory testing.

It also cited the results from the Health Care Fraud Prevention and Enforcement Action Team (HEAT) started in 2009 by HHS and the Department of Justice (DOJ) to strengthen programs and invest in new resources and technologies to prevent and combat health care fraud, waste, and abuse. HEAT continued to identify those who seek to defraud Medicare and Medicaid. The Medicare Fraud Strike Force, which operates in nine major cities and is a key component of HEAT, coordinates law enforcement operations conducted jointly by federal, state, and local law enforcement entities that prosecute health care fraud. During the first half of FY 2015, the efforts of this team resulted in the filing of charges against 69 individuals or entities, 124 criminal actions, and $163 million in investigative receivables. As part of the endeavors, the team refers credible allegations of fraud to CMS so that it can suspend payments to the suspected perpetrators, thereby immediately preventing losses from claims by Strike Force targets.

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 © 2015 Strategic Management Services, LLC. Published with permission.