Kusserow on Compliance: HHS OIG July 2015 update summary

The Office of Inspector General (OIG) issued a number of new reports this month including the following where it found:

  • Enrollment and profitability were lower than health insurance co-ops had projected.
  • Medicare Part B overpaid providers $35.8 million dollars for outpatient drugs from 2009 through 2012.
  • North Carolina needed to refund $34.8 million dollars to the federal government for unallowable bonus payments linked to increased enrollment of children in Medicaid.
  • Maryland needed to refund $34 million dollars to the federal government after finding that the state claimed unallowable Medicaid costs.

The OIG testified at two Congressional Hearings:

  • Gregory Demske, Senior Counsel to the Inspector General (IG) testified about continuing concerns with the handling of live anthrax.
  • Ann Maxwell, Assistant Inspector General for Evaluation and Inspections, testified about strengthening Medicare Part D program integrity.

Significant enforcement actions cited by the OIG included:

  • A Detroit-area oncologist was sentenced to 45 years in prison for falsely diagnosing cancer and administering chemotherapy in a $34 million dollar fraud scheme affecting 553 patients.
  • A California scam artist was sentenced to 15 years in a $20 million dollar Medicare/Medicaid drug conspiracy in which anti-psychotics were fraudulently prescribed and billed.
  • Drug-makers AstraZeneca and Cephalon are to pay a total of $54 million dollars to settle allegations that they underpaid Medicaid rebates.
  • New York Stated reached a $22.4 million dollar settlement with a pharmacy over allegations of improper billing for an injectable pediatric drug.
  • Community Health Network, a nonprofit system, agreed to a $20 million dollar civil settlement over allegations that it filed false outpatient surgery claims.
  • A charge of drug distribution resulting in death was added to a Pennsylvania doctor’s “pill mill” case indictment.
  • Six defendants were sent to prison in a $25.2 million dollar international Medicare/Medicaid fraud and wire fraud scam, involving submission of false and fraudulent enrollment applications that claimed beneficiaries lived in Florida when, in fact, they lived in Nicaragua and the Dominican Republic.
  • In New York, a man was sent to prison for up to 21 years and fined $1.7 million dollars after illegally billing Medicaid for pricey pediatric nutritional formula.
  • A Connecticut advanced practice registered nurse admitted getting $83,000 dollars in kickbacks from a drug manufacturer for prescribing a pain medication used to treat cancer patients.
  • Five nursing home employees in New York were convicted in the death of patient on a ventilator; authorities noted “callous acts of neglect.”
  • Two nurses and an aide at a New York nursing home were charged with neglect and abuse that was caught on a surveillance camera.

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.