Kusserow on Compliance: OIG 2016 Work Plan highlights investigative priorities and accomplishments

The HHS Office of Inspector General (OIG) Work Plan for fiscal year 2016 describes audits, evaluations, and certain continuing legal and investigative initiatives and forecasts areas for which the OIG anticipates planning and/or beginning work. With regards to investigations, the OIG noted that it receives and investigates thousands of complaints involving the scores of programs wherein it provides oversight. The most resources are devoted to oversight of the Medicare and Medicaid programs, many of which involve allegations of billing for services not rendered, services considered medically unnecessary, misrepresented services, and patient harm. This also includes issues related to illegal billing with regard to the sale, diversion, and off-label marketing of prescription drugs; solicitation and receipt of kickbacks, including illegal payments to patients for involvement in the fraud scheme; and illegal referral arrangements between physicians and medical companies.

In fiscal year (FY) 2015, the OIG brought criminal actions against 925 individuals or entities; it brought 682 civil actions. These included false claims actions, civil monetary penalty settlements, and administrative recoveries. During this period, 4,112 individuals and entities were excluded from participation in federal health care programs. The agency also reported expected recoveries of more than $3 billion, consisting of nearly $1.13 billion in audit receivables and about $2.22 billion in investigative receivables, which include about $286.6 million in non-HHS investigative receivables resulting from its work in Medicaid restitution cases. The OIG also identified about $21 billion in savings estimated on the basis of prior-period legislative, regulatory, or administrative actions on OIG recommendations.

Further details of investigative interest are noted throughout the Work Plan in specific planned work areas. It is worth reviewing these projects as they often telegraph situations that eventually blossom into national initiatives.

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.

Connect with Richard Kusserow on Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

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