Kusserow on Compliance: OIG requests 172 more staffers, $68M for Medicare and Medicaid fraud investigations

The HHS Office of Inspector General (OIG) presented its fiscal year (FY) 2017 budget requests, which included a scheduled $334 million to support the oversight of the Medicare and Medicaid programs. This constitutes an increase of $68,096,000 to fund an additional 172 full time employees (FTEs) for the Office of Investigations (OI) to enhance law enforcement efforts, including the Medicare Strike Force teams and affirmative litigation of civil monetary penalty cases, which will increase recoveries and deter future fraud. The OIG budget justification notes the agency will be moving to strengthen its emphasis on targeting improper payments, questionable billing, wasteful payment policies, patient safety and quality of care, and security of data and technology. The OIG also cited some of its major accomplishments in the past year and efforts to expand on prior success in the budget justification.

In 2015, 481 out of the 565 FTEs in the OI were devoted to Medicare and Medicaid enforcement efforts, with the balance addressing other departmental programs. The OI received 3,044 complaints related to those programs that resulted in 1,650 cases being opened for investigation. The results from these investigations resulted in $2.2 billion in investigative receivables. There were 925 criminal actions against individuals or organizations that engaged in crimes against HHS programs. Additionally, 682 civil and administrative enforcement actions were taken as result of implicating the federal False Claims Act (FCA) and unjust enrichment suits filed in federal district court, Civil Monetary Penalty (CMP) law settlements, and administrative recoveries related to provider self-disclosure matters. There were also 4,112 individuals and organizations excluded from participation in federal health care programs and included on the OIG List of Excluded Individuals and Entities (LEIE).

HHS has more than 100 programs that includes the Public Health Service (PHS), the Food and Drug Administration (FDA), the National Institute of Health (NIH), the Centers for Disease Control and Prevention (CDC), and the Indian Health Service (IHS) as well as a host of social programs such as Temporary Assistance for Needy Families (TANF), Head Start, child care, and child support help individuals, families, and communities. However, the CMS programs stand out as the top investigative priority as evidenced by the OIG budget justification, which devotes 85 percent of its investigative resources to police those programs.

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 © 2016 Strategic Management Services, LLC. Published with permission.