Kusserow on Compliance: OIG reports on fraud and abuse actions for the first half of 2016

The HHS Office of Inspector General (OIG) issued its Semi-Annual Report for first half of fiscal year (FY) 2016 (October-March), summarizing key accomplishments, significant problems, abuses, deficiencies, and investigative outcomes relating to the administration of HHS programs and operations that were disclosed during the reporting period.

428 criminal actions, 1662 exclusions

The OIG reported 428 criminal actions against individuals or entities that engaged in crimes against HHS programs and 383 civil actions, which include false claims and unjust-enrichment lawsuits filed in federal district court, civil monetary penalties (CMP) settlements, and administrative recoveries related to provider self-disclosure matters.  In addition, the OIG reported the exclusions of 1,662 individuals and entities from participation in federal health care programs. Recoveries from CMP were reported to have increased five-fold over the past three years, and likely will exceed the prior year’s results by the end of FY 2016.

Recoveries of $2.77 billion

The reported expected recoveries of more than $2.77 billion consisting of nearly $554.7 million in audit receivables and about $2.22 billion in investigative receivables, which include about $336.6 million in non-HHS investigative receivables resulting from our work in areas such as the states’ shares of Medicaid restitution.

100 criminal actions by the Health Care Strike Force

The Health Care Fraud Strike Force teams brought charges against 87 individuals or entities, 100 criminal actions and $116.8 million in recoveries through investigations. The OIG also reported 1,662 individuals and entities barred from participating in federal healthcare programs during the first half of FY 2016, the report said.

1,553 criminal actions by state Medicaid Fraud Control Units (MFCUs)

In 2015, MFCUs reported conducting 17,665 investigations that resulted in 1,553 criminal actions, of which 1,097 were related to Medicaid fraud and 456 were related to patient abuse and neglect. Civil judgments and settlements totaled 795, and monetary recoveries in civil cases totaled over $397 million.  Many of these cases were joint actions with the OIG.  However, what may not be generally known is that the OIG has oversight responsibility for MFCUs and administers grants that provide Federal funding for their operations. The federal government reimburses 75 percent of the costs of operating a Unit; the States contribute the remaining 25 percent.

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.