Kusserow on Compliance: OIG testifies regarding Detroit investigation results

The HHS OIG provided testimony before the House Ways and Means Subcommittee on Oversight, describing their work in Detroit to protect Medicare and Medicaid beneficiaries and to fight health care fraud from the field agent’s perspective. The OIG typically conducts investigations in partnership with other Federal and State agencies, as well as the private sector. Often investigations are part of the Detroit-based Medicare Fraud Strike Force, which combines the resources of Federal, State and local law enforcement entities to prevent and combat health care fraud across the country.

The OIG receives complaints or investigative leads from a variety of sources, including the OIG hotline, law enforcement partners, beneficiaries, providers, and informants. Traditional means of identifying fraud include conducting interviews of cooperating witnesses and surveillance. The schemes investigated range from billing for services not actually performed to organized criminal enterprises. The perpetrators of these frauds can range from highly respected physicians to individuals with no prior experience in the health care industry. The OIG highlighted some major areas of where they have been focusing, including:

  • Home and community-based services. Home and community-based services, including personal care services (PCS), which are particularly vulnerable to fraud, with investigations resulting in more than 350 criminal and civil actions and $975 million in investigative receivables for fiscal years 2011 – 2015.
  • Unnecessary prescriptions. Physicians write medically unnecessary controlled substance prescriptions in exchange for cash or submission by a patient to medically unnecessary services.
  • Prescription drug fraud. Enforcement action against and prevention of prescription drug fraud is a major priority to address a rapidly growing national health care problem, and an opioid epidemic with 678 pending complaints and cases involving Medicare Part D, which represents a 152-percent increase in the last 5 years.

The OIG employs data analytics and real-time field intelligence to detect and investigate program fraud and to target our resources for maximum impact. They also reported being a leader in the use of data analytics, employing a dedicated data analytics unit. The OIG also has direct access to Medicare claims data and use innovative methods to analyze billions of data points to identify trends that may indicate fraud, geographical hot spots, emerging schemes, and individual providers of concern. Testimony summarized the OIG national investigative results during the period of 2013 through 2015, as follows:

  • $11 billion in receivables, or money ordered or agreed in settlements
  • 2,856 criminal actions
  • 1,447 civil actions, and
  • 11,343 program exclusions.

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.

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

Kusserow on Compliance: Largest health care fraud takedown on record; $900M in false billing, 301 individuals charged

The Department of Justice and HHS announced the results of a nationwide sweep led by the Medicare Fraud Strike Force in 36 federal districts that resulted in a record number of individuals being charged. The DOJ-led Strike Force combines investigative resources of the Federal government that includes the HHS Office of Inspector General (OIG) and the Federal Bureau of Investigation (FBI). In addition, 23 state Medicaid Fraud Control Units also participated in the arrests. The DOJ noted this coordinated takedown was the largest in history, both in terms of the number of defendants charged and loss amount. The defendants were charged with various health care fraud-related crimes, including conspiracy to commit health care fraud, violations of the anti-kickback statutes, money laundering, and aggravated identity theft. The charges are based on a variety of alleged fraud schemes involving various medical treatments and services, including home health care, psychotherapy, physical and occupational therapy, durable medical equipment (DME), and prescription drugs. More than 60 of the defendants arrested are charged with fraud related to the Medicare prescription drug benefit program known as Part D, which is the fastest-growing component of the Medicare program overall. The schemes involved submitting fraudulent claims to Medicare and Medicaid and the defendants in these cases involved doctors, nurses, licensed medical professionals, health care company owners, and others.

The Medicare Fraud Strike Force operations are part of the Health Care Fraud Prevention & Enforcement Action Team (HEAT) that has been operating since 2007 as a joint initiative between the DOJ and HHS to focus their efforts to prevent and deter fraud and enforce current anti-fraud laws around the country. They operate in nine locations and since its inception has charged over 2,900 defendants who collectively have falsely billed the Medicare program for over $8.9 billion. A summary of where actions were taken in the “Takedown” announced by the DOJ include the following:

  • Southern District of Florida: 100 charged involving $220 million in false billings.
  • Southern District of Texas: 24 charged involving $146 million in fraud.
  • Northern District of Texas: 11 charged involving $47 million in fraud.
  • Central District of California: 22 charged involving $162 million.
  • Eastern District of Michigan: 19 charged involving $114 million in false claims.
  • Middle District of Florida: 15 charged involving $17 million in fraudulent billing.
  • Northern District of Illinois: six charged involving $12 million in fraud.
  • Eastern District of New York: 10 charged involving $86.
  • Eastern District of Louisiana: three charged with a health care fraud and wire fraud conspiracy.
  • Northern District of Georgia: nine charged involving $7 million in fraudulent billings.
  • Middle District of Alabama: two charged involving $246,000 in fraudulent billings.
  • Middle District of Tennessee: doctor charged in kickback with DME company.
  • Western District of Kentucky: charge of a business entity a health care fraud scheme.
  • Southern District of Ohio: two charged involving a $7.5 million fraud scheme.
  • Western/Eastern Districts of Pennsylvania: three charged for drug diversion and embezzlement.
  • Southern District of New York: pharmacist charged involving $51 million in fraud.
  • Districts of Maine, Alaska, Kansas, Connecticut and Vermont: five charged for Medicaid-related schemes.
  • Eastern District of Missouri: four charged involving $3 million in billings.
  • Southern District of California: eight charged involving $27 million in fraudulent claims.
  • District of New Mexico: two charged in a Medicaid fraud scheme.
  • Northern District of Iowa: a corporate settlement agreement for health care fraud scheme.
  • District of Oregon: one charged involving $1.7 million fraud scheme.
  • District of Puerto Rico: six received civil demand letters for their roles in a Medicaid fraud.
  • Florida, Iowa, South Dakota, Indiana, New York, Michigan, Oklahoma, Rhode Island, Louisiana, Pennsylvania, New Hampshire, Oregon, Kentucky, and Alaska: 49 charged with defrauding the Medicaid program by each state’s respective Medicaid Fraud Control Units.

The court documents for each case will posted online, as they become available, here: https://www.justice.gov/opa/documents-and-resources-june-22-2016-medicare-fraud-strike-force-press-conference.

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