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.

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

Highlight on Michigan: Medicaid expansion did not cause crowding

The expansion of Michigan’s Medicaid program—the Healthy Michigan Plan—did not impede access to care, according to a University of Michigan Health System study. Despite concerns that new rules and growth would be detrimental to those signed up for both the Healthy Michigan Plan and private insurance, according to the study, there was no significant increase in wait times for either group. In addition to not hindering access, expansion improved access for some individuals. For Healthy Michigan enrollees, the odds of getting an appointment increased in the first year of expansion.

Earlier research

The study, published in the American Journal of Managed Care (AJMC), is an extension of an earlier study that examined primary care appointment availability and wait times for new patients with Medicaid and private insurance before and 4 months after Michigan’s Medicaid expansion on April 1, 2014. In those first four months, the researchers found an initial increase in primary care appointment availability for new Medicaid patients and no lengthening of wait times.


The subsequent study—like the earlier research—used a simulated patient or “secret shopper” method. Trained research staff called a random sample of primary care practices, before and after Medicaid expansion, to request a new patient appointment. Wait times were calculated as the difference between the date of the call and the appointment date. The study evaluated 295 clinics.

Appointment availability

The percentage of clinics accepting new Medicaid patients increased from 49 percent, before expansion, to 55 percent 12 months after expansion. The availability of appointments for privately insured individuals fell from 88 percent of clinics before expansion to 86 percent after expansion. The number of Medicaid appointments scheduled with non-physician providers increased from 8 percent before expansion to 21 percent 12 months after expansion. For individuals with private insurance, the proportion of appointments scheduled with non-physician providers increased from 11 percent before expansion to 19 percent 12 months after expansion.

Wait times

For clinics accepting Medicaid patients, median wait times remained stable over the first year of Michigan’s Medicaid expansion. For those with private insurance, median wait times increased from 7 to 10 days in the first year after expansion. Additionally, median new patient wait times were within two weeks. According to the study, 95 percent of new patient wait times satisfied the Health Michigan Law’s requirement that Health Michigan beneficiaries have access to an initial day primary care appointment within 90 days of enrollment.


Medicaid expansion in Michigan had a largely positive impact on patient access to care. With the exception of small increases in wait times for some privately insured individuals, the Health Michigan Program served to improve, rather than hinder, the likelihood and timeliness of care. The researchers concluded that increases in appointment availability for new Medicaid patients was likely attributable to increases in the number of non-physician appointments. As such, the study recommended that future research should examines other team-based approaches—like the use of non-physician appointments—to further improve primary care access.


Michigan expands Medicaid to cover pregnant women and children of Flint

Michigan obtained approval for its Section 1115 waiver request to extend Medicaid coverage to Flint residents affected by exposure to lead. The demonstration will extend Medicaid coverage to 15,000 additional children and pregnant women. Additionally, under the program, 30,000 Medicaid beneficiaries in the Flint area will be able to access expanded benefits.


The expanded coverage will apply to children up to age 21 and pregnant women who used Flint’s water system from April 2014 through a date when the water is deemed safe. The coverage will be limited to those with incomes up to 400 percent of the federal poverty level. However, Michigan will provide individuals with higher incomes an opportunity to purchase coverage without subsidies. The state will provide targeted case management services as part of the arrangement in order to assist impacted residents with obtaining medical, social, and educational services. The demonstration will last for a period of five years.

Water crisis

The lead exposure problem began two years ago when the city’s water supply was changed from Lake Huron to the Flint River. Following the source transition, residents noticed changes in their water—discoloration and bad smell and taste. Ultimately it was determined that lead was present in the water. Research indicated that children from the area younger than five—the population most vulnerable to lead poisoning—showed elevated blood lead levels. According to the Centers for Disease Control and Prevention (CDC), lead can have serious long-lasting effects on children, from learning difficulties to death. The approval of the waiver request follows a declaration by the President that the Flint water crisis reached a state of emergency.


Other states have used Medicaid in emergency situations in the past. For example, approximately 350,000 New Yorkers were covered by Disaster Relief Medicaid (DRM) for the four-month time period following the September, 11, 2001, attacks. Michigan also used a Section 1115 waiver to expand its Medicaid program under the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148). The state’s demonstration waiver, known as the “Healthy Michigan Plan” was initially approved on December 23, 2013. The Healthy Michigan Plan covers eligible adults with income up to and including 138 percent of the federal poverty level.

State Election Results Impacting Healthcare

Earlier this week the voters of Louisiana passed an amendment to the state constitution to protect the state’s Medicaid Trust Fund for the Elderly from cuts in the event of a projected deficit. The state constitution requires the legislature to make adjustments to the budget whenever it expects revenue will not cover existing appropriations. The amendment added the fund to the lists of funds that the state constitution exempts from these legislative budget “sweeps.”

 The amendment was introduced in the state legislature as Senate Bill No. 82. It was one of nine proposed amendments that the legislature directed to be placed on the ballot for the November 6, 2012 election. The Medicaid Trust Fund for the Elderly is targeted to nursing home services.

 Further North, Michigan voters rejected an option to establish a council on home health care that would be responsible for creating a registry and training workers. The home health workers would have had the right to bargain collectively with the council.