Medicare Compliance & Reimbursement

Despite funding cuts HHS and company remain vigilant in their fight to recover assets.

As the stakes continue to rise in healthcare, the opportunity for fraud increases. A recent Office of Inspector General (OIG) publication illustrates that offenders continue to push Medicare’s limits.

Background: In the 2016 Health Care Fraud and Abuse Control Program (HCFAC) Annual Report, the OIG outlines the efforts made by various federal organizations to recover money lost through healthcare fraud and abuse and to highlight the biggest indictments. The program harnesses the collaborative energies of the Department of Health and Human Services (HHS) and the Department of Justice (DOJ) under HIPAA.

“Indeed, the OIG, and the federal government in general, are continuing to step up their efforts to prevent and detect fraud and abuse associated with federal healthcare programs,” says Mark C. Rogers, Esq. with The Rogers Law Firm in Braintree, Mass.

Review the Feds’ 2016 Net Gains

The feds negotiated, won, and attained through settlement more than $3.3 billion in 2016, including recovered funds from years past, which was a large sum in spite of diminished governmental resources to the HCFAC program to fight fraud and abuse. “Of this $3.3 billion, the Medicare Trust Fund received transfers of approximately $1.7 billion during the period,” the HCFAC Annual Report stated. Federal Medicaid funds totaling $235.2 million were transferred to the Treasury as well due to the program’s efforts.

Punitive highlights. Many purveyors of Medicare fraud felt the wrath of the federal government as all involved agencies pursued criminals vigorously in 2016.

Justice. The DOJ brought criminal charges against 802 defendants in 480 cases with a total of 658 convictions for healthcare fraud. “Also in FY 2016, DOJ opened 930 new civil healthcare fraud investigations and had 1,422 civil healthcare fraud matters pending at the end of the fiscal year,” the report said.

OIG. Medicare and Medicaid offenders were targeted by the OIG, who brought both criminal (765) and civil (690) actions against individuals for false claims and other offenses, the report noted. While 3,635 total individuals were excluded from Medicare, Medicaid, and other federal health programs in 2016 by the OIG, of that number 1,448 had their medical licenses revoked.

Expect Steep Civil and Criminal Penalties in 2017

As a recent case published just last week highlights, the feds are not going to lighten up on those who commit Medicare fraud. In fact, the news suggests that they will continue to actively seek out wrongdoers.

Scenario: On March 1, 2017, the DOJ “announced criminal and civil actions relating to a 12-year scheme to defraud Medicaid, Medicare, and other private health insurance companies out of more than $50 million,” a DOJ press release said. The masterminds of the extensive fraud scheme — two New York physicians, a cardiologist and neurologist — were arrested last week along with several of their employees and could serve up to 20 years in prison. Read more about the case here: www.justice.gov/usao-sdny/pr/cardiologist-neurologist-and-others-charged-50-million-health-care-fraud-scheme-and.

“Healthcare fraud schemes like the one alleged here loot government health programs, compromise patient well-being, and undermine the public’s trust in the health profession,” said Scott J. Lampert, HHS-OIG special agent, in the release. “You can bet our agents will continue to thoroughly investigate such allegations and hold fraudsters accountable for their crimes.”

Final thought: When the OIG and other federal watchdogs take down healthcare criminals, providers should take notice and look internally. “The OIG’s Report should be viewed by all medical practices as an opportunity to review their existing policies and procedures to ensure adherence to applicable statutes and regulations,” Rogers advises.

To read the The Department of Health and Human Services And The Department of Justice Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2016, visit https://oig.hhs.gov/publications/docs/hcfac/FY2016-hcfac.pdf.