Medicare Compliance & Reimbursement

Providers of all shapes and sizes should be ready for extra scrutiny.

If you expected the feds to slow down their enforcement activity during a worldwide public health emergency (PHE), think again. The latest statistics show that even in the midst of a once-in-a-lifetime pandemic, they’re focused on stopping Medicare fraud — and COVID-related scams are their primary mark.

Details: With more than 67 reviews of COVID-19-related programs in the works, the HHS Office of Inspector General (OIG) is pushing full steam ahead with its investigations and oversight, suggests the agency’s latest Semiannual Report to Congress released on May 28.

“OIG is aggressively investigating pandemic-related fraud that harms individuals and jeopardizes public health efforts,” said Principal Deputy Inspector General Christi A. Grimm in the report. “We are using every tool in our arsenal to bring criminals to justice, recover ill-gotten gains, and alert the public to emerging fraud schemes.”

Grimm continued, “OIG is partnering on this effort with law enforcement and oversight agencies across Government, including through the recently announced COVID-19 Fraud Enforcement Task Force.”

Here’s a Breakdown of the Numbers

The latest Semiannual Report covers October 1, 2020 through March 31, 2021, and OIG has kept busy. The national watchdog didn’t let the COVID-19 PHE get in the way of its significant oversight and enforcement duties. Take a look at the statistics over the six-month timeframe as well as comparisons with the prior period (April 1, 2020 to Sept. 30, 2020), according to data from the last two OIG briefs:

• Audits: OIG released 75 audit reports and 20 evaluations. These figures were down from the previous reporting period — April 1, 2020 through September 30, 2020 — in which OIG issued 97 audit reports and 27 evaluations.
• Expected recoveries: The agency’s audit work was substantial with expected recoveries at $566.46 million. The agency did not list questioned costs in the latest report.
• Investigative recoveries: OIG anticipated its investigative recoveries at $1.37 billion during the reporting period, which was slightly down from the previous six-month reporting period amount of $1.62 billion.
• Criminal actions: The federal watchdog brought criminal actions against 221 individuals and entities. This was up from 181 criminal actions for the April 2020 to September 2020 duration.
• Civil actions: OIG levied civil actions against 272 individuals and entities compared to 421 civil actions in the prior six-month reporting period.
• Exclusions: The feds excluded 1,036 individuals and entities from federal healthcare programs between Oct. 1, 2020 and March 31, 2021 while 1,245 exclusions occurred during the previous reporting cycle.

Another hallmark of the Semiannual Report is a mention of how the Department of Health & Human Services (HHS) could have saved money over the reporting period — if it had only followed the OIG’s advice. HHS missed out on major savings — upward of $919.97 million — because it didn’t properly implement OIG’s audit recommendations, the report indicates. “During this reporting period, OIG made 228 new audit and evaluation recommendations to encourage positive change in HHS programs,” the report says. “Meanwhile, HHS OpDivs implemented 181 prior recommendations to drive positive impact for HHS programs and beneficiaries.”

Pocket These Top COVID Takeaways

This latest Semiannual Report offers a tally of OIG’s biggest administrative, civil, and criminal actions while also listing its extensive investigative summaries and reports over this six-month time period. A large part of the brief covers COVID-related issues as the agency continues to analyze providers’ data to “identify, monitor, and target potential fraud, waste, and abuse affecting HHS programs and beneficiaries and to promote the effectiveness of HHS’s COVID-19 response and recovery programs,” the report says.

Consider these five OIG highlights in response to the PHE, many of which are ongoing as the feds vigilantly pursue COVID-19 fraud and abuse:

1. Nursing homes: OIG utilized nursing homes’ surveys to uncover that infection controls were significantly lacking and impacting the health of the most vulnerable patients.

2. Hospitals: Analysis of how hospitals responded to the pandemic revealed that “operating in ‘survival mode’ for an extended period of time has created new and different problems than experienced earlier in the pandemic and exacerbated longstanding challenges in health care delivery, access, and health outcomes,” the report indicates

3. Senior care: During the reporting period, OIG looked into the rise in abuse and fraud in elder care during the pandemic, homing in on COVID controls, patient neglect, safety, and misconduct. OIG offers extra assistance and more insight on current investigations on its  Operation CARE website at https://oig.hhs.gov/fraud/care/.

4. Testing: OIG “partnered with six federal OIGs to analyze COVID-19 testing, including the amounts paid by Medicare Part B for these tests,” explain attorneys with King & Spalding LLP in online legal analysis. The culmination of the OIGs’ work, the Federal COVID-19 Testing Report, offers a thorough outline of the factors that impacted national testing issues from lack of actual tests to changing Centers for Disease Control and Prevention (CDC) guidelines to health equity problems. Find the brief at

www.pandemicoversight.gov/media/file/federal-covid-19-testing-report-data-insights-six-federal-health-care-programs.

5. Scams: COVID fraudsters aren’t picky; they are targeting both beneficiaries and providers, according to the report. “Scammers are using telemarketing calls, text messages, social media platforms, and door-to-door visits to perpetrate COVID-19-related scams,” OIG cautions. “Fraudsters are offering COVID-19 tests, COVID-19 vaccine appointments, HHS grants, and Medicare prescription cards in exchange for personal details, including Medicare information.”

Critical: Though the report explores the pandemic’s impact on patient care and how the agency addressed those deficits with oversight and guidance, OIG also touches on an important side effect of the drawn-out PHE: the well-being of healthcare workers. A national pulse survey by OIG revealed that nationwide staffing shortages led to “exhaustion and trauma” that greatly “affected staff’s mental health, the report says.

“OIG noted that this survey reveals longer-term opportunities for improvement to address challenges that existed before and were ultimately exacerbated by the pandemic,” point out the King & Spalding attorneys.

Resource: Review the Semiannual Report at https://oig.hhs.gov/reports-and-publications/archives/semiannual/2021/2021-spring-sar.pdf.