Medicare Compliance & Reimbursement

• Audits: OIG released 47 audit reports and 14 evaluations. It expects to recover more than $1.14 billion from its audit work. The agency also questioned more than $1.6 billion in costs, too.
• Investigative recoveries: OIG anticipated its investigative recoveries at $1.44 billion during the reporting period.
• Criminal actions: The federal watchdog brought criminal actions against 320 individuals and entities.
• Civil actions: OIG levied civil actions against 320 individuals and entities.
• Exclusions: The feds excluded 1,043 individuals and entities from federal healthcare programs over the time period.

Critical: OIG’s focus on COVID was a major factor in its report, particularly related to Medicare. The agency points to an alarming increase in COVID testing that ran adjacent to a marked decrease in non-COVID testing for Part B beneficiaries, highlighting that the feds spent $1.5 billion on COVID-19 tests in 2020, but only $1.2 billion for other tests during the same period. “In total, laboratory spending increased by 4 percent, but the decrease in utilization of non-COVID-19 tests raises concerns about potential impacts on beneficiary health,” warns the report.

Check Out These Top Medicare Enforcement Cases

In the Semiannual Report, OIG both offers advice, insight, and cost-saving measures to HHS and its auxiliary agencies while also informing legislators of fraud and abuse in the federal healthcare spectrum. During the current period, big investigations of Medicare-related fraud included false home health claims as well as kickback and bribery schemes involving DME and telemedicine.

Read on for a brief overview of the top cases.

Home health: The OIG report covers the case of one of its Top 10 Most Wanted Fugitives — Ebong Aloysius Tilong — who was a former Houston HHA owner. Tilong pleaded guilty in 2017 in two separate cases, after being indicted on charges relating to a scheme run through Fiango Home Health Care Inc.

In the $13 million fraud scam, Tilong and his wife and Fiango co-owner Marie Neba paid kickbacks to physicians, patient recruiters and patients themselves, prosecutors said. And they falsified medical records to make it appear patients qualified for and received home care services when they did not.

After Neba was convicted at trial and sentenced to an astonishing 75 years in prison, Tilong “removed an ankle bracelet monitoring his location” and failed to appear for sentencing in October 2017, fleeing to Cameroon. He was sentenced to 80 years in prison in absentia that December. Last December, Tilong “was extradited from the Republic of Cameroon to the United States to serve an 80-year prison sentence,” the report says. He had been under arrest since 2019 there.

DME: Michael and Leah Hagen submitted fraudulent durable medical equipment (DME) claims to Medicare from 2016 to 2019, resulting in more than $59 million in false claims and a take home amount for the Hagens of upward of $27 million.

“To conceal the payments of kickbacks and bribes from the authorities, the defendants, through their DME companies, signed sham contracts that disguised payments as marketing and business process outsourcing,” a DOJ release notes. “The DME claims submitted by the defendants to Medicare were for services that were medically unnecessary and not provided as represented. In some cases, beneficiaries were convinced to accept braces they did not need or want and were offered gift cards in exchange for accepting those braces,” DOJ adds.

The couple, who owned and operated two DME companies, will pay $27 million in restitution and are sentenced to 151 months in prison, the report says.

Lab testing: Flexibilities in place to address COVID and help Medicare beneficiaries were exploited by one telemedicine company and its partners for profit. Leonel Palatnik, co-owner of Panda Conservation Group LLC, along with other owners, engaged in elaborate scheme with Michael Stein, owner of 1523 Holdings LLC, to usurp patients’ information and “arrang[e] for telemedicine providers to authorize genetic testing orders for Panda’s laboratories,” the report indicates.

Palatnik was sentenced to 82 months in prison and required to pay “$61 million in restitution for his role in a $73 million conspiracy to defraud Medicare,” OIG says.

Resource: Review the report at https://oig.hhs.gov/reports-and-publications/archives/semiannual/2022/2022-spring-sar.pdf.