Medicare Compliance & Reimbursement

Hint: OIG steps up its vigorous enforcement.

New technologies can be a boon to healthcare and research, but a recent brief shows they are easily hijacked by fraudsters, too.

Context: In the HHS Office of Inspector General’s (OIG) Semiannual Report to Congress, the agency uncovers fraudulent and abusive behavior in healthcare that impacts federal healthcare programs during a portion of the calendar year. Its recent release focuses on incidents, enforcement, and takedowns from April 1, 2019 to Sept. 30, 2019.

“In this reporting period, OIG continued to produce outstanding results for the American people through independent, objective oversight,” says Joanne M. Chiedi, acting HHS OIG inspector general in the report. Opioid abuse, telemedicine fraud, and challenges with unaccompanied minors in HHS custody were among the OIG’s top issues, Chiedi indicates.

Statistics: During this timeframe, OIG made great strides through audits, enforcement, and recoveries, working in tandem with its partners at the Department of Justice (DOJ), the Medicare Fraud Strike Force, State Medicaid Fraud Control Units, and other federal, state, and local law enforcement. Here’s a breakdown of the report numbers:

• Audits: OIG released 91 audit reports and 36 evaluations. It expects to recover more than $322.7 million from its audit work. The agency also questioned more than $666.5 million in costs, too.
• Investigative recoveries: OIG anticipated its investigative recoveries at $2.74 billion during the reporting period.
• Criminal actions: The federal watchdog brought criminal actions against 388 individuals and entities.
• Civil actions: OIG levied civil actions against 364 individuals and entities.
• Exclusions: The feds excluded 1,347 individuals and entities from federal healthcare programs over the time period, maintains the report.

Review These Top Cases

The OIG oversees fraud and abuse that impact expenses and beneficiaries serviced by the Centers for Medicare & Medicaid Services (CMS). “In 2018, Medicare spent nearly $741 billion, and provided health coverage to 59.9 million beneficiaries,” the report notes. However, the OIG reminds that Medicaid assists more patients — close to 73 million annually — at a cost of $560 billion a year.

According to the report, OIG’s “largest body of work” includes investigating Medicare and Medicaid fraudsters. The investigations range from upcoding, billing for medically unnecessary or never performed services, opioid abuse and fraud, and kickbacks or bribes for referrals. Plus, organized crime surrounding federal healthcare programs is on the rise, too.

“OIG also conducts investigations regarding organized criminal activity, including medical identity theft and fraudulent medical schemes established for the sole purpose of stealing Medicare dollars,” relates the report. “Investigators are opening an increasing number of cases against healthcare providers who engage in these healthcare fraud schemes.”

“Those who participate in the schemes may face heavy fines, jail time, and exclusion from participation in Federal health care programs,” OIG warns.

Here are three of the biggest Medicare-related takedowns over the reporting period:

• Telemedicine: OIG brought charges against 24 defendants who engaged in telemedicine fraud. Telemedicine companies operated in 17 districts and offered kickbacks and bribes to medical professionals to push orthotic braces to beneficiaries who didn’t need them via telemedicine. The scheme resulted in $1.2 billion in Medicare losses.
• Genetic testing: In this case, “dozens of telemedicine companies and laboratories” bribed medical professionals to push unneeded genetic testing for cancer. The massive fraudulent activity was one of the largest takedowns in OIG history and included 35 defendants — including nine doctors — and $2.1 billion charged to Medicare for the genetic tests.
• Opioid abuse: In four separate federal districts in Texas, OIG and its “enforcement partners” charged 58 individuals — including 16 doctors or medical professionals — in a massive opioid fraud scheme that included a “networks of ‘pill mill’ clinics resulting in $66 million in losses to public and private insurers and 6.2 million pills,” notes the report.

Review the Semiannual Report to Congress at https://oig.hhs.gov/reports-and-publications/archives/semiannual/2019/2019-fall-sar.pdf.