Medicare Compliance & Reimbursement

There may be more criminal actions and exclusions on the horizon.

Medical practices across the country have come under OIG scrutiny resulting in millions being recouped from oversight efforts, recommendations, investigative efforts, and audit recovery. The OIG has reported in its 2012 Semiannual Report, that the agency recouped $1.2 billion from Medicare overpayments through as many as 1,264 exclusions and 388 criminal actions.

The report, which covers OIG actions between Oct. 1, 2011, and March 31, 2012, outlines common enforcements, such as those on durable medical equipment (DME) suppliers, as well as new targets.

"We are using advanced data analytics to help us conduct risk assessments; more effectively pinpoint our oversight efforts; and significantly reduce the time and resources required for audits, investigations, evaluations, and other program integrity activities," said Inspector General Daniel R. Levinson in the report.

Some Money Not Yet Collected

In addition to collecting billions, the OIG may also request refunds based on additional recommendations published in the report.

For example: With a renewed focus on fraudulent suppliers opening shop all over the country, the OIG recommends that CMS conduct site visits "for the highest paid new suppliers," the report indicates.

Consider These Examples

Following is a sampling of a few of the OIG's recoveries as outlined in the report:

• $12 million was identified in overpayments for outpatient services during an audit of TrailBlazer Health Enterprises (a Part B payer) for problems such as incorrect HCPCS codes, lack of documentation, and unallowable services.
• Medicare paid portable x-ray suppliers for "questionable return trips to nursing facilities" and reimbursed for services that were ordered by non-physicians -- and therefore should not have been covered.
• A nursing service owner had to pay over $30 million in restitution after he was found paying kickbacks to Medicare beneficiaries and recruiters and billing Medicare for services not rendered.

To read the OIG's Semiannual Report, visit the HHS Web site at: http://oig.hhs.gov/reports-and-publications/semiannual/index.asp.