Medicare Compliance & Reimbursement

If you need a reminder of why your practice may be seeing unprecedented scrutiny, look no further than the HHS Office of Inspector General’s (OIG’s) latest enforcement opus.

Background: In the OIG’s Semiannual Report to Congress, the agency offers insight on its top enforcement actions — both civil and criminal — during a portion of the calendar year. The most recent release focuses on incidents, enforcement, and takedowns from April 1, 2023 to Sept. 30, 2023.

“HHS-OIG oversees more than 100 health and human services programs to ensure that more than $2 trillion in taxpayer funds are responsibly spent and that the more than 150 million Americans who rely on those programs are well served,” notes Inspector General Christi Grimm in the report. Using its extensive tools, from audits to investigations to evaluations and inspections, “the Semiannual Report details enforcement actions and other key oversight work across the scope of HHS programs and operations,” Grimm explains.

The latest iteration “highlights over $3.44 billion in expected recoveries resulting from HHS-OIG audits and investigations conducted during fiscal year (FY) 2023,” the agency expounds in a release about the new report. The OIG expects approximately $3.16 billion to be returned based on investigative work while a much more modest $283 million is expected to be returned based on program audit findings for the 12-month period, it says.

Here’s the Mid-Year Spotlight

Though OIG does offer an overview of the entire fiscal year, the Semiannual Report focuses on a six-month snapshot of enforcement activity. OIG made great strides through audits, enforcement, and recoveries, working in tandem with its partners at the Department of Justice (DOJ), the Medicare Fraud Task Force, the Medicaid Fraud Control Units, and other federal, state, and local law enforcement.

Here’s a breakdown of the report numbers from April 1, 2023 to Sept. 30, 2023:

• Audits: The OIG issued 65 audit reports and 22 evaluations, a slight jump from the previous reporting period.
• Costs and audit recoveries: The agency expects to recover more than $82.7 million — a major recovery decline since expected recoveries were at $200.1 million in the last reporting period. The OIG questioned a whopping $1.2 billion in costs, significantly up from $277.2 million in costs from Oct. 1, 2022 to March 31, 2023.
• Investigative recoveries: The OIG’s work drove investigative recoveries at $2.26 billion during the reporting period, a significant increase from the last report’s numbers at $892.3 million.
• Criminal actions: The federal watchdog brought criminal actions against 362 individuals and entities, up from 345 last March.
• Civil actions: The OIG levied civil actions against 422 individuals and entities, a massive increase from 324 civil actions in the last reporting round.
• Exclusions: The feds excluded 750 individuals and entities from federal healthcare programs over the time period, a substantial decrease from the last reporting period, which saw 1,345 exclusions.

Check Out These Top Cases

The Centers for Medicare & Medicaid Services (CMS) is one of the myriad programs the OIG monitors annually. However, with several fraud and abuse investigations with price tags in the millions, it’s no surprise that Medicare providers sit at the top of the OIG’s watch list.

Take a look at three Medicare-related enforcement actions over the reporting period:

COVID-19: Between 2017 and 2021 — and through the height of the COVID-19 public health emergency (PHE) — Billy Joe Taylor and his co-conspirators submitted shoddy claims to Medicare for a variety of fraudulent lab tests. The labs, which were medically unnecessary, never ordered by providers, and not administered as represented, totaled more than $120 million in false claims.

Taylor and his associates usurped beneficiaries’ data then repeatedly resubmitted it for more unnecessary tests. He “was sentenced to 15 years in prison followed by three years of supervised release and ordered to pay $29,835,825.99 in restitution for conspiracy to commit health care fraud and money laundering,” the report says.

Genetic testing: The intersection between false claims and telemedicine has been a perennial favorite of OIG investigators, and genetic testing continues to be a hot issue. Minal Patel, the owner of Georgia-based LabSolutions LLC, was involved in a $463 million scheme to defraud Medicare. “Patel conspired with patient brokers, telemedicine companies, and call centers to target Medicare beneficiaries with telemarketing calls falsely stating that Medicare covered expensive cancer genetic tests,” the report says.

Once Medicare benes signed on for the tests, Patel paid patient brokers kickbacks and bribes for physician authorizations. Patel was sentenced to 27 years in prison and will personally have to pay back $21 million to Medicare for his portion of the scam, the report indicates.

Upcoding: OIG has been looking into Medicare Advantage organizations’ diagnosis code usage for a while (see Medicare Compliance & Reimbursement, Vol. 49, No. 19). Maine-based Martin’s Point Health Care Inc. recently resolved False Claims Act (FCA) violations for submitting inaccurate diagnosis codes to Medicare for a higher payout.

Between 2016 and 2019, “Martin’s Point engaged in chart reviews of their Medicare Advantage beneficiaries to identify additional diagnosis codes that had not been submitted to Medicare,” the feds allege. “Many of the additional codes submitted, however, were not properly supported by the patients’ medical records.” Martin’s Point submitted the codes to Medicare anyway, receiving higher payments for their claims.

The civil case, which began under a qui tam action filed by Alicia Wilbur, a former manager in Martin’s Point’s Risk Adjustment Operations group, was resolved by Martin’s Point in a $22.4 million settlement.

Resource: Review the Fall 2023 Semiannual Report to Congress at https://oig.hhs.gov/reports-and-publications/archives/semiannual/2023/fall-sar-2023.pdf.