Medicare Compliance & Reimbursement

Caution: AKS issues remain an OIG sticking point.

With the pandemic largely in the rearview mirror, you may be revising your policies and heaving a sigh of relief. But don’t get too comfortable — federal enforcers aren’t taking any breaks and keep adding to their target roster. Read on for the scoop.

Nuts and bolts: In the Semiannual Report to Congress, the HHS Office of Inspector General (OIG) offers insight into the state of the nation’s federal healthcare programs as well as what the national watchdog is tracking on the fraud and abuse landscape. The agency’s most recent report focuses on incidents, enforcement, and takedowns from Oct 1, 2022 to March 31, 2023, with kickbacks, COVID fraud, and opioid and substance abuse under the enforcer’s microscope.

“During this reporting period … OIG and its partners pursued a multi-State, coordinated law enforcement action to apprehend individuals engaged in a brazen scheme to sell more than 7,600 false and fraudulent nursing degree diplomas and transcripts,” reveals Inspector General Christie A. Grimm in the report. “Further, across the Nation, our investigators worked with Federal and State law enforcement partners to bring to justice perpetrators of detrimental kickback, false billing, and other schemes, including an alarming scheme involving unnecessary prescriptions for opioids.”

Grimm warns, “HHS-OIG remains resolute in our commitment to aggressively combat fraud and hold wrongdoers accountable.”

Take a Look at the Enforcement Numbers

During the report timeframe, OIG highlights great strides made through audits, enforcement, and recoveries while working in tandem with its partners at the Department of Justice (DOJ), State Medicare and Medicaid Fraud Control Units, and other federal, state, and local law enforcement.

Here’s a breakdown of the report numbers:

• Audits: OIG released 62 audit reports and 19 evaluations — up from 47 audit reports and 14 evaluations from the same time last year.
• Costs and audit recoveries: The agency expects to recover more than $200.1 million, a steep decline from last year’s $1.14 billion from audit work. OIG questioned more than $277.2 million in costs, but that’s significantly down from $1.6 billion questioned costs from Oct. 1, 2021 to March 31, 2022.
• Investigative recoveries: OIG expects its investigative recoveries to total more than $892.3 during this reporting period, but less than the $1.44 billion from the mid-year 2022 report.
• Criminal actions: The federal watchdog brought criminal actions against 345 individuals and entities, up from 320 last March.
• Civil actions: OIG levied civil actions against 324 individuals and entities in the Semiannual Report to Congress, which remains status quo with 320 a year ago.
• Exclusions: The feds excluded 1,365 individuals and entities from federal healthcare programs during this time period, a slight bump from 1,043 individuals and entities from the previous year’s timeline.

Caveat: Despite the strides OIG’s made in the fraud and abuse enforcement realm, there were “missed opportunities,” Grimm maintains. “Our capacity to shine a light on program vulnerabilities, uncover misspent funds, and undertake enforcement actions is limited only by our available resources,” she says. “Notwithstanding concerted efforts by HHS-OIG and the Department — with strong support from Congress for HHS-OIG’s oversight and enforcement — serious fraud, waste, and abuse continue to threaten HHS programs and the people they serve.”

She adds, “With current resources, HHS-OIG is unable to keep pace with these threats. For example, we are turning down 300 to 400 viable criminal and civil health care fraud cases each year due to lack of resources.” Grimm hopes that resources will come from the 2024 Fiscal Year budget, providing the agency with much-needed funding and more chances to circumvent fraud.

Check Out These Top Takedowns

Every year, Medicare and Medicaid fraudsters factor heavily in the OIG’s Semiannual Report — and the latest update is no different. In fact during this reporting period, 318 of the total 324 civil and 318 out of the total 345 criminal investigations the OIG performed were related to Medicare and Medicaid fraud or abuse as well as $626.8 million of the total $892.3 million investigative recoveries. Unbundling, upcoding, and billing for medically unnecessary or never-rendered services top the list of False Claims Act (FCA) violations, and these types of fraudulent filings are the most common issues OIG sees, the report indicates.

Though these types of issues remain the foundation of OIG’s enforcement activity, more nefarious cases of fraud and abuse continue to dominate the headlines. Here’s a brief look at four of the most intense investigations the agency reviews: