Deeper Than the Headlines: 268.1 Million in Restitution: Highlights From the OIG Semiannual Report

On November 30th, the OIG posted its Semiannual Report to Congress. The report is a summary of the OIG’s activities from April 1, 2017 to September 30, 2017. About 80% of the OIG’s resources are focused on Medicare and Medicaid.

OIG Semiannual Report Highlights

Dr. Jacques Roy was sentenced to 35 years in prison and jointly and severally with his co-defendants, ordered to pay $268.1 million in restitution following his conviction on several counts of healthcare fraud. OIG’s investigation found that Roy and his co-defendants were involved in a large-scale, sophisticated scheme to improperly recruit patients and bill Medicare for unnecessary home health services.

Mylan Inc. and Mylan Specialty L.P. (collectively, Mylan) agreed to pay $465 million to resolve FCA liability associated with allegations that Mylan improperly classified EpiPen as a generic drug for purposes of the Medicaid drug rebate program, resulting in underpaid rebates to Medicaid and overcharges to covered entities participating in the 340B Drug Discount Program. Mylan also entered into a 5-year CIA with OIG.

eClinicalWorks, LLC (ECW), and three of its senior executives agreed to pay $155 million for allegedly causing healthcare providers to submit false claims in connection with the Medicare and Medicaid Electronic Health Record Incentive Programs by concealing from ECW’s customers that ECW’s software did not comply with the requirements for “meaningful use” certification. ECW also entered into a 5-year CIA with OIG.

Jonathan Wade Dunning, CEO of Birmingham Health Center, was convicted on 98 counts related to his embezzlement of Federal grant funds. Dunning was sentenced to 18 years in prison and ordered to pay $13.5 million in restitution. He and his nine companies were also debarred for 10 years.

OIG’s review of records from emergency room visits by Medicare beneficiaries residing in SNFs indicates that the injuries of 134 beneficiaries may have resulted from potential abuse or neglect. More than a quarter of these incidents may not have been reported to law enforcement at the time. OIG has referred all 134 incidents to appropriate law enforcement officials and CMS and suggested immediate actions for CMS to better protect beneficiaries.

In an audit of Medicare EHR incentive payments, OIG estimated that CMS paid $729.4 million to providers who did not meet Federal requirements for “meaningful use.” CMS also made $2.3 million in incentive payments for the wrong payment year when providers switched between incentive programs.

OIG has focused significant attention on improving quality and integrity in HHS programs serving American Indians and Alaskan Natives. This includes improving the quality of care, management, and infrastructure of the Indian Health Service (IHS); combating fraud and misuse of funds; and ensuring adequate internal controls and training for grantees.

In April 2017, OIG conducted a training program for IHS and tribal officials on health care and grants management compliance in South Dakota. The sessions focused on quality of care and service delivery, compliance programs and other tools for combating fraud and abuse, internal controls, and single audits.

In audits of two tribes, OIG identified improper administration of Low Income Home Energy Assistance Program (LIHEAP) grant funds. Grant funds totaling $1.2 million for one tribe and almost $600,000 for the other tribe were not administered in compliance with Federal laws, regulations, and guidance. These funds could have been used to provide additional benefits to eligible LIHEAP beneficiaries. Errors occurred because of insufficient internal controls, and in some cases, because staff circumvented existing internal controls.

Tribal member convicted of theft of federally provided welfare benefits, ordered to pay $30,000 in restitution, and debarred for 3 years. James Leroy Emerson stole Temporary Assistance for Needy Families (TANF) and Supplemental Nutrition Assistance Program (SNAP) Tribal funds when he applied for and received benefit payments from the Blackfeet Tribe from 2007 through 2010, even though he was ineligible. He was convicted of theft of federally provided welfare benefits by fraud, Federal welfare assistance fraud, and theft from an Indian tribal organization, and ordered to pay $30,000 in restitution. Emerson was also debarred for a period of 3 years following an OIG referral to HHS.

These are just some of the highlights from the report. Read the report in its entirety for more example of the OIG’s efforts these last six months.

Questions or Comments?