Deeper Than the Headlines: OIG Semi-Annual Report

The Department of Health and Human Services has an annual portfolio of services that totals over $1.2 trillion. With such a large portfolio, it is no wonder the HHS OIG is the largest Office of Inspector within the Federal Government. Given their major commitment of resources, the OIG issues a semiannual report to the U.S. Congress and in early June 2019, they issued their Semiannual Report to Congress for October 1, 2018, through March 31, 2019.

During this reporting period, OIG’s audit work identified $496 million in expected recoveries. They also identified $247 million in questioned costs (costs questioned by OIG because of an alleged violation, costs not supported by adequate documentation, or the expenditure of funds where the intended purpose is unnecessary or unreasonable). OIG audit work also identified $777 million in potential savings for HHS. These are funds that could potentially be saved if HHS programs implemented all of OIG’s audit recommendations.

OIG also remains at the forefront of the Nation’s efforts to fight fraud in HHS programs and hold wrongdoers accountable. OIG investigative work led to $2.3 billion in expected investigative recoveries and 421 criminal actions during this reporting period. OIG also excluded 1,293 individuals and entities from Federal healthcare programs and took civil actions, such as assessing monetary penalties against 331 individuals or entities.

Some of the most valuable aspects of this semiannual report are the examples they share:

Quality of Care and Protecting Patients From Harm

OIG investigation resulted in the conviction of a doctor who implanted unnecessary pacemakers. A physician was found guilty of healthcare fraud after an OIG investigation showed that he implanted medically unnecessary pacemakers into his patients to bill for these unnecessary procedures and follow-up care. At trial, several patients testified that the physician had pressured them into the procedures and gave them misleading information about their health conditions.

OIG determined that more than 4 in 10 Medicare patients in long-term-care hospitals (LTCHs) experienced some type of harm from their care. Based on the medical expert review, OIG estimated that 25 percent of Medicare patients in LTCHs experienced temporary harm events from their care and an additional 21 percent experience more serious adverse events. This rate of patient harm is higher than OIG found in other settings and may be due, in part, to longer stays and high patient acuity in LTCHs. Medical reviewers determined that more than half of these harm events were preventable with better care. OIG made recommendations to CMS and the Agency for Healthcare Research and Quality (AHRQ) to help LTCHs reduce patient harm. (See report OEI-06-14-00530.)

Ensuring Program Integrity

OIG recommended steps to reduce improper Medicare payments to skilled nursing facilities (SNFs)

An OIG audit identified $86 million in improper Medicare payments to SNFs for beneficiaries not meeting the “3-day rule” (i.e., the requirement that a beneficiary must be an inpatient in a hospital for at least 3 days to be eligible for coverage of SNF care following their hospital discharge). OIG recommended improvements to a claims processing edit, education for hospitals and SNFs, and new notifications from hospitals to beneficiaries and to SNFs regarding whether the beneficiary’s hospital stay qualifies him or her for SNF care coverage. (See report A-05-16-00043.)

California made Medicaid payments on behalf of non-eligible beneficiaries On the basis of OIG sample results, OIG estimated that California made Medicaid payments of $959.3 million ($536 million Federal shares) on behalf of 802,742 ineligible beneficiaries and $4.5 billion ($2.6 billion Federal share) on behalf of 3.1 million potentially ineligible beneficiaries. They recommended that California redetermine, if necessary, the current Medicaid eligibility of the sampled beneficiaries and make procedural changes related to determining Medicaid eligibility. (See report A-09-17-02002.)

Physician False Claims Act Settlement Agreement

The Agreement resolves allegations that from January 1, 2007, through May 31, 2014, Coordinated Health and its owner, Emil DiIorio, M.D. submitted claims to Medicare, Medicaid, TRICARE and FEHBP for orthopedic surgical procedures that were improperly unbundled using Modifier 59; and (2) from April 1, 2009, through December 31, 2009, Dr. DiIorio submitted claims to Medicare, Medicaid, TRICARE, and FEHBP for orthopedic surgical procedures that were improperly unbundled using Modifier 59. Coordinated Health agreed to pay $12.5 million and entered into a 5-year Corporate Integrity Agreement.

Affirmative litigation cases under the CMPL Millennium Laboratories, Inc. entered into a False Claims Act settlement to resolve, in part, allegations that Millennium provided a free point of care urine drug testing cups (POCT cups) to physicians—expressly conditioned on the physicians’ agreement to return the urine specimens to Millennium for additional testing provided by and billed to Federal healthcare programs by Millennium, in violation of the Anti-Kickback Statute and the Prohibition on Certain Physician Referrals. Since September 2017, more than $2 million has been recovered from OIG initiated affirmative litigation actions against physicians, physician practices, and other providers based on their alleged unlawful receipt of free POCT cups from Millennium during the relevant timeframe. A recent example of this is OIG’s settlement with Recovery Pathways, LLC (Recovery), a drug and alcohol rehabilitation center, which resolved its alleged liability for soliciting and receiving remuneration in the form of POCT cups from Millennium. Recovery agreed to pay $64,555 to resolve its alleged liability under the CMPL.

The 79-page semiannual report is full of examples and is a must-read for compliance officers. I highly recommend you sit down with your favorite beverage one night, maybe put on some nice music, and flip through the pages.