In November, the OIG published their Semiannual Report to Congress. Those of you who are familiar with the report know it contains a great summary of investigations, enforcement and other insights from recent work performed by the OIG.
OIG’s enforcement work continues to produce impressive results. During the fiscal year of 2018, OIG reported expected investigative recoveries of $2.91 billion, criminal actions against 764 individuals or entities that engaged in crimes against HHS programs, exclusion of 2,712 individuals and entities, and civil actions against 813 individuals or entities. Key to the OIG’s successes is their partnerships with the Department of Justice, Medicaid Fraud Control Units, and other Federal, State, and local agencies.
This reporting period saw continued progress in OIG’s work combating the opioid epidemic. More than one-quarter of the 601 defendants in the June 2018 Health Care Fraud Takedown was charged with opioid-related conduct.
Further, OIG published a toolkit setting out OIG’s data-driven methodology for identifying beneficiaries at high risk of misuse of opioids. OIG hopes that Federal, State, local, and private entities will use this toolkit to identify at-risk patients who may need case management or other follow up. The Centers for Disease Control and Prevention recently posted the toolkit on its website. OIG employs modern data, tools, and technology to support their multi-disciplinary workforce in providing efficient and effective oversight of HHS’s over $1 trillion in health and human services programs.
Recent examples of significant enforcement accomplishments include the following:
- An owner of a Florida pharmacy was sentenced to 15 years in prison and ordered to pay $54.5 million for a prescription drug fraud scheme. The owner-operated multiple pharmacies, which he used to pay kickbacks and bribes in exchange for prescriptions, as well as submit false claims for prescription compounded medications to private insurance companies, Medicare, and Tricare.
- Two co-conspirators connected with clinics in Brooklyn, NY, were sentenced for their role in a $48.5 million healthcare fraud scheme. The defendants paid cash kickbacks to patients to induce them to attend the clinics and then submitted fraudulent claims to Medicare and Medicaid for services that were induced by prohibited kickback payments to patients or that were unlawfully rendered by unlicensed staff
OIG identified significant vulnerabilities in the Medicare hospice program affecting the quality of care and program integrity. OIG released a portfolio in July 2018 that highlights key vulnerabilities and makes 15 recommendations for protecting beneficiaries and improving the program. The portfolio synthesizes OIG’s body of work on the Medicare hospice benefit. Among its findings, OIG found that hospices do not always provide needed services to beneficiaries and sometimes provide poor quality care. Inappropriate billing and fraud by hospice providers cost Medicare hundreds of millions of dollars. In addition, OIG found that the current payment system creates incentives for hospices to minimize their services and seek beneficiaries who have uncomplicated needs. (See portfolio at OEI-02-16-00570.)
A large hospice chain entered into a settlement agreement for providing services to patients who were not terminally ill. Caris Healthcare LLC and Caris Healthcare, L.P. (collectively, “Caris”) entered into a settlement agreement to resolve allegations that, from April 1, 2010, through December 31, 2013, Caris submitted false claims and improperly retained payments from Medicare for services provided to patients who were ineligible for hospice benefits because they were not terminally ill. Caris agreed to pay $8.5 million to resolve its alleged liability.
Inpatient Rehabilitation Facilities
OIG estimates that Medicare paid inpatient rehabilitation facilities (IRFs) for care that did not meet Medicare’s necessary and reasonable care coverage requirements. Based on a medical review of a sample of IRF claims, OIG estimated that in 2013 Medicare paid IRFs nation-wide $5.7 billion for care to beneficiaries that did not meet requirements. (See report at A-01-15-00500.)
OIG estimated Medicare overpayments for replacement positive airway pressure devices. Within this reporting period, two areas of substantial savings include OIG’s work that found most Medicare claims that durable medical equipment suppliers submitted for replacement positive airway pressure device supplies did not comply with Medicare requirements. Based on their analysis, they estimated that Medicare made overpayments of almost $631.3 million. (See reports at A-05-16-00058, at A-01-15- 00500, and at A-04-17-04056.)
OIG engaged in enforcement actions against providers who were inflicting harm on patients or allegedly denying them access to safe and quality healthcare. In one case, a medical center entered into a $90,000 settlement agreement with OIG to resolve allegations that it violated the Emergency Medical Treatment and Leave Act (EMTALA) by failing to provide an adequate medical screening examination and treatment for a patient and transferring him to another hospital, where his condition worsened and he later expired.
These are just a few examples of OIG work presented in their Semiannual Report. If you’re not a regular reader of this report you should take a moment to review it. Such a review can often provide ideas for audits or work plan items for your compliance program.