Exclusion Case Review: 1st Quarter of 2015 Evidences an Increase in Enforcement Efforts by OIG

gavel exclusion case

(This article was originally posted in the National Alliance of Medical Auditing Specialists‘ “Tip of the Week”)


At Exclusion Screening, we keep track of all of the exclusion cases reported by the OIG and analyze them for any number of obvious reasons. At first glance, the cases reported in the 1st quarter of 2015 seem fairly unremarkable as they show only small increases in the number of cases reported, and the CMPs imposed, and seem to maintain the slow, steady rise of the previous years. However, a closer examination of the cases strongly suggests that the OIG is picking up the pace of exclusion enforcement, and that it may even be headed toward a national exclusion enforcement project.

I.  Increasing Involvement in Active Investigations

As we indicate above, the overall case numbers and CMPs imposed remained fairly consistent in the 1st quarter. However, a more focused analysis of the cases and their data, when compared with the cases reported in the previous years, provides strong evidence that direct OIG involvement in exclusion investigations and exclusion enforcement is clearly on the rise. Here’s how we reach that conclusion.

Looking at the case data from 2010 through 2013, it is reasonable to conclude that OIG involvement in exclusion enforcement principally took the form of processing self disclosures. In 2013, for instance, 82% of all exclusion cases reported on the OIG website were self disclosure cases meaning less than 1 in 5 exclusion cases (18%) were investigated on front end by the OIG. The percentages in 2010 and 2011 were similar at 80% and 85% respectively.   It would appear, however, that things began to change when the Update of the Special Advisory Bulletin in May of 2013 with second half of 2013 showing marked improvement, and the OIG’s direct involvement in case origination and investigation increased to about 1/3 of the reported cases in 2014. The first quarter of this year continues this trend, and even though the sample size is relatively small, the OIG investigational involvement is reported cases was 45% for the period. In addition, and perhaps more convincing, the agency took the extraordinary action of excluding an Illinois home health agency for submitting claims by an excluded employee!

II.  Is the “Data Analysis Project” the new “Excluded Provider Project”?

In 2010, a number of US Attorney Offices in the Northeast participated in a so-called “Excluded Provider Project.” Though the scope and details of the project are somewhat unclear, it was supported by the OIG, referenced in an article or two in connection with the 2010 OIG Work Plan, and held out to the public as a proactive approach to exclusion enforcement. Over time, however, only a few relatively small settlements were actually announced, and nothing was from or heard about it for several years.

Last October the OIG announced that it had reached a large exclusion violation settlement, and in so doing, it gave special credit to a “Data Analysis Project” conducted by its Office of Audit Services in support of the investigation. Though the press release went no further, it suggested that a more proactive approach was being taken as compared to a reactive one. This “suggestion” was left hanging, but it gained additional traction in the 1st quarter of 2015 with announcement of another settlement supported by another “Data Analysis Project” conducted by a sister investigative agency within HHS/OIG (the Office of Evaluations and Inspections and not the Office of Audit Services). Whether these “Projects” are connected or a part of some larger initiative can’t be known at this point, but additional clues are likely to be forthcoming.

III.  Conclusions?

The evidence strongly supports the conclusion that OIG’s involvement in exclusion enforcement is increasing. What, exactly, the “data analysis” project (or projects) are or will become is not yet knowable, but with the OIG increasingly involved in investigations and with its enforcement interest and involvement spread throughout the agency – compliance is more critical than ever!

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