The Office of Inspector General (OIG) recently published its Semi-Annual Report to Congress covering from October 1, 2018 to March 31, 2019. The OIG report focuses on the enforcement actions that were brought and the exclusions that were imposed during the past reporting period in support of the agency’s mission to protect patient safety and the financial integrity of federally funded healthcare programs. Since 2004, the OIG has recovered over $53 billion and Excluded 50,877 Individuals and Entities from participating as enrolled providers in Federal healthcare programs. It has also filed over 11,000 criminal actions against those who were alleged to have committed crimes against its healthcare programs and filed over 7,000 civil actions seeking civil monetary penalties and administrative recoveries in “False claims and unjust-enrichment lawsuits filed in Federal district court.[1]
I. Highlights of OIG Actions
During the last reporting period of the OIG issued 71 audits and 10 evaluations in which the OIG issued 212 recommendations to HHS operating divisions. The OIG also identified just short of $500 million in expected recoveries. In addition, OIG identified over $245 million in “questionable costs” from alleged violations, inadequate documentation, or unreasonable spenditures.
As a result of its actions during the reporting period, the OIG expects to recover $2.3 billion in addition to pursuing 391 criminal healthcare fraud matters and initiating 327 civil actions against individuals or entities that also engaged in offenses related to healthcare fraud and risked the financial integrity of its healthcare programs.
In April, 2019, the OIG announced, with other healthcare enforcement components, participation in a massive takedown of one of the largest healthcare fraud schemes in U.S. history. The investigations involved allegations of telemarking scams directed at senior citizens that resulted in almost $1 billion in fraudulent claims for medically unnecessary orthopedic braces which were administrated through
II. OIG Exclusions
During this past reporting period the OIG reported that most of its exclusions came from license revocation, convictions for crimes relating to Medicare or Medicaid, financial misconduct, controlled substances, or patient abuse or neglect. This is consistent with past OIG Exclusions as you can see on this chart.
The Exclusion Program is integral to the OIG’s mission of keeping healthcare programs and its beneficiaries safe from wrongdoers. During the audit period, the OIG excluded 1,293 individuals and took civil actions, typically in the form of civil monetary penalties, against 331 individuals and entities. The agency continues to maintain its focus on handing out OIG Exclusions as a means of protecting patients and the healthcare programs that serve them.
III. New Actions and Programs
The report also confirmed two significant changes in the OIG’s structure and a new program intended to facilitate the imposition of exclusions predicated on convictions obtained by State Medicaid Fraud Units (MFCUs). The OIG announced the creation of an Affirmative Litigation Branch dedicated to collecting and enforcing its civil monetary penalties and its exclusion authorities. We expect this new program to head off and increase the amount of Medicare and Medicaid Exclusions that the OIG gives out. Also, a new Cyber Information Technology Audit Division will be devoted to focusing on the growing threats to the cyber security of its Department Programs.
If successful, the most significant change with respect to exclusions, however, will be the deployment announced by the OIG of a new service which allows Medicare Fraud Control Units (MFCU) to report convictions and State exclusions through a centralized web-based portal. In the past, State health care fraud enforcement actions have not always reported to the OIG and, as a consequence, have often exclusion by the OIG. But if the deployment is successful, it could substantially reduce the number of this problem.
IV. HHS-OIG Hotline
The HHS-OIG Hotline is another aspect of the OIG’s efforts in support of its mission to protect healthcare programs and their beneficiaries. In the past reporting period, the OIG Hotline received 59,956 calls to its 1-800-HHS-TIPS phone line. Overall, the OIG received a total of 79,398 tips of which 9,7632 were referred for action. The chart here shows the breakdown of each source of tips that were referred for action.
These numbers provide strong support for value to healthcare providers of having an anonymous hotline service. Complaints and concerns will almost always be reported to someone, and third party Compliance Hotlines are consistently chosen as the preferred method of internal whistleblowing because the party making the complaint can remain anonymous. Further, most reporters would prefer to make their complaints directly to provider as they are in the best position to respond quickly – and this is, of course, also best for the provider. However, if there is no safe reporting option, as can be seen, complaints may well go to the OIG; and experience teaches us that complaints to law enforcement can result in the expenditure of significant time and money even under circumstances where the “issue” is nothing more than an innocent misunderstanding!
V. Concluding Thoughts
The OIG continues to expand and create new programs in its efforts to protect healthcare programs and its beneficiaries from fraud, but its Exclusion Authority remains one of its most potent and visible weapons – and the best and most important way a provider can protect itself is by having an effective exclusion screening program that monitors all state and federal exclusion screening databases. If screening your employees against each federal and state list that your state requires is not cost-effective for your office to do in-house, contact Exclusion Screening, LLC today at 1-800-294-0952 or fill out the form below. We would be happy to discuss your specific state obligations, provide a cost assessment, and help you create your employee and vendor list.
[1]United States. Department of Health and Human Services. Office of Inspector General. Semi-annual Report. Washington, D.C.: Department of Health and Human Services, Office of Inspector General, 2019.