Watchdog Report: Nearly $3B Recovered From Providers

healthcare fraud investigation

Fighting healthcare fraud remains among the priorities for the U.S. Department of Health and Human Services Office of the Inspector General as evidenced by its most recent semiannual report to Congress.

The watchdog organization reported recovering $2.91 billion from providers in fiscal year 2018. It took criminal actions against 764 individuals or healthcare providers that engaged in healthcare-related crimes and excluded 2,712 individuals and entities from participating in federal healthcare programs – Medicare, Medicaid, etc. The agency also filed civil actions against 813 individuals or entities.

A big chunk of that came from a nationwide healthcare fraud take down that happened in June in which more than 600 defendants in 58 federal districts were charged with participating in healthcare-related fraud schemes.

That crackdown focused on healthcare providers who engaged in opioid-related fraud, including 76 doctors who were charged for their roles in prescribing and distributing opioids and other dangerous narcotics. The government has made it clear that it intends to go after unethical prescribers cashing in on the epidemic.

Improper payments are another area of concern for the OIG. It estimates that in 2013, Medicare paid inpatient rehabilitation facilities $5.7 billion for care that did not meet Medicare’s “necessary and reasonable care” coverage requirements. More on that can be found here.

OIG has recommended that CMS educate inpatient rehabilitation facility billing and clinical personnel on coverage and documentation requirements, increase oversight, and re-evaluate the current payment system, among other things.

Telehealth payments also have raised cause for concern. A review of telehealth claims made in 2014 and 2015 found that more than half paid by Medicare did not have matching originating-site facility fee claims. CMS paid practitioners for some telehealth claims associated with services that did not meet Medicare requirements. The OIG recommended, and CMS agreed, that it conduct periodic post-payment reviews to disallow payments for errors for which telehealth claim edits can’t be implemented, to work with Medicare contractors to implement all telehealth claim edited listed in the Medicare Claims processing manual, and to offer education and training sessions to practitioners on requirements and other resources.

Durable Medical Equipment (DME) has been an area of concern for many years and continues to be. The report found that CMS allowed $18.4 million in Medicare payments for inappropriate claims that DME provided during skilled nursing facility stays not covered by Medicare and also may have allowed inappropriate claims for DME provided in Medicaid-only nursing facilities.

Other areas addressed in the report include:

  • Medicare made improper payments of $8.7 million to providers for non-emergency ambulance transports to destinations not covered by Medicare.
  • Medicare payments for selected items and services ordered by chiropractors did not comply with federal requirements. Specifically, for calendar years 2013-2016, Medicare improperly paid providers $6.7 million. As we recently wrote about, CMS is looking to draft a rule that will make it harder for some chiropractors to submit Medicare claims.
  • Between 2013 and 2015, Medicare overpaid hospitals nationwide as much as $21.5 million for outpatient Intensity-Modulated Radiation Therapy Planning (IMRT) services, along with another $4.2 in potential overpayments for other IMRT services not included in their sample.

Practices that discover evidence of potential fraud have the opportunity to self-disclose, giving them the chance to avoid costs or disruptions that may come with an investigation. If you do suspect a problem, it’s always best to first consult with an attorney.

Many providers also elect to settle before a case goes to litigation, opting to enter into a corporate integrity agreement to avoid exclusions from Medicare, Medicaid and other federal healthcare programs. This requires a provider to take steps to ensure compliance in the future. OIG will monitor the practice for a period of time to ensure compliance is taking place.

Many of the cases investigated come through the OIG hotline. The agency reported that between April and September 2018 there were more than 60,000 calls to the hotline with 11,152 tips. Of those, 8,096 were referred for action; 4,148 were closed with no basis for further action; and 523 found no HHS violation. During this semiannual period, OIG reported expected recoveries of $27 million as a direct result of cases that originated from calls to its hotline.

Given the government’s increased emphasis on investigating healthcare fraud, providers would be well-advised to make sure their practice is in compliance. The Health Law Offices of Anthony C. Vitale has more than 25 years of representing clients under investigation. We also can help you set up a compliance program so that you don’t find yourself the target of an investigation. Contact us for additional information at 305-358-4500 or send us an email to info@vitalehealthlaw.com and let’s discuss how we might be able to assist you.

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It is not intended as professional advice and should not be construed as such.