HHS-OIG Details Successes of Efforts to Curb Healthcare Fraud and Abuse in Semiannual Report to Congress

The U.S. Department of Health and Human Services Office of the Inspector General (HHS-OIG) recently released its Semiannual Report to Congress touting its many successes but also adding that a lack of funding has resulted in an inability to go after even more healthcare fraud and abuse.

“We are turning down 300 to 400 viable criminal and civil healthcare fraud cases each year due to lack of resources. Each case means unaddressed potential fraud and missed opportunities for deterrence,†writes IG Christi A. Grimm in her opening message.

During the last six months, ending March 31, the OIG issued 62 audit reports and 19 evaluation reports and identified $200 million in expected recoveries, as well as $277.2 million in questioned costs resulting from the agency’s audits and investigations, according to its report.

During this reporting period, OIG made 213 new audit and evaluation recommendations, which it said are “crucial to encourage positive change in HHS programs.â€

The watchdog agency said its investigative work led to $892.3 million in expected investigative recoveries and 345 criminal actions during this reporting period. OIG also took civil actions, such as assessing monetary penalties, against 324 individuals and entities, and excluded 1,365 individuals and entities from federal healthcare programs.

The HHS-OIG highlighted a number of cases it handled including a multi-state, coordinated law enforcement effort dubbed “Operation Nightingale†to catch individuals engaged in a scheme to sell more than 7,600 false and fraudulent nursing degree diplomas and transcripts that took place in Florida.

Investigators also worked with federal and state law enforcement partners to go after those involved in of a variety of healthcare schemes including kickbacks and false billing, as well as the provision of unnecessary prescriptions for opioids.

The agency catalogued several cases, including one that resulted in a 20-year prison sentence for the medical director of a drug and alcohol addiction treatment facility involved in a $746 million, multiyear scheme to bill for fraudulent tests and treatments.

The COVID-19 pandemic resulted in a significant number of cases relating to fraud and abuse. As we wrote about, in May 2021 the U.S. Department of Justice launched a task force to specifically go after a wide range of COVID-related cases. OIG cited a case in which during this reporting period, an individual was sentenced to three years of probation for creating false COVID-19 vaccine records. The individual, who worked as a data entry specialist for a company providing vaccinations, created fraudulent vaccination cards, and made false vaccination entries to record-keeping systems for 14 individuals.

OIG uses the Civil Monetary Penalties Law (CMPL) to settle liabilities with facilities that self-disclose inappropriate billing practices. For example, during this reporting period, OIG entered into a $14.3 million settlement agreement with a facility that submitted incorrect claims to Medicare for inpatient rehabilitation stays that did not meet coverage criteria.

In addition to outlining the cases it handled, the OIG detailed some of the recommendations it made to the Centers for Medicare & Medicaid Services (CMS). For example, providers did not always comply with federal requirements when claiming Medicare reimbursement for Medicare bad debts. The OIG recommended that CMS consider issuing instructions to the MACs that require or encourage more review of Medicare bad debts claimed on cost reports, such as defining thresholds beyond which individual Medicare bad debts would trigger an audit, and that direct the MACs to revise their cost report audit work plans accordingly.

The OIG laid out numerous other instances in which providers failed to abide by certain rules and regulations and made suggestions of actions CMS could take to ensure they did in the future. In some cases, CMS agreed with the IG’s recommendations, in others, the agency did not.

OIG has a workplan which it releases each month which sets forth various projects, including OIG audits and evaluations that are underway or planned to be addressed during the fiscal year and beyond by OIG’s Office of Audit Services and Office of Evaluation and Inspections.

The Health Law Offices of Anthony C. Vitale is recognized as a leader in healthcare law and consultation. Our firm can assist with the creation of compliance procedures and advise practitioners who may find themselves the target of a healthcare fraud investigation. For more information, contact us at 305-358-4500 or email info@vitalehealthlaw.com