OIG to Recover $4B in 2020 Resulting From Investigative Efforts

The U.S. Department of Health and Human Services Office of Inspector General recently reported that it expects to recover more than $4 billion in misspent Medicare, Medicaid and other HHS dollars as a result of its investigative efforts. While that is a lot of money, it is considerably less than the nearly $5.9 billion the watchdog agency said it recouped in the previous year.

Of the more than $4 billion in expected recoveries, the report shows that for Fiscal Year (FY) 2020, some $942 million could be returned based on program audit findings and more than $3.14 billion in expected investigative recoveries.

By comparison, in FY 2019, more than $819 million was expected to be recovered from audits and approximately $5.04 billion was expected from investigative recoveries.

In FY 2020, OIG reported 624 criminal actions against individuals or entities that engaged in crimes that affected HHS programs. That was down from 809 criminal actions brought in the previous year.

However, the number of civil actions OIG reported in FY 2020 was 791, up from 695 in FY 2019. These civil actions include false claims and unjust-enrichment lawsuits filed in federal district court, civil monetary penalty settlements, and administrative recoveries related to provider self-disclosure matters. The agency also excluded 2,148 individuals and entities from participation in federal health care programs, including Medicare and Medicaid, down from 2,640 exclusions in the previous year.

One of the greatest challenges the agency said it faced in 2020 was oversight of COVID-19 issues related to fraud and abuse. As we wrote about in June, the OIG stated it was focusing its efforts on reimbursement and the potential for fraud and abuse as it relates to the pandemic.

Very early on in the pandemic government agencies were seeing COVID-19-related schemes – from illegal kickbacks in exchange for referring Medicare beneficiaries for COVID-19 tests to the fraudulent use of Paycheck Protection Program Loans.

OIG noted it was using risk assessment and data analytics “to identify, monitor, and target potential fraud, waste, and abuse affecting HHS programs and beneficiaries and to promote the effectiveness of HHS’s COVID-19 response and recovery programs.â€

The report laid out its various accomplishments for the year. This included a number of fraud cases it handled such as:

• A skilled nursing facilities provider who entered into a $10 million settlement to resolve allegations that it violated the False Claims Act by knowingly causing certain facilities to submit false claims to Medicare for rehabilitation therapy.

• A provider agreed to pay $117 million to resolve alleged violations of the False Claims Act for billing medically unnecessary inpatient behavioral health services; failing to provide adequate and appropriate services; and paying illegal inducements to Federal health care beneficiaries.

• A pain clinic and two of their former executives agreed to pay a total of $41 million to resolve alleged violations of the False Claims Act for billing Medicare, Medicaid, TRICARE, and other Federal health care programs for medically unnecessary urine drug tests.

The OIG also laid out how it went about reducing improper payments:

• OIG found that CMS could have saved $192 million by targeting home health claims for review. 

• OIG found that inadequate edits and oversight caused Medicare to overpay more than $267 million for hospital inpatient claims with post-acute-care transfers to home health services. 

• OIG found hospitals overbilled Medicare $1 billion by incorrectly assigning severe malnutrition diagnosis codes to inpatient hospital claims.

OIG stated that telefraud and opioid schemes were the main targets of government enforcement efforts during the month of September. It pointed to a number of cases including that of an individual who was sentenced to 108 months in prison for leading a conspiracy to distribute opioids via sham medical clinics.

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.