OIG Unveils Fraud Risk Indicator

The Health and Human Services Office of Inspector General has launched a new initiative designed to draw attention to those healthcare providers it considers to be high risk for committing healthcare fraud after having been charged under the False Claims Act.

The OIG posted this Fraud Risk Indicator on its website after Gregory Demske, the OIG’s chief counsel announced the initiative during the American Health Lawyers Association’s Fraud and Compliance Forum late last month. Soon providers will be listed with their risk ranking.

The OIG evaluates healthcare fraud cases on a continuum with Highest Risk being those who have been excluded from participating in federal healthcare programs (i.e. Medicare and Medicaid) to Lowest Risk, being those who self-disclosed potential fraud and abuse to the OIG.

The OIG laid out the details of its fraud risk spectrum in a 2016 report.

Other levels on the fraud risk spectrum include:

  • High Risk – Those the OIG determines to pose significant risk because they have refused to enter into Corporate Integrity Agreements, despite the government’s determination that more oversight is needed.
  • Medium Risk – Those providers that have signed Corporate Integrity Agreements as part of their settlement with the OIG.
  • Lower Risk – Those providers who have cases that OIG closed without seeking exclusion or having to sign a Corporate Integrity Agreement.

Excluding providers from participating in federal healthcare programs – meaning they will not be paid for any items or services furnished, ordered or prescribed by an excluded entity – can significantly impact a provider’s bottom line. Corporate integrity agreements allow the OIG to enact penalties and/or monitor providers that continue to deliver healthcare services. By publicly listing those entities it considers to be high risk for healthcare fraud, the federal government hopes to create more transparency.

“Because OIG’s assessment of the risk posed by a FCA defendant may be relevant to various stakeholders, including patients, family members, and healthcare industry professionals, OIG makes public information about where a FCA defendant falls on the risk spectrum,” the OIG noted on the website.

Last year, the Department of Justice obtained more than $3.7 billion in settlements and judgments from civil cases involving fraud and false claims against the government. Of that, $2.4 billion involved the healthcare industry.

The Health Law Offices of Anthony C. Vitale represents those charged with healthcare fraud. If you have any questions, contact us at 305-358-4500 or send us an email to info@vitalehealthlaw.com.

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The Health Law Offices of Anthony C. Vitale