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From Health Law Daily, March 25, 2015

HHS OIG focused on fraud enforcement, encourages additional oversight

By Kayla R. Bryant, J.D.

The Deputy Inspector General for Investigations for the HHS Office of Inspector General (OIG), Gary Cantrell, testified before the U.S. House of Representatives Committee on Ways and Means about the importance of fighting Medicare fraud. Cantrell outlined the OIG’s role in protecting program integrity, which includes extensive enforcement activity. Cantrell emphasized that the OIG’s oversight efforts are directed toward preventing fraud so that enforcement efforts are unnecessary, and that the OIG prioritizes cases that involve predictable patient harm (Testimony of Deputy Inspector General Gary CantrellMarch 24, 2015).

Enforcement. The Office of Investigations acts as law enforcement for OIG, and its special agents have full law enforcement authority. This allows the OIG to execute search warrants and arrests. These efforts have resulted in generating $14.8 billion in receivables ordered to be paid back to government programs. This money was recovered through thousands of criminal and civil actions. The OIG’s investigations have also led to over 10,000 program exclusions. The OIG feels that sending program dollars to the Health Care Fraud and Abuse Control Program (HCFAC) is a good investment, as the OIG and Department of Justice (DOJ) have returned $7.70 for every dollar provided to fund HCFAC.

Data driven process. The OIG uses extensive data analytics to audit billions of records. These audits look for trends that indicate fraud schemes and any geographic regions where fraud may be rampant. Specifically, the OIG has monitored a huge jump in Medicare Part D spending for prescription drugs that is indicative of the national prescription drug abuse problem potentially damaging Medicare’s program integrity. Evaluators designed studies to identify questionable billing by pharmacies, odd patterns by prescribers, and prescriptions written by people without authority. These identifications resulted in leads that led to multiple investigations and recommendations for CMS to prevent Part D fraud.

Medicare Fraud Strike Force. Strike forces to combat Medicare fraud began in 2007. HHS and the DOJ created a joint agency initiative, the Health Care Fraud Prevention and Enforcement Action Team (HEAT) in 2009. The Medicare Fraud Strike Force is a component of HEAT and utilizes the combined resources of the OIG, the DOJ, including U.S. Attorneys’ offices and the FBI, and local law enforcement to fight Medicare fraud in certain geographic regions that have been identified as hotspots. Data analytics have allowed HEAT to investigate fraud in its early stages.

Evolution of fraud. Cantrell emphasized the need to stay vigilant, as new fraud schemes are constantly emerging. Home health fraud schemes are common and difficult to identify when a physician and fraudulent home health agency collaborate to bill for services that are not provided. A new development in this type of scheme is to bill “adult day care services” (which are not allowed or medically necessary) as home health services. The OIG has also tracked fraud schemes perpetrated by the same individuals through different geographic areas, especially when complex criminal networks are involved.

Identity theft. The OIG has seen an increase in Medicare claims submitted using stolen beneficiary identifiable information. Marketers or recruiters will ask beneficiaries for this information in exchange for kickbacks. This information has also been stolen by insiders in the profession who sell it to other parties. The OIG has successfully investigated several cases where this information was illegally obtained and used, but Cantrell noted that medical identity theft is difficult to predict and prevent.

Recommendations. The OIG offered several recommendations to improve program integrity and prevent fraud before it begins. It urges CMS to adopt a practice used by some state Medicaid programs that limits the number of providers and pharmacies that certain Part D beneficiaries can use. CMS should also require Medicare Advantage and Part D sponsors to report fraud and abuse. The OIG found that home health care compliance requirements created to reduce inappropriate reimbursements are not being met, and increased oversight is needed. Additionally, removing Social Security numbers from Medicare cards could better protect beneficiary information and reduce medical identity theft.

MainStory: TopStory OIGReports FraudNews CMSNews AuditNews BillingNews ConfidentialityNews DrugBiologicNews HomeNews IdentityTheftNews PartANews PartBNews PartCNews PartDNews PrescriptionDrugNews ProgramIntegrityNews SafetyNews

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