HHS OIG Recovers $4B in Penalties for Health Care Fraud

[oneround]

Three-quarters of investigations in 2009 involved shams; OIG reveals investigation secrets.

While many of us would prefer to quickly forget 2009—the HHS OIG had a pretty good year. The OIG walked away with $4 billion in its hands at the end of FY2009—the money coming from settlements and court-ordered fines, penalties, and restitution. Seventy-five percent of the haul involved health care fraud—according to recent testimony by an OIG official.

In March 2010, Timothy Menke, deputy inspector general for investigations at HHS OIG, testified before Congress to update the federal government on its mission against fraud, waste, and abuse. The testimony also included a statistical overview of OIG’s performance in the past year, highlights of which are:

671 criminal actions, 515 of which involved health care fraud;
over 362 civil actions, 355 of which involved health care fraud;
almost $500 million in receivables through recommended disallowances; and
over 2,500 expelled providers from federal health care programs.
He added that about 80 percent of OIG’s resources go to promoting the effectiveness of the Medicare and Medicaid’s programs and running after fraudsters. The agency has nearly 400 professional criminal investigators.

The OIG, along with CMS, and the DOJ constitute the Health Care Fraud Prevention & Enforcement Action Team (HEAT), which the Obama administration established in May 2009. The task force collaborates on spotting fraud trends and reinforcing the law accordingly.

Methods to the madness

There are five foolproof ways to carry out an investigation successfully, according to a special agent of OIG in Miami. First and foremost, agents analyze and evaluate claims data so they can identify questionable billing patterns. In an online report by Wolters Kluwer Law & Business, he described other methods that agents follow, including:

Obtaining Medicare enrollment applications, which identify the registered owners, their financial information, and the authorized medical billing representatives;
Identifying the medical biller who electronically submitted patient information to a Medicare claims contractor for processing and reimbursement (investigators interview the medical biller to determine her or his level of complicity, and identify who provided the billing information);
Identifying and obtaining bank information, including the true owner of the fraudulent provider’s bank account; and
Identifying the true owner of the clinic or durable medical equipment company, and attempting to interview him/her in furtherance of the investigation.
Find out more about how to avoid inappropriate PT and OT referrals

[DMK]

It's interesting that they report this kind of stuff but give no details.  Is it fraud if the doctor failed to sign notes one day?  Or are we talking about fake patients receiving fake services?  Is it real fraud or finding errors and charging someone with fraud?  I know it's out there but is it $4 Billion bad?  And they wonder why no one wants to be a doctor...........

[oneround]

This is just an overall finding.  There have been many, many full articles on these cases and the type of fraud involved.  Notice that the key word here is fraud and not abuse.  A MD not signing off on his report does not constitute fraud.  The over OIG recoup has been Intentional fraud.  Keep in mind that fraud does not always mean the MD.  In the last few years orginized crime and even drug dealers have turned to Medicare fraud.  Many good articles out there on this.  Does an MD forgetting to sign off on his/her dictation constitute fraud no, does an MD who dictates services not preformed or knowingly upcode to a higher level of of service constitute fraud, yes.

[PMRNC]

There is fraud and there is abuse and both are different, also in the healthcare industry IGNORANCE is never an acceptable defense to fraud or abuse. The laws are written to include that verbiage.

[Pay_My_Claims]

There is fraud and there is abuse and both are different, also in the healthcare industry IGNORANCE is never an acceptable defense to fraud or abuse. The laws are written to include that verbiage.

Dang that kills my defense right there......*boooo*