Recent Industry News
The Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently testified before the House Ways and Means Subcommittee on Oversight. The OIG described its initiatives in Detroit to protect Medicare and Medicaid beneficiaries, and to fight health care fraud from the field agent’s perspective. The OIG conducts investigations with other federal and state agencies, and occasionally with the private sector. Investigations are typically part of the Medicare Fraud Strike Force, which combines federal, state, and local law enforcement resources to prevent and combat health care fraud across the country.
The OIG receives complaints and investigative leads from a variety of sources including the OIG hotline, law enforcement partners, beneficiaries, providers, and informants. Traditional means of identifying fraud include conducting interviews of cooperating witnesses and surveillance. The schemes investigated range from billing for services not actually performed to organized criminal enterprises. The perpetrators of these frauds can range from highly respected physicians to individuals with no prior experience in the health care industry.
Major areas of focus include:
- Home and community-based services, including personal care services (PCS);
- Physicians writing medically unnecessary controlled substance prescriptions in exchange for cash or submission by a patient to medically unnecessary services, and subsequently billing for those services; and
- Enforcement action against and prevention of prescription drug fraud, including an opioid epidemic and cases involving Medicare Part D.
Further, the OIG summarized the following statistics pertaining to national investigative results between 2013 and 2015:
- The OIG obtained over $11 billion in investigative receivables and money ordered or agreed to be paid as a result of criminal, civil, or administrative judgments or settlements;
- Investigations led to 2,856 criminal actions and 1,447 civil actions; and
- Investigations resulted in 11,343 program exclusions.
The OIG testimony is available at: