HHS OIG Spring Semi-Annual Report To Congress

Under federal law, the Office of Inspector General (OIG) must report semiannually to Congress and to the Department of Health and Human Services (HHS) Secretary on the activities of the office during the 6-month periods ending on March 31 and September 30.  These reports are intended to keep the Secretary and the Congress fully informed of significant findings and recommendations by the OIG.  The OIG released their 80-page report on June 1, 2015.  The OIG reported more than $1.8 billion in expected recoveries ($544.7 million in audit receivables and $1.26 billion in investigative receivables including $142 million in areas such as the States’ shares of Medicaid restitution).  The $1.8 billion expected recovery represents a one-third reduction since the 2014 Spring Semi-Annual Report estimate of over $3 billion and is almost two thirds below the $5 billion reported in 2013.

The OIG also reported 486 criminal actions against individuals and entities for crimes involving HHS programs.  This was slightly above the figure reported for the same period in the previous year.  The OIG also reported 326 civil actions, civil monetary penalties settlements, and administrative recoveries related to provider self-disclosure matters.  This figure represented an increase from the reported 266 civil actions during the same period last year.  In addition, the OIG excluded 1,735 individuals and entities from participation in Federal health care programs, which is about the same for last year.  All of these metrics continue to increase over the years.  Major cases are highlighted in the report.

The largest proportion of OIG work involves investigating matters related to the Medicare and Medicaid programs such as: patient harm; billing for medically unnecessary services, services not rendered or up-coding; illegal billing, sale, diversion and off-label marketing of prescription drugs; and solicitation and receipt of kickbacks, including illegal payments to patients for involvement in fraud schemes and illegal referral arrangements between physicians and medical companies.  The OIG also investigated cases involving organized criminal activity, medical identity theft and fraudulent medical schemes established for the sole purpose of stealing Medicare dollars. Those who participate in these schemes may face heavy fines, jail time and exclusion from participation in federal health care programs. The OIG highlighted some of the most common criminal fraud scheme case types including: (a) controlled and non-controlled prescription drugs; (b) home health agencies and personal care services; (c) ambulance transportation; (d) durable medical equipment; and (e) diagnostic radiology and laboratory testing.

The OIG reported results from the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiated by HHS and the Department of Justice to strengthen programs and invest in new resources and technologies to prevent and combat health care fraud, waste and abuse.  The Medicare Fraud Strike Force, operating in nine major cities, is a key component of HEAT that coordinates federal, state and local law enforcement entities to prosecute healthcare fraud.  During the first half of FY 2015, their efforts resulted in the filing of charges against 69 individuals or entities, 124 criminal actions, and $163 million in investigative receivables.  The Medicare Fraud Strike Force refers credible allegations of fraud to CMS so that it can suspend payments to the suspected perpetrators, thereby immediately preventing losses from claims by Strike Force targets.

It should be noted that HHS has many other programs besides those of the Centers for Medicare & Medicaid.  As such, OIG audit and evaluation activities reported on many other agencies of the Department.  The Public Health Service programs include the Center for Disease Control and Prevention, Health Resources and Services Administration, Health Education Assistance Loan Program, Indian Health Service, among others.  Social programs include the Administration for Children and Families with the Head Start Program, Adoption Assistance, Child Support Enforcement, among others.