Office of Inspector General Reports $5 Billion Return as Result of Their Efforts

The HHS OIG is required to issue semiannual reports to Congress regarding the results of their efforts. On December 10, the OIG released their report for the second half of (FY) 2014 which included a summary of accomplishments for the entire year. The report contains a lengthy list of achievements by the OIG.

One of the major accomplishments claimed was a recoupment by the government of $4.9 billion in improperly spent federal health care dollars obtained as result of the OIG’s oversight and investigation efforts conducted during the year. This was broken down into $834.7 million in program audits and about $4.1 billion in investigative work that included $1.1 billion in State shares of Medicaid restitution. The OIG also reported $15.7 billion in estimated savings resulting from legislative, regulatory, and administrative actions that were supported by report recommendations. Some other statistical accomplishments noted included a number of enforcement actions:

• 4,017 individuals and entities were excluded from Federal health care programs;
• 971 criminal actions against individuals or entities that engaged in crimes against HHS programs;
• 533 civil and administrative cases, including false claims and unjust-enrichment lawsuits filed in Federal district court and civil monetary penalties administrative matters, which included both OIG-initiated actions and provider self-disclosures; and
• DOJ Strike Force efforts resulting in the filing of charges against 228 individuals or entities, 232 criminal actions, and $441 million in investigative receivables.

Other highlights from the report included the following:

• The OIG conducted congressionally mandated reviews of the implementation of the Affordable Care Act that include the Health Insurance Exchanges (Marketplaces) and found that not all internal controls implemented by the Federal, California, and Connecticut Marketplaces were effective in ensuring that individuals were enrolled in qualified health plans according to Federal requirements.

• The Marketplaces were unable to resolve, from October through December 2013, 2.6 million of 2.9 million inconsistencies, most commonly in regards to citizenship and income issues.

• Medicare inappropriately paid $6.7 billion for claims for evaluation and management (E/M) services in 2010 that were incorrectly coded and/or lacking documentation, representing 21 percent of Medicare payments for E/M services that year. Furthermore, E/M services are 50 percent more likely to be paid for in error than other Part B services.

• Medicare beneficiaries could save $12 billion during calendar years 2012 through 2017 if CMS reduces hospital outpatient department payment rates for ambulatory surgical center (ASC) approved procedures to the same level as ASC payment rates. When outpatient surgical procedures that do not pose significant risk to patients are performed in an ASC instead of an outpatient department, the payment rates are generally lower.