Budget Constraints May Hurt Fight Against Health-Care Fraud

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By James Swann

Cuts in personnel and funding could mean fewer resources for federal health-care fraud investigations, a senior government official told Bloomberg BNA.

“We have no shortage of allegations of fraud, it’s only our resources that limit our ability to tackle some of these issues,” Gary Cantrell, deputy inspector general for investigations at the HHS, said in a recent interview.

The Health and Human Services Office of Inspector General hit a peak in staffing in 2011 with 644 investigators and analysts, Cantrell said. But, staffing has since dropped to around 600. Cantrell said the current level is an improvement from recent years, when the staff count was down to about 545, but said the agency is still not back to its peak.

The OIG may not get additional manpower due to a 90-day hiring freeze instituted by the Trump administration on Jan. 22.

Each OIG agent carries a case load of roughly eight to 10 investigations, so the drop in staffing means fewer health-care fraud investigations and fewer prosecutions, Cantrell said March 3.

Data analytics has been useful in identifying fraud trends, Cantrell said, but it can’t replace “boots on the ground.” Cantrell said people are the most important source for OIG cases, such as someone who has direct knowledge of a fraud scheme and can testify about it.

Opioid Abuse

Cantrell identified several health-care fraud trends, including the continued growth of prescription drug fraud, especially involving opioid pain medications. OIG investigations into prescription drug fraud and abuse have found claims for opioids prescribed inappropriately, occasionally resulting in overdoses, as well as noncontrolled substances that have been billed but never dispensed.

Home-health fraud remains a problem for federal enforcers as well, Cantrell said. While there have been some reductions in home-health payments in areas where the OIG has focused enforcement efforts, fraud concerns haven’t gone away, Cantrell said.

The OIG also prioritizes investigations into any fraud schemes that could lead to patient harm, Cantrell said.

Fraud Strike Force

The Medicare Fraud Strike Force remains one of the OIG’s major anti-fraud efforts, Cantrell said.

Created in 2007, the Strike Force operates in nine cities (Chicago, Dallas, Miami, Los Angeles, Detroit, Houston, Baton Rouge, La., Brooklyn, N.Y., and Tampa, Fla.) and involves collaboration among the HHS OIG, the Federal Bureau of Investigation and the Department of Justice on health-care fraud cases.

Cantrell said an annual Strike Force fraud recovery announcement has expanded beyond the nine cities over the last two years. This past year, for example, the announcement covered 34 judicial districts and included 24 Medicaid Fraud Control Units (MFCUs), Cantrell said.

The June 2016 announcement unveiled charges against 301 individuals for allegedly participating in various health-care fraud schemes that led to roughly $900 million in fraudulent Medicare claims,

The MFCUs have become an increasingly important partner in the fight against health-care fraud, Cantrell said, and the OIG is coordinating with them more than in the past.

Public-Private Partnership

Cantrell also discussed the Healthcare Fraud Prevention Partnership (HFPP), which was launched in July 2012. The HFPP includes representatives from the private and public sectors and fosters information sharing on health-care fraud.

Cantrell said the HFPP ensures that many of the players from the private sector and state and federal agencies are in the same room, sharing information.

Information on fraud schemes is submitted to a trusted third party and stored in a centralized repository, ensuring that it can’t be used to identify the company that submitted it, Cantrell said.

To contact the reporter on this story: James Swann in Washington at jswann1@bna.com

To contact the editor responsible for this story: Brian Broderick at bbroderick@bna.com

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