BNA’s Health Care Fraud Report™ is the go-to source for health care fraud reporting, with in-depth information on government and private enforcement actions and strategies designed to...
By James Swann
Dec. 10, 2014 — Investigative and oversight efforts by the Department of Health and Human Services Office of Inspector General are expected to return $4.9 billion in improper payments to the government in fiscal year 2014, according to the OIG's semiannual report to Congress released Dec. 10, 2014.
The expected recoveries include roughly $835 million in improper payments identified through federal health-care program audits, as well as $4 billion identified through investigations, the report said.
The FY 2014 expected recoveries are about $1 billion less than the expected $5.8 billion in recoveries for FY 2013.
In addition to the recoveries, the OIG excluded 4,017 individuals and entities from participating in federal health-care programs, and reported 973 criminal actions and 533 civil actions.
The OIG's report covers the period between April 1, 2014, and Sept. 30, 2014, but also includes a summary of the OIG's accomplishments for the full fiscal year.
Over the course of FY 2014, the OIG said Medicare Fraud Strike Force efforts led to indictments being filed against 228 individuals as well as the recovery of $441 million through investigative work.
While the FY 2014 indictments dropped off from the 274 filed in FY 2013, the $441 million in Strike Force recoveries were more than $100 million than recoveries from FY 2013 ($330 million).
Successful Strike Force efforts in FY 2014 included an investigation that led to the conviction of an executive at a Florida mental health hospital who was involved in a roughly $70 million Medicare fraud scheme, as well as the conviction of a Detroit-based owner of psychotherapy services provider who was involved in a scheme to fraudulently bill Medicare for $16 million in services that were never provided.
The OIG's provider self-disclosure protocol, which was updated in April 2013, resulted in $23 million in recoveries stemming from settlements.
For example, the Ukiah Valley Medical Center in Ukiah, Calif., self-disclosed a potential violation of the anti-kickback statute through its operation of an ambulatory surgical center, the report said.
The hospital reached a $1.7 million settlement in March with the OIG to resolve all allegations.
Likewise, Amedisys, a home-health provider in West Virginia, self-disclosed that it billed Medicare for hospice care without having certification documents that met Medicare requirements. Amedisys reached a $2 million settlement with the OIG in March to resolve it's alleged violations.
The OIG self-disclosure protocol establishes a process for providers to voluntarily identify and disclose potential cases of fraud involving federal health care programs, including “guidance on how to investigate this conduct, quantify damages, and report the conduct to OIG to resolve the provider's liability under OIG's civil monetary penalty (CMP) authorities,” according to the updated self-disclosure protocol.
OIG Inspector General Daniel R. Levinson said the OIG efforts in FY 2015 will include evaluating the operations of programs created by the Affordable Care Act, such as the health insurance marketplaces.
“Additional marketplace work is examining, among other things, expenditures, Department management and administration of marketplace programs, and information technology security,” Levinson said in the report.
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The OIG Semiannual Report is at http://oig.hhs.gov/reports-and-publications/archives/semiannual/2014/sar-fall2014.pdf.
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