Enforcement Trends: 5 Insights from the OIG Semi-Annual Report

You can always count on OIG semiannual reports to Congress for two things: self-congratulation and insight into the enforcement priorities for the next six months. The most recent edition, published on Oct. 31, covers the period between April 1 and Sept. 30, 2016. Here are the five key takeaways for labs and pathologists.

1. Continuation of Aggressive Enforcement by Strike Force
In the past year, the Health Care Fraud Strike Force achieved its largest takedown involving $900 million in false billing, 301 individuals targeted and 350 OIG agents. Although home healthcare was the primary target, the program's current success and profitability is likely to foster new efforts targeting other providers, including labs.

2. Continued Reliance on Data Analytics
As noted in the report's discussion of the Takedown, data analytics continue to be a major investigative tool for the OIG and Strike Force. "OIG continues to expand its use of data analytics to strengthen oversight efforts." One enforcement example included a $9.3 million settlement with a Tennessee lab and a physician over alleged false claims to Medicare for drug testing referred to the lab by physicians to whom the lab donated money for purchasing EHR systems and for false claims for non-covered FISH testing.

3. Use of Data Beyond Enforcement
The OIG emphasizes "the critical role that complete, accurate, timely, and secure data must play in strengthening the performance of HHS programs" and renews its recommendation that "CMS improve Medicare and Medicaid provider data systems" including security of those systems.

4. Prioritization of Program Integrity
Program integrity "must be a top priority," says the OIG, because of the growth of HHS programs and "new paradigms focused on value, quality, and patient-centered care."

5. What the Fraud Investigators Are Looking for
The report notes that fraud investigations continue to focus on "patient harm; billing for services not rendered, medically unnecessary services, or upcoded services; 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." Lab testing is specifically identified as an area of concern for fraud schemes.

2016 Enforcement By the Numbers
The OIG report lists the following statistics on the agency's enforcement efforts in fiscal year 2016:

• Over $5.66 billion in expected recoveries;

• 844 criminal actions against individuals or entities relating to HHS programs;

• 708 civil actions, including false claims and unjust-enrichment lawsuits, CMP settlements and "administrative recoveries related to provider self-disclosure matters";

• Exclusions of 3,635 individuals and entities;

• Strike Force charges filed against 255 individuals or entities, 207 criminal actions and $321 million in investigative receivables.

Takeaway: The OIG's latest report on its oversight efforts highlights large-scale investigations and recoveries as well as areas for improvement in HHS program integrity.