Enforcement Trends: 5 Takeaways from OIG’s New Semiannual Report

Veteran OIG semiannual report aficionados will find little in the most recent edition to distinguish it markedly from its predecessors. But while a new administration has done little to change the fundamental tone, extent, direction or tenor of OIG federal health care fraud enforcement activities, the 2017 semiannual report is rife with insight about what happened between April and September and what is likely to happen in 2018. Here are the five key takeaways for labs and pathologists.

1. Continued Growth of the Strike Force
National Strike Force Takedowns featuring coordination among the OIG, Department of Justice and local law enforcement have become the centerpiece of federal health care fraud enforcement in recent years. This July, witnessed the biggest Takedown in history resulting in charges against over 400 defendants in 41 federal districts involving schemes worth about $1.3 billion, not to mention 112 criminal actions.

2. Growing Focus on Opioids and Narcotics
While the extent of Takedown growth is a continuation of previous trends, the new focus on opioids represents a change in direction. Notably, over 120 of the 400+ defendants booked by the Takedown were involved in illegal prescribing and distribution of opioid drugs, including 22 doctors. The OIG also issued 295 exclusion orders for opioid offenses. While not directly targeting lab testing, labs that provide urine testing to patients who are legally prescribed opioids are among the providers with a bull’s eye on their back.

3. Prioritization on Cybersecurity and EHR
Cybersecurity, information security continue to figure prominently in OIG activities, as do related issues related to electronic health records (EHR) fraud. An OIG Medicare audit unearthed $729.4 million in EHR incentive payments to providers who failed to meet “meaningful use” requirements. CMS also made $2.3 million in incentive payments for the wrong payment year to providers who switched between incentive programs.

2017 OIG Enforcement By the Numbers

The OIG report lists the following statistics on the agency’s enforcement efforts from April through September 2017:

• $4.13 billion in expected investigative recoveries;
• 881 criminal actions against individuals or entities relating to HHS programs;
• 826 civil actions; and
• 3,244 exclusions of individuals and entities.

4. Internal Overpayment Cleanups
The OIG did a lot of looking inward over the past six months, especially with regard to a continuing sore spot: recovery of Medicare overpayments. Although CMS has made marginal improvement since 2010 when it collected overpayments at a 7% clip, there is still lots of work to be done. According to the OIG, collections reached 20% in 2014, leaving $386 million uncollected.

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 types of fraud schemes of principle concern to the OIG.