OIG Report Highlights Aggressive Enforcement

The OIG’s latest semiannual report to Congress, as usual, touts its successes with oversight and enforcement and provides a guide to the enforcement priorities the agency will continue to pursue. Here are the main takeaways labs and pathologists should be aware of:

• Strike Force continues aggressive enforcement. This 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. Most of the providers involved home health care but this is another example and warning to the rest of the provider community that such large scale enforcement efforts are not abating and continue to be very profitable for the government.

• Data analytics are key. As the OIG highlights in discussion of the Takedown success, data analytics continue to be major investigative tool for the OIG and the Strike Force. “OIG continues to expand its use of data analytics to strengthen oversight efforts.” One enforcement example included is a $9.3 million settlement with a Tennessee lab and a physician regarding 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.

• Data isn’t just for enforcement. The OIG emphasized “the critical role that complete, accurate, timely, and secure data must play in strengthening the performance of HHS programs” and renewed its recommendation that “CMS improve Medicare and Medicaid provider data systems” including security of those systems.

• 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.”

• 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 was specifically identified in the types of fraud schemes that are a top OIG concern.

The report includes the following statistics and data regarding the agency’s efforts in fiscal year 2016:

• more than $5.66 billion expected in recoveries
• 844 criminal actions against individuals or entities relating to HHS programs
• 708 civil actions, which include 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