Semiannual OIG Report to Congress Outlines Challenges as Well as Successes

The Office of Inspector General's latest semiannual report to Congress provides a guide to the enforcement priorities the agency will continue to pursue, and proclaims its achievements in oversight and enforcement.

The OIG semiannual report notes that together with the Top Management and Performance Challenges report (see box), the agency has outlined areas of improvement for the Department of Health and Human Services. In particular, the agency cautioned: "Program integrity must be a top priority as HHS programs grow in size and complexity and incorporate new paradigms focused on value, quality, and patient-centered care."

Here are the main takeaways labs and pathologists should be aware of from the OIG report to Congress:

• 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 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 "go to" enforcement tool. As the OIG highlights in discussion of the Takedown success, data analytics continue to be a major investigative tool for the OIG and the Strike Force. "OIG continues to expand its use of data analytics to strengthen oversight efforts." The report notes a $9.3 million settlement with a Tennessee lab and a physician regarding alleged false claims to Medicare for drug testing and non-covered FISH testing. The drug tests were allegedly referred to the lab by physicians to whom the lab donated money for purchasing EHR systems.

• 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 is a top priority. That's because of the growth of HHS programs and "new paradigms focused on value, quality, and patient-centered care."

• Top OIG fraud concerns include labs. Fraud investigations continue to focus on medically unnecessary services and kickbacks among other issues. Lab testing was specifically identified among the types of fraud schemes that are a top OIG concern.

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.