By Rebecca Mayo, J.D.
For the semiannual reporting period of April 1, 2018 through September 30, 2018 the Office of Inspector General (OIG) used 80 audits and 32 evaluations, which resulted in 320 new recommendations issued to HHS operating divisions. Additionally, during fiscal year (FY) 2018, OIG reported expected investigative recoveries of $2.91 billion, criminal action against 764 individuals or entities that engaged in crimes against HHS programs, exclusion of 2,712 individuals and entities, and civil actions against 813 individuals or entities (OIG Semiannual Report to Congress, November 30, 2018).
Fraud and spending. The OIG partners with Department of Justice, State Medicaid Fraud Control Units, and other Federal, State, and local law enforcement agencies to combat health care fraud. In June 2018, the OIG, with the help of State and Federal law enforcement partners, participated in a nation-wide health care fraud takedown that resulted in more than 600 defendants in 58 Federal districts being charged with participating in health care-related fraud schemes totaling $2 billion.
While projections show that Medicare spending will continue to grow, the OIG continues to work to identify improper payments and areas where spending may be reduced. The OIG reviewed sample claims from inpatient rehabilitation facilities and found that, in 2013, $5.7 billion in payments were made for care to beneficiaries that did not meet requirements. Additionally, $631.3 million in overpayments were made to durable medical equipment suppliers for replacement positive airway pressure device supplies that did not comply with Medicare requirements.
The OIG reviewed California’s Medicaid spending for specialty mental health services and found that California claimed at least $180.6 million in unallowable federal reimbursement for speciality mental health services that did not comply with federal and state requirements. In a separate review of managed care organizations (MCOs), the OIG found that it is difficult to identify fraud and abuse in Medicaid spending and some MCOs identified and referred few cases of suspected fraud or abuse to the state.
Opioid misuse. Addressing the opioid abuse epidemic is a top priority for the OIG and OIG officials testified in front of the Senate Committee on Finance, Health Care Subcommittee and in front of the Senate Special Committee on Aging to discuss OIG’s work to curb the opioid epidemic. The OIG also participated in the largest ever national health care fraud takedown of providers engaged in opioid-related fraud, which resulted in over 600 individuals charged and 163 defendants, including 76 doctors, charged with their roles in prescribing and distributing opioids and other dangerous narcotics.
The OIG also analyzed Medicare Part D data to identify 15,000 beneficiaries who appeared to be "doctor shopping" and 300 prescribers engaged in questionable opioid prescribing. Additionally, the OIG completed the first state-specific Medicaid review, which found more than 700 beneficiaries in Ohio who are at serious risk of prescription opioid misuse or overdose and 50 prescribers who stood out by ordering opioids for more of these beneficiaries than other prescribers.
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