The HHS Office of Inspector General (OIG) reported expected recoveries in excess of $2.77 billion through the first half of fiscal year (FY) 2016. In the agency’s Spring 2016 Semiannual Report to Congress, the OIG explained how it works to review Medicare and Medicaid claims and prevent fraudulent billing or recover fraudulent payments. It also offered examples of its work related to oversight of the health insurance marketplaces established by the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), such as reviewing internal controls related to enrollment (OIG Report, May 31, 2016).
CMS oversight. The OIG has recently reviewed CMS’ oversight of its contractors, finding that the agency has failed to complete required contract closeouts. It has also discovered several issues with billing and payment, including overpayment issues for bone marrow and stem cell transplant procedures and inappropriate hospice billing. Reviews of state Medicaid programs revealed various issues with reimbursement for some services, federal matching, and bonus payments. These reviews resulted in various recommendations to CMS controls, plan developments, benchmarks, and plans for improved Medicaid agency coordination.
Investigations. OIG investigations of fraud, abuse, and waste range from durable medical equipment (DME) schemes, organized medical theft, illegal business relationships, off-label drug marketing, and use of grants by various other government organizations. Investigations over the last six months resulted in 384 criminal and 370 civil actions. The OIG attempts to investigate and shut down fraudulent activities through its Health Care Fraud Prevention and Enforcement Action Team (HEAT) and its health care fraud strike force teams.
Marketplaces. The OIG reviews marketplaces for payment accuracy, eligibility and enrollment controls, and security. It identified leadership issues as one of the leading causes for the issues with the launch of HealthCare.gov. The OIG praised CMS for its efforts to correct the issues and facilitate enrollment. It also reviewed the state-based marketplaces’ internal controls, finding that many had issues ensuring that consumers were properly enrolled in plans.
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