Health Reform WK-EDGE OIG releases semiannual report to congress for fall 2019
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Tuesday, December 17, 2019

OIG releases semiannual report to congress for fall 2019

By Rebecca Mayo, J.D.

The report summarizes the programs reports and reviews OIG issued and included summaries of its investigations into fraud and abuse, criminal activity, and violations of the False Claims Act.

According to the HHS Office of Inspector General (OIG), in the six-month reporting period the OIG worked to further combat the devastating opioid epidemic and helped dismantle a massive healthcare fraud scheme involving fraudulent telemedicine companies. It also conducted a first-of-its-kind investigation of a major genetic testing fraud scheme. The OIG provided summaries of the program reports and reviews it issued related to improper payments, quality of care, program integrity, and drug pricing and reimbursement. The OIG also provided summaries of its investigations into allegations of fraud, waste and abuse in HHS programs, and investigations regarding organized criminal activity intended to steal Medicare dollars, as well as investigations into allegations of violations of the False Claims Act. (OIG Semiannual Report to Congress, November 30, 2019).

Reports and reviews. The OIG analyzed trends in deficiencies at nursing homes and reviewed the oversight of nursing homes. According to one OIG report, the number of nursing home surveys and deficiencies slightly increased each year from 2013 through 2016 and then slightly decreased in 2017. In a separate report, the OIG estimated that one in five high-risk hospital ER Medicare claims for treatment provided in 2016 were the result of potential abuse or neglect, including injury of unknown source, of beneficiaries residing in skilled nursing facilities. The OIG further found that skilled nursing facilities failed to report many incidents to the state survey agencies as required and some state survey agencies failed to report findings of substantial abuse to local law enforcement.

The OIG also looked at the trends in prescribing opioids in various states to determine whether efforts to curb the opioid epidemic were effective. Notably, the OIG found that nearly 3 in 10 Medicare Part D beneficiaries received opioids in 2018, which is a decrease from the previous two years. Additionally, the number of beneficiaries who received drugs for medication-assisted treatment for opioid use disorder steadily increased and reached almost 174,000 in 2018. The number of beneficiaries receiving prescription Part D for naloxone more than doubled from 2017 to 2018. In a separate review, the OIG noted that 36 percent of Medicare beneficiaries in five states in the Appalachian region received a prescription opioid through Medicare Part D in 2017.

Legal and investigative activities. One OIG investigation resulted in a $700 million civil false claims act settlement between the United States and Reckitt Benckiser Group PLC. The claims related to the pharmaceutical company’s marketing and promotion of the opioid addiction treatment drug Suboxone. Another investigation resulted in a $122.6 million settlement between the United States and Alexion Pharmaceuticals Inc. for allegations that the company illegally paid copayments for their own products through non-profit foundations.

During the reporting period, Medicare Fraud Strike Force efforts resulted in the filing of charges against 163 individuals or entities, 79 criminal actions, and more than $130.2 million in investigative receivables. In April 2019, the OIG and law enforcement partners announced an investigation (knowns as Operation Brace Yourself) that dismantled a healthcare fraud scheme involving over $1.2 billion in losses. This operation led to charges against 24 defendants against 17 federal districts. In that same month, the OIG and law enforcement partners led the first Appalachian Regional Opioid Strike Force Takedown. This resulted in enforcement actions involving 60 charged defendants across 11 federal districts, including 31 doctors, 7 pharmacists, 8 nurse practitioners, and 7 other licensed medical professionals for their alleged participation in the illegal prescribing and distribution of opioids and other dangerous narcotics. And in September the Strike Force dismantled a healthcare fraud scheme that resulted in charges in 5 federal districts against 35 defendants for allegations that they fraudulently billed Medicare for more than $2.1 billion in cancer genetic tests.

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