The Department of Health and Human Services (“HHS”) Office of Inspector General (“OIG”) recently published its Semiannual Report to Congress. The Report covers the period of October 1, 2019 through March 31, 2020 and describes “OIG’s work to detect and prevent fraud, waste and abuse and to promote the economy, efficiency and effectiveness of HHS programs and operations” for that period.
During the reporting period, OIG prioritized its efforts on responding the pandemic, combating opioid-related fraud, home fraud schemes, and interagency communications related to various policies, and other areas, as follows.
Preparing for and Responding to the COVID-19 Pandemic and Other Public Health Emergencies: In response to the crisis, OIG, deployed law enforcement personnel to provide assistance to local, state, tribal and federal organizations, launched a series of oversight and enforcement actions for pandemic-related fraud, and initiated an assessment of the provision of COVID-19 test kits and oversight of laboratory testing.
Protecting Unaccompanied Children in the Department’s Care: OIG assessed interagency communication and internal management decisions and determined that poor communication and decision-making left HHS unprepared to protect children’s interests that developed in response to the Administration’s zero-tolerance policy.
Preventing and Treating Opioid Misuse: OIG used a multidisciplinary approach to detect fraud and abuse, and brought enforcement actions against a number of parties, including a doctor for allegedly operating a pill mill in Virginia, the state of New York for claiming Medicaid funds for opioid treatment programs that did not meet the necessary requirements, and a several co-owners and directors of a group of substance abuse treatment centers.
Fighting Fraud to Protect the Medicare and Medicaid Programs: OIG worked to reduce improper payments, reached a $11.85 million settlement agreement with a pharmaceutical company for a False Claims Act violation, and recommended various fraud prevention tools to the Centers for Medicare and Medicaid Services (“CMS”).
Ensuring Medicaid Program Integrity: Here, OIG provided testimony at a congressional hearing about Medicaid beneficiary eligibility, and determined that states should take additional steps to prevent terminated providers from serving Medicaid beneficiaries.
Ensuring Appropriate Use of HHS Funds: OIG chart reviews raised concerns about the completeness of payment data submitted to CMS, the validity of diagnoses and quality of care to Medicare Advantage beneficiaries. OIG also found excessive outlier payments were made to dozens of hospitals, the Medicare improperly paid acute-care hospitals $54 million for inpatient claims, and other instances of Medicare improper payments.
Protecting Beneficiaries from Abuse, Neglect and Unsafe Conditions: Here, OIG was involved in a couple issues relating to the Indian Health Services (“IHS”), including the conviction of an IHS pediatrician for multiple instances of child abuse. OIG also determined that IHS needs to fully integrate patient protection policies into practice and organizational culture. In other matters, OIG found that Pennsylvania did not adequately monitor and report incidents relating to Medicaid beneficiaries with developmental disabilities that reside in community-based settings.
Safeguarding the Security and Integrity of Medical Research: Following $5 million in congressional appropriations, OIG conducted an oversight review of the National Institutes of Health (“NIH”) cybersecurity protections, and determined that NIH has IT control weaknesses in its electronic health record, and provided recommendations to improve its security environment.
Promoting Information Sharing in the Drug Supply Chain: Here, OIG provided recommendations to the US Food and Drug Administration (“FDA”) to continue establishing a system to trace drug product ownership through the supply chain to ensure the security of the drug supply.
The Report indicates that these activities have resulted in $605.2 Million in expected audit recoveries, $288.4 Million in questioned costs, and $911.3 Million in potential savings during the reporting period. In addition, the OIG investigative work led to $1.51 Billion in expected investigative recoveries, 443 criminal actions, 903 exclusions from healthcare programs, and 370 civil actions. Finally, the OIG reported 273 new audit and evaluation recommendations, and 130 recommendations implemented by HHS Operating Divisions.
At noted above, the OIG directs its efforts at the most significant and high-risk healthcare issues. Thus, healthcare providers and entities should review their practices, particularly with these focus areas, to ensure compliance with all relevant HHS, FDA and CMS regulations.