The United States Department of Health and Human Services Office of Inspector General (HHS OIG) recently released its Semiannual Report to Congress, covering the period from October 1, 2022, through March 31, 2023.
Recoveries and Civil Actions
During the six-month period, HHS OIG reports $892.3 million in expected investigative recoveries as a result of HHS OIG audits and investigations. HHS OIG also reiterated its focus on certain issues in health care, including the COVID-19 pandemic, nursing homes, Medicare and Medicaid integrity, and prescription drug issues.
HHS OIG reported 324 civil actions, including False Claims Act matters, civil monetary penalties, and recoveries in connection with provider self-disclosures. HHS OIG excluded a total of 1,356 individuals and entities from participation in federal health care programs during the period covered in the report.
One False Claims Act action involved DePuy Synthes, Inc., a subsidiary of Johnson and Johnson. DePuy agreed to pay $9.75 million to resolve allegations that it violated the False Claims Act by paying kickbacks to an orthopedic surgeon to induce the use of their products. DePuy admitted that from at least July 2013 through February 2018 the company – via several former sales representatives – gave the surgeon thousands of dollars in free DePuy implants and instruments that the surgeon used to perform surgeries for overseas patients who were not federal health care beneficiaries.
A nursing home action involved Tranquility Incorporated d/b/a San Miguel Villa, a 190-bed nursing home in Concord, California. The company agreed to pay $2.3 million, resolving all claims that from 2012 to 2017 San Miguel Villa submitted, or caused to be submitted, claims to the programs for payment of its services that were grossly substandard and failed to meet minimum required standards of skilled nursing care in multiple ways.
Criminal Enforcement Actions
In addition to the recovery amounts and civil actions, HHS OIG reported 345 criminal enforcement actions against individuals and/or entities for crimes against HHS programs. One such criminal action resulted in a multi-state coordinated law enforcement action to apprehend individuals who were engaged in a “brazen scheme” to sell more than 7,600 false and fraudulent nursing degree diplomas and transcripts.
Another criminal action involved a medical director of a drug and alcohol addiction treatment facility who was involved in a multiyear scheme to bill for fraudulent tests and treatments, to the tun of $746 million. The medical director is now serving a 20-year prison sentence for their involvement in the scheme.
In another scheme, a physician was sentenced to 16.5 years in prison for his role in a “shots for pills” scheme, where patients were required to receive unnecessary back injections in exchange for prescriptions of medically unnecessary opioids. These injections and opioids totaled more than $250 million in false and fraudulent claims submitted to federal health care and insurance programs.
Civil and Criminal Actions
Some actions involved both civil and criminal components, such as the case of Zaya Powell of Waterbury, CT, who was sentenced to three years of probation, 200 hours of community service, and a $5,000 fine for creating false COVID-19 vaccine records for 14 individuals.
Additional Resources Needed
Inspector General Christi Grimm also noted that the agency turns down between 300 to 400 viable criminal and civil health care fraud cases each year because of their lack of resources. She stated that additional resources would help the agency keep pace with threats to HHS programs, especially in light of the “serious fraud, waste, and abuse” the agency has seen. Each turned down case means that there are unaddressed potential fraud and missed opportunities for deterrence.