ENFORCEMENT

Brief Your CEO: 5 Takeaways from OIG’s New Semiannual Report

Like many lab managers, you may provide a year-end compliance briefing to your executive team. If so, you will want to cover the new OIG Semiannual Report to Congress in which the agency explains what it thinks it accomplished in the past six months and what it hopes to do going forward. Here are the five key points about the most recent Report to touch on during your briefing.

1. Continued Growth of the Strike Force
By now, you should have made your executives aware of the fact that the National Strike Force Takedowns featuring coordination among the OIG, Department of Justice and local law enforcement have become the centerpiece of federal health care fraud enforcement. The new OIG Report makes it clear that this trend is still going strong. This July, witnessed the biggest Takedown in history resulting in charges against over 400 defendants in 41 federal districts involving schemes worth about $1.3 billion, not to mention 112 criminal actions.

2. Growing Focus on Opioids and Narcotics
While the extent of Takedown growth is a continuation of previous trends, the new focus on opioids represents a change in direction that your executives need to be aware of. Notably, over 120 of the 400+ defendants booked by the Takedown were involved in illegal prescribing and distribution of opioid drugs, including 22 doctors. The OIG also issued 295 exclusion orders for opioid offenses. While not directly targeting lab testing, labs that provide urine testing to patients who are legally prescribed opioids are among the providers with a bullseye on their back.

3. Prioritization on Cybersecurity and EHR
Let the executives know that cybersecurity continues to figure prominently in OIG activities, as do related issues related to electronic health records (EHR) fraud. An OIG Medicare audit unearthed $729.4 million in EHR incentive payments to providers who failed to meet "meaningful use" requirements. CMS also made $2.3 million in incentive payments for the wrong payment year to providers who switched between incentive programs.

4. Internal Overpayment Cleanups
You may want to mention that the OIG did a lot of looking inward over the past six months, especially with regard to a continuing sore spot: recovery of Medicare overpayments. Although CMS has made marginal improvement since 2010 when it collected overpayments at a 7% clip, there is still plenty of work to be done. According to the OIG, collections reached 20% in 2014, leaving $386 million uncollected.

5. What the Fraud Investigators Are Looking for
The report notes that fraud investigations continue to focus on "patient harm; billing for services not rendered, medically unnecessary services, or upcoded services; illegal billing, sale, diversion, and off-label marketing of prescription drugs; and solicitation and receipt of kickbacks, including illegal payments to patients for involvement in fraud schemes and illegal referral arrangements between physicians and medical companies." Lab testing is specifically identified as types of fraud schemes of principle concern to the OIG.

Labs Figure Prominently in OIG’s Newest Top 10 Challenges List

Although the OIG has its flaws, lack of transparency is not among them. Exhibit A: the agency’s ongoing list of top 10 management and performance challenges facing the Department of Health and Human Services in the coming year. As it usually does, maintaining program integrity tops the newest list. And while not expressly spelled out, we all know that "program integrity" is code for billing and payment of lab and diagnostic services, among other things. Here’s the entire Top 10. While most are re-runs, there are a few new items (denoted by the asterisk):

  1. Ensure Medicare Program Integrity
  1. Ensure Medicaid Program Integrity
  1. Curb the Opioid Epidemic*
  1. Improve Care for Vulnerable Populations
  1. Ensure Integrity in Managed Care and Other Programs Delivered via Private Insurers
  1. Improve Financial and Administrative Management and Reduce Improper Payments
  1. Protect Integrity of Public HHS Grants
  1. Ensure Safety of Food, Drugs and Medical Devices
  1. Ensure Program Integrity and Quality in American Indian and Alaska Native Populations Programs*
  1. Protect HHS Data, Systems and Beneficiaries from Cyber Threats
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