Enforcement Trends

COVID-19 Distractions Cause 2020 OIG Health Care Fraud Recoveries to Dip to 5-Year Low

Not surprisingly, the COVID-19 pandemic is hampering federal fraud fighting. The recoveries numbers bear this out. Here are the key findings from the OIG’s new Semi-Annual Report to Congress summarizing enforcement activities for FY 2020.

2020 OIG Fraud Enforcement by the Numbers

First, some context: After two decades of steady growth, OIG fraud recoveries have been trending downward in recent years. It began in FY 2018, when the recovery figures actually declined for the first time in years. Although recoveries rebounded in FY 2019, the distracting effect of the pandemic has caused the metrics to take another downward turn in FY 2020.

After the decline from $4.13 billion to $3.43 billion between FY’s 2017 and 2018, total OIG health care fraud investigative recoveries topped $5 billion in FY 2019, only to turn downward again in 2020 with expected recoveries expected to a total $3.14 billion. The agency also expects to recover another $942.06 million from audits. Additionally, total criminal actions also decreased from 804 to 624, which is lower than even the FY 2018 numbers.

Meanwhile, another metric that began to decline in FY 2018 fell again this year, namely exclusions, which dropped from 2,640 to 2,148. However, civil actions, increased from 695 in FY 2019 to 791 in FY 2020; still, that number is below the 813 civil actions reported in FY 2018. What makes the low FY 2020 number surprising is that it is the first full year total reported since CMS’ draconian affiliations exclusion rule took effect See, “The New CMS Medicare Exclusion Rules & How to Comply with It,” National Intelligence Report (NIR), Oct. 28, 2019.

 OIG Enforcement Year Over Year Enforcement Action

Metric 2020 2019 2018
Expected investigative recoveries $3.14 billion $5.04 billion $3.43 billion
Criminal actions 624 809 764
Civil actions 791 695 813
Exclusions of individuals and entities 2,148 2,640 2,712

 

Labs in the OIG’s Crosshairs

As usual, the new OIG Report cites significant recoveries for the year in cases involving labs, including:

  • $41 million against Florida pain clinic: A Tampa pain clinic and two former executives shelled out $41 million to resolve allegations of falsely billing Medicare, Medicaid, TRICARE and other federal health care programs for medically unnecessary urine drug tests (UDTs). According to the government, the lab had a practice of automatically ordering both presumptive and definitive UDTs for all patients at every visit, without having a physician make an individualized determination that either test was medically necessary for the patient.
  • Pennsylvania drug and alcohol rehab owner jailed, fined $3.2 million: The other case the OIG cites involves the co-founder of a rehabilitation organization sentenced to 37 months in prison and ordered to pay $3.07 million in restitution, $110K in forfeitures and a $15,000 fine for his role in several fraud conspiracies, including an elaborate kickback scheme involving thousands of medically unnecessary UDTs referred to Florida-based reference labs.

Takeaway

Even though recovery figures have been trending down over the past three years, the $3.14 billion total for 2020 is shockingly low. What’s going on here? Part of the answer is the pandemic. In its Dec. 2 press release, the OIG acknowledged that the COVID-19 pandemic has been its primary focus this year to the detriment of standard enforcement efforts. “Oversight of COVID-19-related issues commanded much of OIG’s attention and remains a primary focus,” noted Christi A. Grimm, OIG’s Principal Deputy Inspector General in the press release. While COVID-19 has spun out its own brand of fraud—witness the Operation Rubber Stamp takedown targeting telemedicine abuses—the year 2020 is a very atypical one for OIG enforcement activity.

 

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