Enforcement for First Half of Fiscal 2015 to Yield $1.8 Billion in Recoveries

The U.S. Department of Health and Human Services Office of Inspector General (OIG) expects to recover more than $1.8 billion from its investigative and enforcement efforts during the first half of fiscal year 2015 (Oct. 2014 to March 2015), according to the OIG's semi-annual report to Congress.

That figure includes approximately $544.7 million attributable to audits and $1.26 billion due from investigative efforts. The OIG excluded 1,735 individuals from participating in federal health care programs and reported 422 criminal actions and 320 civil actions relating to health care compliance issues. The Health Care Fraud Prevention and Enforcement Action Team (HEAT)'s Medicare Strike Force enforcement yielded $163 million, charges against 69 individuals or entities, and 124 criminal actions. Medicare and Medicaid investigations included fraud relating to laboratory testing, according to the report, as well as prescription drugs, home health agencies, and durable medical equipment. For example, the report described a case resulting in a prison sentence and $246,536 in restitution for health care fraud involving an allergy testing laboratory that was alleged to have billed Medicare, Medicaid, TRICARE and private payers for blood sample allergy testing not actually performed. The OIG also reported another example regarding a chief financial officer of a medical center prosecuted for allegedly falsely attesting to electronic health records usage and meaningful use, to meet incentive requirements of the Electronic Health Records Incentive programs.

The OIG's efforts also uncovered inefficiencies in Medicare policies and practices that could "invite exploitation or hinder consistent payment determinations" and potentially improper payments. For example, the OIG noted hospice care to assisted living residents reached $2.1 billion in 2012 potentially indicating that hospices may be targeting beneficiaries in assisted living facilities because they yielded higher Medicare payments than other settings.

Takeaway: Fraud enforcement continues to be successful in gaining big recoveries and continues to include diagnostic testing as a productive target.