ENFORCEMENT

Enforcement Trends: Increase in OIG Fraud Recoveries Belies Continued Decline in Enforcement Actions

OIG fraud recovery has been a solid growth business for nearly two decades. So, when the agency announced a decline in FY 2018 recovery figures, it was more than a bit surprising. But things got back to normal this year, as far as recoveries go. Even so, exclusions and especially civil actions continue to fall. Here are the key findings from the OIG’s new Semiannual Report to Congress summarizing enforcement activities for FY 2019.

2019 OIG Fraud Enforcement by the Numbers

After last year’s decline from $4.13 billion to $3.43 billion, total OIG health care fraud investigative recoveries topped $5 billion in FY 2019. The agency also expects to recover another $819 million from audits. While total criminal actions also increased (from 764 to 809), they didn’t surpass FY 2017 levels the way total recoveries did.

Meanwhile, two other metrics that declined in FY 2018 continued to fall this year, with exclusions dropping from 2,712 to 2,640 and civil actions dropping even more precipitously from 813 to 695. However, look for exclusions to bounce back now that CMS’ affiliations exclusion rule is in effect.

OIG Enforcement Year Over Year Enforcement Action

Metric 2019 2018 2017
Expected investigative recoveries $5.04 billion $3.43 billion $4.13 billion
Criminal actions 809 764 881
Civil actions 695 813 826
Exclusions of individuals and entities 2,640 2,712 3,244

 

Labs in the OIG’s Crosshairs

The Report also lists enforcement actions involving labs among its top accomplishments for the year, most notably OIG’s involvement in Operation Double Helix, the first-of-its-kind multidistrict federal investigation targeting a $2.1 billion cancer genetic testing (CGx) fraud scheme. In September 2019, OIG and Federal and State law enforcers announced the laying of criminal charges against 35 defendants, including nine doctors and individuals associated with telemedicine companies and cancer genetic testing labs, who took part in a massive scam involving payment of kickbacks for referrals of medically unnecessary CGx tests.

 

Top 12 HHS Management & Performance Challenges

  1. Curb Opioid Epidemic
  2. Ensure Medicare Program Integrity
  3. Ensure Medicaid Program Integrity
  4. Ensure Integrity in Managed Care and Other Programs Delivered via Private Insurers
  5. Protect Health and Safety of Vulnerable Populations
  6. Improve Financial and Administrative Management and Reduce Improper Payments
  7. Protect Integrity of Public HHS Grants
  8. Ensure Safety of Food, Drugs and Medical Devices
  9. Ensure Program Integrity and Quality in American Indian and Alaska Native Populations Programs
  10. Protect HHS Data, Systems and Beneficiaries from Cyber Threats
  11. Ensure HHS Prescription Drug Programs Work as Intended
  12. Ensure Effective Preparation and Response to Public Health Emergencies
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