OIG Steps Up Enforcement Activity, but Recovery Numbers Still Lag

After two years of steady decline, U.S. Department of Health & Human Services Office of Inspector General (OIG) enforcement activity is getting back to near pre-pandemic levels. But while civil actions, criminal actions, and exclusions are up, the increased activity isn’t yet reflected in total recoveries. Those are the takeaways from the new Fall 2022 Semiannual Report to Congress (SAR) summarizing the agency’s health fraud and program integrity efforts during the second half of fiscal year (FY) 2022 covering the period from April 1, 2022, through September 30, 2022.

FY 2022 OIG Fraud Enforcement by the Numbers

After last year’s decline from $3.14 billion to $3.00 billion in FY 2021, total OIG expected healthcare fraud investigative recoveries for the entire year slipped back to $2.73 billion in FY 2022. While that number represents a five-year low, it belies the fact that enforcement actions are up across the board. After decreasing for three years in a row, total criminal actions in the second half of FY 2022 rebounded from 532 to 710, the highest since 2019 before the pandemic began.

After declining from 791 to 689 last year, civil actions in the second half of FY 2022 bounced back to 736. Eventually, this increase in civil actions, which includes false claims and unjust-enrichment lawsuits filed in federal district court, civil monetary penalty (CMP) settlements, and administrative recoveries from provider self-disclosure matters, will result in higher recovery amounts. It’s also worth noting that the OIG expects to recover another $1.199 billion from audits.

Meanwhile, total exclusions reversed last year’s significant declines, with an increase from 1,689 to 2,332, just 308 behind the pre-pandemic year of 2019. The rebound in exclusions isn’t all that surprising given that the new draconian Centers for Medicare & Medicaid Services affiliations exclusions rule is now in full force and effect. (For more on the rule, see Laboratory Compliance Advisor, October 28, 2019.)

OIG Enforcement Year-Over-Year Enforcement Action (April – September, FY 2018-2022)