Written by: Compliance blogger
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Posted 12/11/2017
Updated 10/21/2020
The exponential growth of technology and the internet, while facilitating patient care and providing uninterrupted accessibility of information, has opened doors to new risks. Perhaps the biggest risk of all is health care fraud. The Office of Inspector General (OIG) is the government “watch dog”, conducting investigative audits.
OIG: Health Care Fraud and Abuse Control Program Report
Efforts to combat fraud were consolidated and strengthened under Public Law 104-191, the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The Act established a comprehensive program to combat fraud committed against all health plans, both public and private. The legislation required the establishment of a national Health Care Fraud and Abuse Control Program (HCFAC), under the joint direction of the Attorney General and the Secretary of the Department of Health and Human Services (HHS) acting through the Department's Inspector General (HHS/OIG).
The HCFAC program is designed to coordinate Federal, State and local law enforcement activities with respect to health care fraud and abuse. The Act requires HHS and Department of Justice (DOJ) detail in an Annual Report the amounts deposited and appropriated to the Medicare Trust Fund, and the source of such deposits.
During Fiscal Year (FY) 2019, the Federal Government won or negotiated over $2.6 billion in health care fraud judgments and settlements in addition to other health care administrative impositions. As a result of these efforts, as well as those of preceding years, $3.6 billion was returned to the Federal Government or paid to private persons in FY 2019. Of this $3.6 billion, the Medicare Trust Funds received transfers of approximately $2.5 billion during this period, in addition to the $148.6 million in Federal Medicaid money that was similarly transferred separately to the Treasury due to these efforts.
During Fiscal Year (FY) 2018, the Federal Government won or negotiated over $2.3 billion in health care fraud judgments and settlements, in addition to other health care administrative impositions. As a result of these efforts, as well as those of preceding years, $2.3 billion was returned to the Federal Government or paid to private persons in FY 2018. Of this $2.3 billion, the Medicare Trust Funds received transfers of approximately $1.2 billion during this period, in addition to the $232 million in Federal Medicaid money that was similarly transferred separately to the Treasury as a result of these efforts.
During Fiscal Year (FY) 2017, the Federal Government won or negotiated over $2.4 billion in health care fraud judgments and settlements, and it attained additional administrative impositions in health care fraud cases and proceedings. As a result of these efforts, as well as those of preceding years, in FY 2017 $2.6 billion was returned to the Federal Government or paid to private persons. Of this $2.6 billion, the Medicare Trust Funds received transfers of approximately $1.4 billion during this period, and $406.7 million in Federal Medicaid money was similarly transferred separately to the Treasury as a result of these efforts.
During Fiscal Year (FY) 2016, the Federal Government won or negotiated over $2.5 billion in health care fraud judgments and settlements, and it attained additional administrative impositions in health care fraud cases and proceedings. As a result of these efforts, as well as those of preceding years, in FY 2016 over $3.3 billion was returned to the Federal Government or paid to private persons. Of this $3.3 billion, the Medicare Trust Funds received transfers of approximately $1.7 billion during this period, and $235.2 million in Federal Medicaid money was similarly transferred separately to the Treasury as a result of these efforts. Of the approximately $31.0 billion returned by the HCFAC account to the Medicare Trust Funds since the inception of the Program in 1997, over $17.9 billion has been returned from 2009 through 2016.
During Fiscal Year (FY) 2015, the Federal Government won or negotiated over $1.9 billion in health care fraud judgments and settlements, and it attained additional administrative impositions in health care fraud cases and proceedings. As a result of these efforts, as well as those of preceding years, in FY 2015, approximately $2.4 billion was returned to the Federal Government or paid to private persons. Of this $2.4 billion, the Medicare Trust Funds3 received transfers of approximately $1.6 billion during this period, and $135.9 million in Federal Medicaid money was similarly transferred separately to the Treasury as a result of these efforts. Of the approximately $29.4 billion returned by the HCFAC account to the Medicare Trust Funds since the inception of the Program in 1997, over $16.2 billion has been returned between 2009 and 2015.
Does Your Organization Monitor the OIG Work Plan?
If not, it should!
The OIG Work Plan sets forth various projects including OIG audits and evaluations that are underway or planned to be addressed during the fiscal year and beyond by OIG's Office of Audit Services and Office of Evaluation and Inspections. Projects listed in the Work Plan span the Department and include:
- Centers for Medicare & Medicaid Services (CMS);
- Public health agencies such as the Centers for Disease Control and Prevention (CDC) and National Institutes of Health (NIH); and
- Human resources agencies such as Administration for Children and Families (ACF) and the Administration on Community Living (ACL).
The OIG also plans work related to issues that cut across departmental programs, including State and local governments' use of Federal funds, as well as the functional areas of the Office of the Secretary of Health & Human Services (HHS). Some Work Plan items reflect work that is statutorily required.
The OIG carries out its mission to protect the integrity of HHS programs and the health and welfare of the people served by those programs through a nationwide network of audits, investigations, and evaluations, as well as outreach, compliance, and educational activities.
If the OIG is investigating a service that your organization provides, you should be conducting your own internal investigations of that area for risk mitigation purposes.
Active Work Plan Items reflect OIG audits, evaluations, and inspections that are underway or planned. Search the Work Plan using any words or numbers or download the Active Work Plan Items into a spreadsheet. This is the URL to the OIG’s Active Work Plan Items:
https://oig.hhs.gov/reports-and-publications/workplan/active-item-table.asp
Let’s review 1 item from the Active Work Plan “Use of Medicare Telehealth Services During the COVID-19 Pandemic”. It states
“In response to the COVID-19 pandemic, the Centers for Medicare & Medicaid Services (CMS) made a number of changes that allowed Medicare beneficiaries to access a wider range of telehealth services without having to travel to a health care facility. CMS is proposing to make some of these changes permanent. This review will be based on Medicare Parts B and C data, and will look at the use of telehealth services in Medicare during the COVID-19 pandemic. It will look at the extent to which telehealth services are being used by Medicare beneficiaries, how the use of these services compares to the use of the same services delivered in-person, and the different types of providers and beneficiaries using telehealth services.” Expected Issue Date of their report is 2021.
Consider the following questions:
- When performing routine auditing and monitoring at your organization, would your auditors know how to preserve evidence in the event they encounter potential fraud?
- Does your organization have any training for your billing staff to help them detect and appropriately report suspected fraud?
NHCAA
The National Health Care Anti-Fraud Association (NHCAA) considers health care fraud a costly plague on our health care system, which undermines our national economy and impacts every patient and taxpayer in America. The NHCAA estimates that the financial losses due to health care fraud are in the tens of billions of dollars each year. A conservative estimate is 3% of total health care expenditures, while some government and law enforcement agencies place the loss as high as 10% of our annual health outlay, which could mean more than $300 billion.
The NHCAA mission is heavily focused on this need for increased payer awareness of fraud. After all, their full mission is “to protect and serve the public interest by increasing awareness and improving the detection, investigation, civil and criminal prosecution and prevention of health care fraud and abuse.” To accomplish this, they employ a unique partnership of private sector and government agencies to investigate potential fraud.
Overall, when it comes to prevention and detection, the NHCAA believes that a successful anti-fraud program ought to include:
- Data analytics and aggregation
- Sharing anti-fraud information among payers
- Rigorous screening processes for providers entering a program or network
- Innovative investigative methodologies
- Continuous investment in an adequate and skilled anti-fraud workforce
- Education about fraud risks for consumers and providers
One of the most common fraud schemes, particularly in Medicare and Medicaid, is medical identity theft. Individuals at risk for medical identity theft include physicians and other providers. There are two common medical identity theft schemes. The first is the use of provider medical identifiers to make it seem that providers have ordered or referred patients to additional health services. The second most common scheme involves using provider medical identifiers to make it look like a physician provided and billed services.
According to the Medicare Learning Network, a few ways that providers’ medical identifiers are put at risk for these types of fraud schemes include:
- Signing referrals for patients they do not know
- Signing Certificates of Medical Necessity (CMNs) for patients they know but who do not need the service or supplies
- Signing CMNs for more than what patients actually need
- Signing blank referral forms
The Centers for Medicare and Medicaid Services (CMS) note that proactive approaches to detecting and preventing medical identity theft include:
- Managing enrollment information with payers
- Monitoring billing and compliance processes
- Engaging with patients so they are aware of the risks of medical identity theft.
Conclusion
Our modern health care system relies upon an enormous amount of data spread across the health care claim adjudication systems of numerous payers. This means that it is crucial for payers to have access to preventive and investigative information, so that they are able to successfully identify and prevent fraud.
Your organization is expected to monitor, detect and take corrective action to prevent fraud and abuse. This goes beyond routine auditing and monitoring. Do you have the skills to conduct these special audits? Click Here to learn more about Conducting Internal Forensic Audits today – safely online, on-demand with option to certify with a proctor online!
