Everyone has someone they report to, and for the OIG, one of those bosses is the U.S. Congress. Twice a year, the OIG submits a report to “the boss”, summarizing some of their significant activities and tooting their own horn, so to speak.
OIG Reveals Impressive Return in Expected Recoveries and Receivables
In a recent report, the OIG announced a $12.70 return in expected recoveries and receivables for every $1 invested, an ROI any of us would love to have.
For the most recent six-month period, OIG also reported substantial financial and enforcement activity to Congress.
OIG report to Congress
OIG by the Numbers
Key results from the most recent six-month period reported to Congress.
and entities
completed
issued
Report Reveals Advance Insights into OIG Game Plan
The report also provides insight into areas OIG may plan to target. These four areas are especially worth watching for compliance professionals.
What the report may signal
Four Areas to Watch in the OIG Plan
Select a focus area for a quick view of the examples highlighted in the report.
1. Criminal and Civil Enforcement Highlights
OIG highlighted many cases, but a couple are especially likely to catch compliance professionals’ attention:
Wound Graft False Claims Fraud Results in Prison, Restitution and Settlement
The owners of several wound graft companies were sentenced to prison, ordered to pay restitution, and agreed to pay a settlement to resolve False Claims Act liabilities. OIG reported that these individuals ran a nationwide scheme targeting Medicare patients that resulted in orders for medically unnecessary, oversized skin grafts. They also accepted millions of dollars in illegal kickbacks and directed nurse practitioners to apply unwarranted grafts, resulting in more than $1.2 billion in fraudulent claims submitted to Federal health care programs.
Convicted Physician Excluded from Federal Health Programs for 50 Years
A rheumatologist was excluded from participating in Federal health care programs for 50 years after being convicted of health care fraud involving more than $118 million in false claims. Specifically, the OIG reported that the doctor falsely diagnosed patients with chronic illnesses to bill for tests and treatments that were medically unnecessary. These false diagnoses led patients to receive unnecessary treatments, including injections, infusions and X-rays.
2. OIG Financial Integrity Efforts Target Improper Payments
Knowing the possible OIG focus areas helps compliance professionals when they are performing risk assessments, auditing and monitoring. You can get a sense of where OIG is looking and where you might need to assess and prepare.
Relating to financial integrity, the OIG highlighted areas of their work designed to prevent and detect improper payments. Noteworthy examples included:
Autism Services
OIG determined that two states (Maine and Colorado) made improper Medicaid payments for applied behavior analysis (APA), which is a behavioral therapy often used to help individuals with autism.
Maine made an estimated $45.6 million ($28.7 million Federal share) in improper payments and an estimated $22.4 million ($14.2 million Federal share) in potentially improper payments. Colorado made an estimated $77.8 million ($42.6 million Federal share) in improper payments and an estimated $207.4 million ($112.5 million Federal share) in potentially improper payments.
Durable Medical Equipment (DME)
OIG looked at payments for a 7-year period for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) that were provided during inpatient stays. They found that $22.7 million in Medicare payments to suppliers should not have been paid.
The overpayments were a result of system edits to CMS’s claims processing system for Medicare Parts A and B that were not working properly to prevent or detect such overpayments.
Managed Care Enforcement
OIG continues to emphasize concerns with potential overpayments in Medicare Managed Care. In addition to their publishing the Industry Segment-Specific Compliance Program Guidance for Medicare Advantage, they also highlighted two large settlements.
The first was a $556 million settlement with five Kaiser Permanente affiliates to resolve False Claims Act allegations that they systematically submitted invalid diagnosis codes for Medicare Advantage enrollees to receive inflated payments.
The second settlement was with Aetna, which agreed to pay $117.7 million to resolve allegations under the False Claims Act that it submitted, or failed to retract inaccurate Medicare Advantage diagnosis codes to inflate payments from CMS. The insurer certified and maintained false and unsupported patient diagnoses, including for morbid obesity and chart review coding, resulting in overpayments.
3. Patient Safety Gets Continued Emphasis in OIG Plan
Compliance professionals know that over recent years, the OIG has emphasized patient safety in much of their guidance. In their report to Congress, OIG again highlights activities around protecting people from harm.
Examples
- A physician in Michigan who was excluded from participating in Federal health care programs for 60 years based on convictions of criminal sexual misconduct.
- Work overseeing improper use of antipsychotic medications in nursing homes.
- 64% of nursing homes received a serious deficiency within three years of graduating from the CMS Special Focus Facility program, which is supposed to address quality problems at the poorest performing nursing homes with track records of serious noncompliance.
- Nursing home owners in New Jersey were excluded from Federal health care programs for cost-cutting activity that resulted in facility residents being neglected, abused, receiving inadequate medical care and residing in unsanitary conditions.
- A nursing facility CEO was sentenced to prison for diverting funds for personal enrichment when those funds were intended for resident care. With the resulting lack of funds for care, the facility was understaffed and unsafe.
4. Integrity of Grants and Contracts Puts Millions at Risk
HHS offers a significant number of grants and enters into many contracts, and OIG is looking at compliance with requirements associated with grants and contracts.
Examples
- Compliance With Federal Contracting Requirements–Administration for Children and Families (ACF)
- Gaps in National Institutes of Health (NIH) oversight put millions in funding for “Other Transactions” at greater risk of fraud, waste or abuse.
- A cancer institute agreed to pay $15 million to settle False Claims Act allegations that it caused the submission of false claims to NIH related to scientific grants. The institute admitted that between 2014 and 2024, it used NIH funding to support cancer research publications containing misrepresented, duplicated, rotated, magnified or stretched images, often depicting different experimental conditions or timepoints across 14 journal articles tied to six NIH grants.
Compliance Leaders Can Find Clues in OIG Plan
As you assess your organization’s compliance risks, look for clues in these four areas and others included in the OIG plan submitted to Congress. With their impressive return on investment, the OIG is likely to continue to receive the resources they need to prevent, detect and enforce compliance, and their plan likely shares some of their roadmap.
CJ Wolf, MD, M.Ed. is a healthcare compliance professional with over 22 years of experience in healthcare economics, revenue cycle, coding, billing, and healthcare compliance. He has worked for Intermountain Healthcare, the University of Texas MD Anderson Cancer Center, the University of Texas System, an international medical device company and a healthcare compliance software start up. Currently, Dr. Wolf teaches and provides private healthcare compliance and coding consulting services as well as training.
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