The OIG's Big Three for FY 2018

The OIG's Big Three for FY 2018

The recent Semiannual Report to Congress from the Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) that summarizes the activities for the last half of the Fiscal Year (FY) had some big reveals! Including $2.91 billion in investigative recoveries and $521 million in audit recoveries expected for FY 2018.

According to the report, in FY 2018 OIG brought criminal actions against 764 individuals or organizations engaging in crimes against HHS programs and the beneficiaries they serve, and an additional 813 civil actions. OIG also excluded 2,712 individuals and entities from participation in Federal healthcare programs.

OIG's Three Key Activities in 2018

1. The largest national healthcare fraud takedown in history!

In June of 2018, OIG and their law enforcement partners arrested over 600 individuals, constituting the largest national healthcare fraud takedown in history. One hundred and sixty-two defendants, including 76 doctors, were charged for illegally prescribing and distributing opioids and other dangerous drugs. In addition, between July 2017 and June 2018, OIG issued exclusion notices to 587 individuals for their conduct related to opioid diversion and abuse.

2. Data brief alerts to 15,000 beneficiaries suspected of "Doctor Shopping."

OIG analyzed opioid prescribing data in the Medicare Part D program and released a data brief identifying concerning patterns. As part of their analysis, OIG identified about 15,000 beneficiaries who appeared to be "doctor shopping," a potentially-dangerous practice where patients obtain high amounts of opioids from multiple prescribers and/or multiple pharmacies, generally without adequate care coordination to prevent the risk of overdose and abuse.

3. $5.7 billion for care that did not meet "necessary and reasonable" requirements.

OIG released an audit that found that Medicare paid inpatient rehabilitation facilities (IRFs) $5.7 billion for care that did not meet Medicare's "necessary and reasonable" care coverage requirements. It's important to note that all services billed to Medicare must meet the criteria of "medically necessary and reasonable."

What's in store for OIG in 2019?

In 2019, we expect OIG to remain vigilant in battling the ongoing opioid epidemic. For example, as part of their work plan, OIG revealed they will review the oversight of opioid prescribing and monitoring of opioid use in several States. Specifically, OIG expects to review policies and procedures, data analytics, programs, outreach, and other efforts. To support HHS's ongoing efforts to identify and disseminate effective practices to address the opioid epidemic in the United States, the OIG will highlight these state-wide efforts. The results from these efforts are expected to be released in FY 2019.

We also expect OIG to continue looking at billing practices. For example, in the Active Work Plan, we can see that CMS and OIG have identified problems with upcoding in hospital billing: the practice of mis- or over-coding to increase payment. OIG will conduct a two-part study to assess inpatient hospital billing.

  • The first part will analyze Medicare claims data to provide landscape information about hospital billing. OIG will determine how inpatient hospital billing has changed over time and describe how inpatient billing varied among hospitals.
  • OIG will then use the results of this analysis to target certain hospitals or codes for a medical review to determine the extent to which the hospitals billed incorrect codes.The results from this audit are not expected until FY 2020. But, it is something we are going to keep on our radar because of the current emphasis on billing and coding accuracy from the government.

Healthcare Compliance Pros will continue to monitor the OIG Work Plan and provide updates to be aware of for 2019 and beyond. We will continue to review and update our opioid training to help our clients ensure they are doing their part in battling the opioid epidemic! Additionally, we will update our billing and coding resources, to keep clients prepared in the event of a billing and coding audit.