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$3.35 Billion Expected to Return to Taxpayers as a Result of OIG Work in FY 2015 Fiscal Year 2015 Report to Congress Outlines Achievements

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America's taxpayers are expected to see $3.35 billion in improperly spent Federal health care dollars returned to the Government from oversight work, including audits and investigations, conducted this year by the Office of Inspector General (OIG) of the Department of Health and Human Services (HHS), according to a recently issued report.

"During this reporting cycle, OIG participated in the largest nationwide Strike Force operation in history," said Inspector General Daniel R. Levinson. "This operation involved over $700 million in potential false billings to Medicare and Medicaid and resulted in charges against 243 defendants."

While the Semiannual Report to Congress reviews OIG activities for the last half of fiscal year (FY) 2015 (April 1, 2015 - September 30, 2015), it also summarizes the full year's achievements.

The $3.35 billion in expected recoveries for FY 2015 consist of nearly $1.13 billion in program audits and about $2.22 billion in investigative work, which includes about $286.6 million in areas such as States' shares of Medicaid restitution.

OIG also reported $20.6 billion in estimated savings resulting from legislative, regulatory, or administrative actions that were supported by report recommendations. Such savings generally reflect third-party estimates (such as those by the Congressional Budget Office) of funds made available for better use through reductions in Federal spending and/or avoidance of unnecessary expenditures.

OIG excluded 4,112 individuals and entities from participation in Federal health care programs in FY 2015. OIG also reported 925 criminal actions against individuals or entities that engaged in crimes against some of the 100 HHS programs overseen by OIG. There were 682 civil and administrative cases, including false claims and unjust-enrichment lawsuits, filed in Federal district court and civil monetary penalties administrative matters, which included both OIG-initiated actions and provider self-disclosures.

Additional highlights of OIG accomplishments in the FY 2015 Semi-annual report include:

  • Medicare Fraud Strike Force led the largest single takedown in OIG history, which resulted in charges against 243 defendants, including doctors, nurses, and other licensed medical professionals. The takedown was part of a coordinated nationwide operation across 17 districts and potentially involved over $700 million in false billings to Medicare and Medicaid.
  • In June 2015, OIG released a "Portfolio Report" summarizing nearly a decade worth of OIG investigations, audits, evaluations, and legal guidance regarding Medicare Part D. The Portfolio Report highlighted recommendations to address systemic weaknesses in the use of data to identify vulnerabilities, as well as in the oversight provided by plan sponsors, program integrity contractors, and the Centers for Medicare & Medicaid Services (CMS).
  • In July 2015, oncologist Farid Fata was sentenced to 45 years in prison and ordered to forfeit more than $17 million after he pleaded guilty to charges of health care fraud, conspiracy to pay or receive kickbacks, and money laundering. Fata owned and operated the cancer treatment clinic Michigan Hematology Oncology, P.C., which had several locations in Michigan. Fata admitted that he prescribed and administered aggressive chemotherapy, cancer treatments, intravenous iron, and other infusion therapies to 553 individual patients who did not need these therapies, in order to increase his billings to Medicare and other insurance companies.
  • In the report Medicare Part B Overpaid Millions for Selected Outpatient Drugs, OIG found that Medicare contractors in 13 jurisdictions overpaid providers $35.8 million for selected outpatient drugs from July 1, 2009, through June 30, 2012. For 88 percent of the overpayments, providers billed either incorrect units of service or, otherwise, a combination of incorrect units of service and incorrect Healthcare Common Procedure Coding System codes. The Medicare claims processing systems did not have sufficient prepayment edits in place to prevent all overpayments. CMS said that, as of May 4, 2015, Medicare contractors had recovered 63 percent of the $35.8 million in overpayments, and 10 of the 13 Medicare contractors had used the results of our audits in ongoing provider education activities.
  • The Affordable Care Act (ACA) requires States to terminate providers who had been terminated for cause in another State. But States face challenges complying with this mandate. In the report Providers Terminated from One State Medicaid Program Continued Participating in Other States, OIG found that providers terminated in one State continued to take part in other States' Medicaid programs. Specifically, about one-third of providers continued to receive payments for services provided to Medicaid beneficiaries after being terminated for cause. Continued participation of providers after their terminations for cause presents a vulnerability to Medicaid and raises concern that these providers could continue to treat Medicaid beneficiaries. This report built on previous work that found weaknesses in the CMS process for sharing termination information among the States. OIG found that not all State Medicaid agencies were reporting to a database and that not all submitted records met the definition of a "for cause termination."

With the implementation of the Affordable Care Act, OIG's work identified several issues related to the Federal and State-based Health Insurance Exchanges, also called Federally-facilitated and State-based Marketplaces. OIG's August 2015 report found that not all of the Federally-facilitated Marketplace's internal controls were effective in determining applicants' eligibility for qualified plans or premium assistance. In September 2015, OIG issued a report demonstrating similar concerns with the New York State-based Marketplace.