OIG expects $2.91 billion in investigative recoveries for FY 2018, according to its Semiannual Report to Congress

Washington, DC-The Department of Health and Human Services (HHS) Office of Inspector General (OIG) expects $2.91 billion in investigative recoveries and $521 million in audit recoveries for fiscal year (FY) 2018, according to a recently released report.

The Semiannual Report to Congress summarizes OIG activities for the last half of FY 2018 (April 1, 2018-September 30, 2018), and some achievements for the full year.

"OIG continues to serve the American people by providing objective, actionable information and recommendations to improve fiscal stewardship of HHS programs, ensure program beneficiaries receive high-quality services, and hold those who harm taxpayers accountable," said Inspector General Daniel R. Levinson. "The dedication, professionalism, and expertise of OIG employees drives this high-impact work."

OIG leads the fight against fraud, waste, and abuse in HHS programs and holds wrongdoers accountable for their actions. 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.

In June, 2018, OIG and our 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.

Additionally, OIG analyzed opioid prescribing data in the Medicare Part D program and released a data brief identifying concerning patterns. The data brief noted that nearly one in three Medicare beneficiaries received an opioid prescription in 2017. Many Medicare beneficiaries received high amounts of opioids, including about 71,000 beneficiaries whose prescriptions put them at serious risk for opioid abuse. OIG also 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. OIG also found that almost 300 prescribers engaged in questionable opioid prescribing by ordering opioids for the highest number of beneficiaries at serious risk of opioid misuse or overdose. (See report at OEI-02-18-00220.)

Further, OIG published a toolkit setting out OIG's data-driven methodology for identifying beneficiaries at high risk of misuse of opioids. Public and private sector stakeholders, like insurance plans, can use this toolkit to analyze their own prescription drug claims data to identify patients at high risk of opioid misuse or overdose and target those individuals for potentially-life-saving intervention.

The April 1, 2018–September 30, 2018 Semiannual Report also highlights the following reports:

OIG released a portfolio in July 2018 that highlights key vulnerabilities in the Medicare Hospice program and makes 15 recommendations for protecting beneficiaries in hospice and improving the program. The portfolio synthesizes OIG's body of work on the Medicare hospice benefit. OIG found that hospices do not always provide needed services to beneficiaries and sometimes provide poor quality care. Inappropriate billing and fraud by hospice providers cost taxpayers hundreds of millions of dollars. In addition, OIG found that the current payment system creates incentives for hospices to minimize their services and avoid caring for beneficiaries with the greatest needs. (See portfolio at OEI-02-16-00570.)

In September 2018, OIG published a rollup report, based on reviews in five States that found troubling deficiencies in treatment planning and medication monitoring for children in foster care who were treated with psychotropic medications. OIG found that one in three children in foster care who were treated with psychotropic medication did not receive required treatment planning or medication monitoring. OIG recommended that the Administration for Children and Families develop a comprehensive strategy to improve States' compliance in this area. (See report at OEI-07-15-00380.)

In another report, OIG raised concern about program integrity in Medicaid managed care. Managed care organizations (MCOs) play an increasingly important role in fighting fraud and abuse in Medicaid, yet they made inadequate efforts to identify and address fraud and abuse. During this reporting period, OIG found that although the number of referred cases varied widely, some MCOs identified and referred few cases of suspected fraud or abuse to the State. (See report at OEI-02-15-00260.)

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. OIG found that some hospitals did not comply with Medicare coverage and documentation requirements for IRFs. On the basis of a medical review of a sample of IRF claims, OIG estimated that in 2013, Medicare paid IRFs nation-wide $5.7 billion for care to beneficiaries who did not meet requirements. (See report at A-01-15-00500.)

In a review of adult day care facilities in 3 States, OIG identified 200 instances of noncompliance with health and safety administrative requirements in facilities providing adult day care in Minnesota, 105 in Illinois, and 564 in Mississippi. Instances of noncompliance occurred for reasons such as lack of sufficient training on State requirements and budget reductions. OIG recommended that these States correct the identified instances of noncompliance and improve oversight of staffing, training, and administration. (See reports on Minnesota at A-05-17-00009, Illinois at A-05-17-00028, and Mississippi at A-04-17-00116.)