The Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently released its second Semiannual Report (Report) to Congress for 2018. The report highlights the OIG’s key accomplishments in its top areas of concern and summarizes reports, congressional hearings, legal and investigative activities, and related reviews and investigations that it released or conducted between April 1, 2018 to September 30, 2018.
The Report includes the following key enforcement statistics for Fiscal Year 2018:
- Expected audit recoveries of $521 million;
- Expected investigative recoveries of $2.91 billion;
- Criminal actions against 764 individuals or entities that engaged in crimes against HHS programs;
- Exclusion of 2,712 individuals and entities from federal health care programs; and
- Civil actions against 813 individuals or entities.
The OIG Report Highlights include:
Significant Enforcement Actions
During the reporting period, in conjunction with other federal and state agencies, the OIG participated in a health care fraud takedown that involved more than 600 defendants across 58 federal districts and fraud schemes totaling $2 billion. The OIG also participated in an action against a Florida pharmacy owner who was sentenced to 15 years in prison and ordered to pay $54.5 million for a prescription drug fraud scheme that involved kickbacks, bribes, and false claims sent to private insurance, Medicare and Tricare. Another significant enforcement action involved two co-conspirators who paid cash kickbacks and bribes to induce individuals to seek treatment at a clinic and submitted false claims based on those visits.
Preventing and Treating Opioid Misuse
- Addressing the opioid epidemic is a top priority for the OIG. The OIG investigated fraud and opioid diversion cases and used data analytics to review suspected improper prescribing and other related issues. During the semiannual period, the OIG has worked on addressing opioid addiction by: testifying before Congress on two occasions; releasing a data analysis toolkit to assist both the private and public sector in combating the crisis; engaging in the largest ever national health care fraud takedown of providers participating in opioid related fraud; and reporting on the effect of the opioid epidemic and opioid prescribing practices on Medicare Part D and its beneficiaries. The OIG also conducted its first state specific Medicaid review targeted toward the opioid epidemic. It found that some Ohio Medicaid beneficiaries were at serious risk of opioid misuse or overdoes and that some 50 prescribers were more likely to prescribe opioids than their peers.
Protecting the Health and Safety of Children in HHS Programs
- The OIG has found that some states and providers have failed to meet the health and safety requirements necessary to care for the children in HHS custody. HHS is responsible for providing critical health and human services to children in its care, including children in the Unaccompanied Alien Children (UAC) program, foster care, and the Child Care and Development Fund (CCDF). The OIG has taken several actions during this reporting period to combat health and safety issues affecting this population. The OIG conducted site visits of 45 facilities to identify vulnerabilities in the Office of Refugee Resettlement (ORR) facilities. The OIG will be releasing a report with the visit results for the next reporting period. The OIG also found, reported, and made recommendations for specific ORR grantees that failed to meet health and safety requirements.
The OIG conducted reviews of five different states’ foster care facilities during the reporting period. The foster care facilities failed to fully comply with state requirements for treatment planning and medication monitoring for children receiving psychotropic drugs while in foster care. The OIG recommended that the Administration for Children and Family Services develop a comprehensive plan to increase state compliance with these requirements. The OIG also found that some state CCDFs failed to ensure the health and safety of children in their care, including failing to comply with background check requirements for employees.
Ensuring Quality and Integrity in Medicare
- During the reporting period, the OIG focused on improving the quality of care in hospice settings and protecting hospice benefits from fraud, waste, and abuse. The OIG and Caris Healthcare, LLC, a large hospice chain, entered into a settlement agreement resolving allegations that Caris submitted false claims and retained payments from Medicare for care provided to ineligible individuals. The OIG addressed quality of care issues by releasing a portfolio of highlights and 15 recommendations for improving hospice care for Medicare beneficiaries.
Improving Financial Management and Reducing Improper Payments in Medicare
- HHS must reduce improper payments to ensure continued access to care for Medicare beneficiaries. The OIG has pursued this goal during the reporting period by identifying waste by inpatient rehabilitation facilities (IRFs) that provided $5.7 billion in care but did not meet Medicare’s necessary and reasonable coverage requirements. The OIG also identified $631 million in overpayments related to replacement positive airway pressure device supplies that did not comply with Medicare requirements.
Protecting Medicaid Program Integrity:
- The OIG and states continue to focus on protecting Medicaid integrity by combatting fraud, waste, and abuse. During the reporting period, the OIG found that Managed Care Organizations (MCOs) identified few cases of fraud and abuse and failed to refer the incidents to the state when they were identified. Additionally, the OIG has found that California’s Medicaid agency failed to properly comply with federal and state Medicaid requirements for specialty mental health services. The OIG recommends that CMS and states work with state Medicaid Fraud Control Units (MFCUs) to combat Medicaid fraud and encourage MCOs to follow proper reporting duties.
Protecting Health and Safety in Adult Day Care Facilities
- The OIG has found that many adult day care facilities fail to meet certain requirements to ensure the health and safety of individuals in the facilities’ care. The OIG has worked to address this issue through both state level reviews and enforcement actions. During the reporting period, the OIG reviewed adult day care facilities in four states and found that many of them failed to meet state requirements, often sighting the lack of sufficient training and budgets. The OIG recommended that states correct instances of patient harm and improve oversight of staffing, training, and administration in adult day care facilities. The OIG also pursued enforcement actions against providers who failed to meet patient safety and access requirements that led to patient harm.
Ensuring Quality and Integrity in Programs Serving American Indian/Alaska Native (AI/AN) Populations
- The OIG continued its oversight to ensure effective grant management and quality and safety of services for AI/AN populations. The OIG supported these oversight efforts in May 2018 by hosting compliance and quality training for over 200 individuals from IHS facilities, Tribes, Tribal organizations and other stakeholders. Additionally, the OIG pursued oversight through audits of tribal grantees and health care providers. Among the audits that the OIG conducted, it found that some facilities and tribes did not properly administer Low-Income Home Energy Assistance Program (LIHEAP) grant funds and failed to meet health and safety requirements.
The report also provides the OIG’s semi-annual findings regarding questioned costs and funds, savings decisions supported by OIG recommendations, peer-review results, summary of sanction authorities, reporting requirements under the Inspector General Act of 1978, reporting requirements under the Inspector General Empowerment Act of 2016, and review of the Anti-Kickback Statute Safe Harbors.
The OIG’s Fall 2018 Semiannual Report to Congress is available at: https://oig.hhs.gov/reports-and-publications/archives/semiannual/2018/2018-fall-sar.pdf