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Information is provided in a breakdown of the annual HHS-DOJ fiscal report.

On July 27, the U.S. Department of Health and Human Services (HHS) and the U.S. Department of Justice (DOJ) issued the healthcare fraud and abuse control program annual report for the 2019 fiscal year (FY 2019). This report provides a recap of all focuses during the previous year, and potentially provides a glimpse into future audits.

In FY 2019, the DOJ:

  • Opened 1,060 new criminal healthcare fraud investigations.
  • Filed criminal charges in 485 cases involving 814 defendants.
  • Convicted 528 defendants of healthcare fraud-related crimes.
  • Opened 1,112 new civil healthcare fraud investigations, and had 1,343 civil healthcare fraud matters pending at the end of FY 2019.

FBI investigative efforts resulted in over 558 operational disruptions of criminal fraud organizations and the dismantlement of the criminal hierarchy of more than 151 healthcare fraud schemes.

In FY 2019, investigations conducted by the HHS Office of Inspector General (OIG) resulted in:

  • 747 criminal actions against individuals or entities that engaged in crimes related to Medicare and Medicaid, and
  • 684 civil actions, which include false claims and unjust-enrichment lawsuits filed in federal district court, civil monetary penalty settlements, and administrative recoveries related to provider self-disclosure matters.
  • OIG also excluded 2,640 individuals and entities from participation in Medicare, Medicaid, and other federal healthcare programs. Among these were exclusions based on criminal convictions for crimes related to Medicare and Medicaid, totaling 1,194.
  • HHS-OIG also issued numerous audits and evaluations with recommendations that, when implemented, would shore up program vulnerabilities and save Medicare and Medicaid tens of millions of dollars.

The report also addressed the monetary results, and they are spectacular! For Medicare and Medicaid, the amount totaled more than $627 million; restitution and compensatory damages totaled more than $972 million, for a combined total of more than $1.5 billion. The total healthcare recoveries amounted to more than $3.5 billion in FY 2019.

You may be wondering what specific areas were targeted. The answer includes a wide array of vendors and providers: vascular clinics, device companies, diagnostic services, durable medical equipment, electronic health records, home health providers, hospitals and health systems, laboratories, nursing homes, physical therapy, physicians and non-physician practitioners, psychiatric testing, and transportation. Investigations into these areas resulted in findings of False Claims Act violations and Anti-Kickback Act schemes.

The final thing I found interesting about the report was the OIG’s continued enhancement of technology and data analysis capabilities used to detect healthcare fraud. OIG continues to use several approaches for monitoring and analyzing healthcare payments and trends. Sophisticated data analytics and statistical modeling allow for better targeting of OIG’s resources for overseeing the Medicare and Medicaid programs. OIG has developed analytic tools to largely automate its work, increasing efficiency and reducing cost. The tools use nearly real-time data to examine Medicare data for high-risk providers, conduct peer-to-peer comparisons, calculate analytic metrics for services rendered and ordered, and perform other assessments “on demand.”

There is no doubt that the government is prepared to move forward with audits and investigations, and having cutting-edge data increases their confidence in audit findings to push for more indictments and/or settlement agreements.

As we prepare for 2021, monitoring the OIG’s annual Work Plan, as well as keeping tabs on what CMS and commercial s are auditing during the final quarter of 2020, will be important steps in projecting where the focus will be next year. There is no doubt in this compliance guy’s mind that telehealth, evaluation and management (E&M) services, E&M services with a minor procedure during the same office visit/same day with modifier 25, LSO braces (back and knee), and a whole host of other high-dollar, high-volume services will be in payers’ crosshairs.


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