Tag Archives: Fraud and Abuse

CMS Fraud Prevention System Credited with $820 Million in Medicare Savings to Date

CMS has announced that its Fraud Prevention System identified or prevented $820 million in inappropriate Medicare payments during its first three years, including $454 million in 2014 alone. The Fraud Prevention System uses predictive analytics technologies to identify fraudulent claims before they are paid. CMS also intends to expand the Fraud Prevention System and its algorithms … Continue Reading

July Congressional Committee Hearings on Health Policy Issues

Congressional committees continue to hold hearings on various health policy topics, including the following:  A Senate Finance Committee hearing today focused on “Reviewing HealthCare.gov Controls.” The House Energy and Commerce Committee held hearings entitled “Medicare Part D: Measures Needed to Strengthen Program Integrity” and “Medicaid at 50: Strengthening and Sustaining the Program.” The Senate Special … Continue Reading

CMS Extends Medicare Prior Authorization for Power Mobility Devices Demonstration through August 2018

CMS has announced that it is extending its Medicare Prior Authorization for Power Mobility Devices (PMDs) demonstration for three years, through August 31, 2018. This demonstration was launched on September 1, 2012 in seven states that CMS describes as having “high levels of improper payments and incidents of fraud related to PMDs” – California, Illinois, Michigan, … Continue Reading

Obama Administration Announces Record Medicare Strike Force “Takedown”

On June 18, 2015, HHS Secretary Sylvia M. Burwell and Attorney General Loretta E. Lynch announced that a nationwide Medicare Fraud Strike Force sweep resulted in health fraud charges against 243 individuals involving approximately $712 million in false billings – the largest number of defendants and dollar amount in Strike Force history. Charges in the cases … Continue Reading

GAO Calls for Tighter Medicaid Fraud Controls

A recent GAO review of Medicaid claims in four selected states (Arizona, Florida, Michigan, and New Jersey) discovered that thousands of Medicaid beneficiaries and hundreds of providers were involved in potentially improper or fraudulent payments during FY 2011. Such potentially improper payments involved, among other things, beneficiaries concurrently receiving benefits paid by two or more … Continue Reading

OIG Posts Spring Semiannual Report to Congress

The OIG’s latest Semiannual Report to Congress describes significant investigative and enforcement activities relating to HHS programs and operations during the first half of FY 2015 (October 1, 2014 – March 31, 2015). The OIG reports expected recoveries of more than $1.8 billion during this period, consisting of nearly $544.7 million in audit receivables and about $1.26 … Continue Reading

OIG Releases FY 2015 Work Plan Mid-Year Update

The HHS OIG has updated its FY 2015 Work Plan to reflect new and/or completed items since release of its Work Plan in October 2014. Of note, the OIG has announced its plans to conduct several new Medicare reviews addressing: intensity-modulated radiation therapy; hospital preparedness and response to high-risk infectious diseases; access to DME in competitive … Continue Reading

CMS Issues Guidance to States on Medicaid/CHIP Provider Fingerprint-Based Criminal Background Checks

On June 1, 2015, CMS provided additional guidance to state Medicaid directors on implementation of fingerprint-based criminal background checks (FCBCs) as a component of ACA Medicare, Medicaid, and CHIP provider screening requirements. CMS stipulates that states have 60 days from the date of the letter to begin implementation of the FCBC requirement, and implementation must be … Continue Reading

Congressional Health Policy Hearings

A number of Congressional panels have held hearings this month on health policy issues, including the following: A House Ways and Means Committee hearing on Affordable Care Act implementation and the FY 2016 HHS budget request; A Senate Health, Education, Labor and Pensions (HELP) Committee hearing on “Health Information Exchange: A Path Towards Improving the … Continue Reading

OIG Partners with Industry Associations by Issuing Practical Guidance for Health Care Governing Boards on Compliance Oversight

On April 20, 2015, the Office of the Inspector General of the Department of Health and Human Services (“OIG”) released educational guidance designed to assist governing boards of health care organizations (“Boards”) in their compliance oversight functions. This guidance, entitled “Practical Guidance for Health Care Governing Boards on Compliance Oversight” (the “Guidance”), was developed in … Continue Reading

OIG Releases Medicaid Fraud Control Units Fiscal Year 2014 Annual Report

The OIG has released its Medicaid Fraud Control Units (MFCU) Fiscal Year 2014 Annual Report, which highlights statistical achievements of the 50 MFCUs nationwide, along with related OIG oversight activities. With regard to criminal cases, the report notes: MFCUs reported 1,318 criminal convictions, most frequently involving home health care aides, certified nursing aides, and other medical support; … Continue Reading

Health Care Fraud and Abuse Control (HCFAC) Program Reports $3.3 Billion in Recoveries

According to the FY 2014 HCFAC program report, more than $3.3 billion was recovered in FY 2014 as a result of the government’s health care fraud judgments and settlements, including $2.3 billion won or negotiated by the federal government in FY 2014. Since the HCFAC program began in 1997, it has returned more than $27.8 … Continue Reading

Congressional Health Policy Hearings

Congressional committees have held several hearings this week on health policy issues. On March 24, the Energy and Commerce Health Subcommittee held a hearing on the 340B drug pricing program. Also on March 24, the House Ways and Means Subcommittee on Oversight examined CMS’s use of the Fraud Prevention System (FPS) to identify and stop … Continue Reading

Ways & Means Committee Schedules March 24 Hearing on Use of Data Analysis to Stop Medicare Fraud

On March 24, the House Ways and Means Subcommittee on Oversight is holding a hearing on CMS’s use of the Fraud Prevention System (FPS) to identify and stop Medicare fraud. Government and non-governmental witnesses will discuss the progress that the FPS has made and how data analysis is being used to identify and stop Medicare fraud … Continue Reading

OIG Posts FY 2014 State Medicaid Fraud Control Unit (MFCU) Data

The HHS Office of Inspector General (OIG) has released detailed statistical data on MFCU enforcement actions, recoveries, and expenditures for fiscal year 2014. Overall, state MFCUs reported more than $2 billion in criminal and civil recoveries (settlements, judgments, or prefiling settlements) in FY 2014, more than $1.7 billion of which were civil recoveries. The states … Continue Reading

GAO Seeks Stronger CMS Measurement of State Medicaid Program Integrity System Effectiveness

Based on a review of 10 state Medicaid Management Information Systems (MMIS) used to process claims and support program integrity efforts, the GAO has concluded that the effectiveness of these systems is not known because CMS does not require states to measure results related to detecting and preventing improper payments. The GAO therefore recommends that … Continue Reading

Ways and Means Committee to Markup Medicare Fraud, Competitive Bidding, and other Medicare Policy Bills

On February 26, 2015, the House Ways and Means Committee is scheduled to vote on the following bills: H.R. 1021, “Protecting the Integrity of Medicare Act of 2015” – a sweeping bill to promote Medicare program integrity and efficiency. Among many other things, the bill would: eliminate civil money penalties for inducements to physicians to … Continue Reading

OIG Announces Plans for Health Reform Oversight Activities

On February 24, 2015, the HHS Office of Inspector General (OIG) released its “Health Reform Oversight Plan” for FY 2015, which describes the OIG’s current and planned efforts to oversee the implementation and management of HHS programs under the ACA. The plan outlines the OIG’s key tactical considerations (e.g., assessing relative risks; monitoring emerging issues … Continue Reading

CMS Needs More Time to Finalize ACA Rule on Return of Medicare Overpayments

CMS warns requirement to report/return overpayments is in effect even without regulations The Centers for Medicare & Medicaid Services (CMS) needs more time to finalize its February 16, 2012 proposed rule on reporting and returning of Medicare overpayments, according to a CMS notice to be published on February 17, 2015. The 2012 rule would provide details … Continue Reading

GAO Highlights Medicare Program Risks and Recommends Program Integrity Actions

The Government Accountability Office (GAO) has released its latest update to its “High-Risk Series” reports, which again lists Medicare as a high-risk program, in part because of the program’s substantial size and scope, and its wide-ranging effects on beneficiaries, the health care industry, and the U.S. economy. The latest report highlights five areas of particular … Continue Reading

Obama Administration Releases FY 2016 Budget Proposal with Medicare/Medicaid Provisions

On February 2, 2015, the Obama Administration released its proposed federal budget for fiscal year (FY) 2016. The budget would impact all types of health care providers, health plans, and drug manufacturers if adopted as proposed – which is unlikely given Republican control of the House and Senate. Nevertheless, Congress can be expected to consider … Continue Reading

CMS Announces New 6-Month Extension of Moratoria on Enrollment of HHAs, Ambulance Suppliers in Designated Areas

CMS is extending — for another 6 months — its current enrollment moratoria for new ground ambulance suppliers and home health agencies (HHAs) in designated metropolitan areas. The moratoria, which affect enrollment in Medicare, Medicaid, and the Children’s Health Insurance Program, apply to new ground ambulances in the Houston and Philadelphia metropolitan areas and new HHAs … Continue Reading

CMS Announces DMEPOS/Home Health/Hospice RAC, Improvements to RAC Process

CMS has announced that it has awarded the Region 5 Recovery Audit contract to Connolly, LLC (although the General Accounting Office subsequently reported that a bid protest has been filed regarding this award). The purpose of this contract will be to identify improper Medicare payments for durable medical equipment (DME), orthotics, prosthetics, and supplies and home … Continue Reading

Annual OIG Solicitation of Anti-Kickback Safe Harbor, Fraud-Alert Topic Proposals

Today the HHS Officeof Inspector General (OIG) published its annual solicitation of recommendations for new or modified safe harbor provisions under the federal anti-kickback statute, as well as potential topics for new OIG Special Fraud Alerts. Comments will be accepted until March 2, 2015.  In a separate report, the OIG discusses three safe harbor proposals received … Continue Reading
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