Frustrated business executive at desk

The enforcement arm of the federal health department has been busy, with more than 300 criminal enforcement actions in six months.

Of any unsavory traits one might think to accuse the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) of exhibiting, laziness is not a viable choice.

The enforcement arm of the federal health oversight apparatus this week reported 320 criminal enforcement actions and 320 civil actions in the six months from October 2021 to March 2022 – an average of three and a half total such actions per day.

It was the highlight of the OIG’s Spring 2022 Semiannual Report to Congress (SAR), which also pointed to nearly $3 billion in expected recoveries as a result of HHS-OIG audits and investigations.

“We rigorously analyze data to detect concerning trends and outliers, issue compliance guidance for the healthcare industry, and make recommendations to HHS to improve program integrity,” HHS Inspector General Christi A. Grimm said in a statement. “OIG’s deep expertise in fraud, waste, and abuse enables us to offer HHS and its operating divisions technical assistance to design safeguards that mitigate risk in new and expanded programs.”

The recent enforcement actions included moves against individuals or entities engaged in crimes that affected HHS programs. The civil actions included moves to file false claims and unjust-enrichment lawsuits in Federal district court, civil monetary penalty settlements, and administrative recoveries related to provider self-disclosure matters. The agency noted that it also excluded more than 1,000 individuals and entities from participation in federal healthcare programs during the identified time frame.

Specific efforts the OIG mentioned in a press release also included:

  • A determination that COVID-19 tests drove an increase in Medicare Part B spending on laboratory tests in 2020, while at the same time, non-COVID-19 test spending decreased significantly. Medicare Part B spent $1.5 billion on COVID-19 tests in 2020, officials noted, while spending on non-COVID-19 tests decreased by $1.2 billion. In total, laboratory spending increased by 4 percent, but the decrease in utilization of non-COVID-19 tests “raises concerns about potential impacts on beneficiary health,” the OIG said.  
  • A determination that 84 percent of Medicare beneficiaries received telehealth services from providers with whom they had an established relationship over the six-month time frame. On average, these beneficiaries tended to see their providers in person about four months prior to their first telehealth service. Beneficiaries enrolled in traditional Medicare were more likely to receive services from providers with whom they had an established relationship, compared to beneficiaries in Medicare Advantage (MA), officials noted.
  • A determination that more than half of states failed to meet performance measures for their oversight of nursing homes in three or four consecutive years during the 2015-2018 fiscal years. “State surveys of nursing homes are the primary safeguard for ensuring quality of care and resident safety,” the OIG said, noting that states’ most commonly missed performance measures related to survey timeliness. The remedy that the Centers for Medicare & Medicaid Services (CMS) consistently imposed on states for missing performance measures was requiring submission of corrective action plans, officials noted; however, 10 percent of plans were missing from CMS files and many others lacked substantive details. In three states, CMS escalated concerns about performance to senior state officials, but “rarely imposed formal sanctions and never initiated action to terminate any of its agreements with states for conducting surveys.”
  • A determination that 1,178 children were separated from a parent or legal guardian and referred to the Office of Refugee Resettlement’s (ORR’s) care between June 27, 2018 and Nov. 15, 2020. Seventy percent of separated children referred to ORR care had been separated by immigration officials because of a parent’s criminal history, officials said. Additionally, separated children spent longer in ORR’s care and were less likely than non-separated children to be released to a sponsor.
  • A determination that of the roughly 1 million Medicare beneficiaries diagnosed with opioid use disorder in 2020, less than 16 percent received medication to treat it. “Further raising concerns that beneficiaries face challenges accessing treatment, less than half of beneficiaries who received medication to treat opioid use disorder also received behavioral therapy,” the OIG said. “We also found that beneficiaries in Florida, Texas, Nevada, and Kansas were less likely to receive medication to treat their opioid use disorder than beneficiaries nationwide; that Asian/Pacific Islander, Hispanic, and Black beneficiaries were less likely to receive medication than white beneficiaries; and that older beneficiaries, and those who did not receive the Part D low-income subsidy were also less likely to receive medication to treat their opioid use disorder.”

HHS-OIG also noted that it has made 130 new audit and evaluation recommendations, which it described as “crucial to encourage positive change in HHS programs.” Meanwhile, officials said, HHS operating divisions implemented 265 prior recommendations.

To access links to the full reports associated with all of the above bulleted determinations, click here.

Programming Note: Listen to healthcare attorney Andrew Wachler report the details of this story live during Monitor Mondays, Monday, June 13, 10 Eastern.

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