OIG and Health Care Fraud

Transcription

1 OIG and Health Care Fraud August 7, 2015 Bill Young Assistant Special Agent in Charge Office of Inspector General/ Office of Investigations U.S. Department of Health and Human Services St. Louis, Missouri OIG OVERVIEW st Statutory Office of Inspector General Created Department of Health and Human Services (HHS) Office of Investigations (OI) principal investigative arm for HHS OIG Components Office of Investigations (OI) Office of Audit Services (OAS) Office of Evaluations and Inspections (OEI) Office of Counsel to the Inspector General (OCIG) Office of Management and Policy (OMP) OIG/OI Personnel Criminal Investigators (a/k/a Special Agents) Investigations Analysts Investigations Assistants General Investigators Investigative Resource Specialist 2 1

2 INVESTIGATIVE AUTHORITY Healthcare Fraud Medicare (Part A, B, C, & D) Medicaid (Fraud Control Units) HHS Employee Misconduct Travel Voucher Fraud Theft of Government Funds Misuse of Government Owned Equipment (G-Cars, Computers, etc) Child Support Interstate, Intent, and Payment Status 3 INVESTIGATIVE AUTHORITY Grant Fraud Investigations - HHS is the largest grant making organization in the Federal Government. - FY 2013 HHS awarded over 82,000 grants totaling over billion dollars. Exclusions Responsible for insuring providers determined to be abusing the programs are prohibited from participating in HHS programs. Secretarial Protection Provide protection for the Secretary when she travels. 4 2

3 OI Regions OI is divided into 10 separate Regions Boston New York Philadelphia Atlanta Florida (Miami) Dallas Chicago Kansas City Los Angles San Francisco 8/5/2015 LIMITED OFFICIAL USE ONLY 5 OIG Investigations Kansas City Region 6 3

4 OIG Statistics Office of Inspector General Statistics OIG Action FY10 FY11 FY12 FY13 FY14 Total Criminal Actions ,079 Civil Actions ,132 Exclusions 3,340 2,662 3,131 3,214 4,017 16,364 HHS Investigative Receivables $3.2 Billion $3.6 Billion $4.3 Billion $4.0 Billion 2.9 Billion $ 18.2 Billion Non-HHS Investigative Receivables $576.9 Million $952.8 Million $1.7 Billion $1.02 Billion 1.1 Billion $5.3 Billion Total Investigative Receivables $3.8 Billion $4.6 Billion $6.0 Billion $5.0 Billion 4.1 Billion $ 23.6 Billion 7 Where Does OIG Get Referrals? INDUSTRY SENIOR MEDICARE PATROL HOTLINES LAW ENFORCEMENT PARTNERS DATA ANALYTICS 8 4

5 Kansas City Regional Office Part D physicians dispensing imported, non-fda approved drugs. Drug diversion issues mid-level providers PCS big issue in IL Hospice ongoing area State Block Grants fraudulent applications for TANF and LIHEAP benefits in Native American nations. Long-Term Care Facilities unnecessary services podiatry, optometry, physical therapy. 9 Example of Coding and Documentation Issues Dr. Iken was a podiatrist practicing in St. Louis. We received a hot line complaint from a patient of Dr. Iken s asserting Medicare was billed for services she did not receive. Based upon the hotline information OI opened a case and began interviewing patients, requesting records and reviewing billing data. The billing data revealed that Dr. Iken was performing a significant number of incisions and drainages (I&D)on almost all of his patients. Dr. Iken s records were severely lacking in substance and did not properly document an I&D. 10 5

6 11 In an effort to confirm the allegation that Iken was upcoding his services an undercover operation was commenced. As a result of the undercover operation, the Government obtained footage of the exact services being performed by Iken. The footage allowed the Government to compare Iken s services with Iken s billings. 12 6

7 13 Thank You!! Questions? 7