The OIG By Charles Hackney Assistant Special Agent in Charge What is the OIG Office of Inspector General's (OIG) mission is to protect the integrity of Department of Health & Human Services (HHS) programs as well as the health and welfare of program beneficiaries. 1
Components There are 6 components who carry out this mission. Immediate office (IO) Office of Policy and Management (OMP) Office of Audit Services (OAS) Office of Evaluation and Inspections (OEI) Office of Counsel to the Inspector General (OCIG) Office of Investigations (OI) IO IO is responsible for generally supervising and coordinating the activities of OIG's component offices; setting direction, in collaboration with the components, for OIG's priorities. 2
Daniel R Levinson, Inspector General U.S. Department of Health and Human Services OMP OMP provides management guidance and resources to support the OIG. Administration Office 3
OAS The Office of Audit Services (OAS) examines the performance of HHS programs and/or HHS grantees and contractors in implementing their responsibilities and provides independent assessments of HHS programs and operations. Review of Place of Service Coding for Physician Services Report A-05-04-00025 The objective of the audit was to determine the extent of Medicare Part B overpayments made to physicians by Wisconsin Physicians Service Insurance Corporation (WPS) for billings with an incorrect place of service code. Findings Medicare overpaid physicians due to incorrect place of service coding. 4
OEI Mission is to protect the integrity of HHS programs, as well as the health and welfare of beneficiaries, by conducting evaluations that provide timely, useful, and reliable information and recommendations to decision makers and the public. Correct Coding Initiative (CCI) SEPTEMBER 2003 OEI-03-02-00770 In January 1996, CMS implemented the National Correct Coding Initiative (CCI). This initiative was developed to promote correct coding of health care services by providers and to prevent Medicare payment for improperly coded services. CCI consists of automated edits provided to the carriers to evaluate claim submissions when a provider bills more than one service for the same beneficiary on the same date of service. 5
OCIG The Office of Counsel to the Inspector General (OCIG) promotes the overall mission of the Office of Inspector General through timely, accurate and persuasive legal advocacy and counsel. OI OI conducts criminal, civil, and administrative investigations of fraud and misconduct related to HHS programs, operations and employees. 6
FY 2015 Statistics Criminal Actions 925 Civil Actions 682 Exclusions 4,112 Total Investigative receivables - $2.2 billion $8 to 1 Resources 7
Sample hotline Complaint JOHN DOE STATES MEDICAL CENTER IS MAKING THE LABORATORY STAFF COME UP WITH ICD-10 CODES. JOHN DOE STATES MEDICAL CENTER ARE MAKING THE LABORATORY STAFF UP CODE BECAUSE THE DOCTORS WON T DO IT. JOHN DOE STATES LABORATORY STAFF MEMBERS ARE FORCED TO SELECT A CODE THAT DOES NOT APPLY TO THE PATIENT. JOHN DOE STATES ONLY A PHYSICIAN OR A PHYSICIAN ASSISTANT CAN SELECT THE BILLING CODE. JOHN DOE BELIEVES THIS HAS BEEN GOING ON FOR 6 MONTH. JOHN DOE IS CONCERNED HE COULD LOSE HIS CPT1 LICENSE (CALIFORNIA PHLEBOTOMIST LICENSE). JOHN DOE DOES NOT WANT MEDICAL CENTER TO KNOW HE MADE THE REPORT BECAUSE HE WILL GET FIRED. JOHN DOE WOULD LIKE TO BE CONTACTED BY AN INVESTIGATOR. OIG Focus Fraud, Waste and Abuse 8
Tools to Combat Fraud, West, and Abuse False Claims Act - 31 U.S.C. 3729 Health Care Fraud 18 U.S.C. 1347 Tool To Combat Fraud, Waste, and Abuse False Claims Act 31 U.S.C. 3729: FALSE CLAIMS LAW: any person who (A) knowingly presents, or causes to be presented, a false or fraudulent claim for payment or approval; 9
False Claims Act (cont.) is liable to the United States Government for a civil penalty of not less than $5,000 and not more than $10,000, plus 3 times the amount of damages which the Government sustains because of the act of that person. Did you know? State False Claims Act Reviews To qualify for the financial incentive (10-percentage-point increase in their share of any amounts recovered), a State s false claims act must: establish liability to the State for false or fraudulent claims, as described in the Federal False Claims Act (FCA), with respect to Medicaid spending, contain provisions that are at least as effective in rewarding and facilitating qui tam actions for false or fraudulent claims as those described in the FCA, contain a requirement for filing an action under seal for 60 days with review by the State Attorney General, and contain a civil penalty that is not less than the amount of the civil penalty authorized under the FCA 10
Tool To Combat Fraud, Waste, and Abuse Health Care Fraud 18 U.S.C. 1347 (a) Whoever knowingly and willfully executes, or attempts to execute, a scheme or artifice (1) to defraud any health care benefit program Healthcare Fraud (cont.) shall be fined under this title or imprisoned not more than 10 years, or both. If the violation results in serious bodily injury (as defined in section 1365 of this title), such person shall be fined under this title or imprisoned not more than 20 years, or both; and if the violation results in death, such person shall be fined under this title, or imprisoned for any term of years or for life, or both. 11
Tool To Combat Fraud, Waste, and Abuse Grant Fraud In fiscal year (FY) 2011 alone, HHS awarded over 82,000 grants totaling approximately $385 billion. Of these, 80,000 grants, for a combined $91 billion, were for programs other than Medicare and Medicaid. Largest Grant making organization. Tool To Combat Fraud, Waste, and Abuse 18 U.S.C. 371 Conspiracy to Defraud the United States creates an offense "[i]f two or more persons conspire either to commit any offense against the United States, or to defraud the United States, or any agency thereof in any manner or for any purpose. each shall be fined under this title or imprisoned not more than five years, or both. 12
Exclusions FY 2015 Number of Excluded Individuals: 4,112 Number of Reinstated Individuals: 520 Tool To Combat Fraud, Waste, and Abuse Suspensions and Debarments SUSPENSION AND DEBARMENT ARE ADMINISTRATIVE ACTIONS THAT PROTECT THE GOVERNMENT FROM SUBJECTS WHO HAVE DEMONSTRATED THEIR LACK OF INTEGRITY OR INABILITY TO MANAGE GOVERNMENT RESOURCES. THESE ACTIONS MUST BE CONSIDERED IN ALL INVESTIGATIONS CONCERNING GRANTS AND CONTRACTS, WHETHER OR NOT THE INVESTIGATION RESULTED IN A SUCCESSFUL PROSECUTION OR CIVIL JUDGMENT 13
CASES Bad Practices Donald Ray Keip, 39, of Mount Vernon, Illinois, pled guilty to a onecount indictment charging that he engaged in a scheme to commit health care fraud. Keip will face up to 10 years in prison, a fine of up to $250,000, and up to 3 years of supervised release. Keip admitted that he had submitted false and fraudulent bills in relation to his alleged performance of personal assistant services in the Home Services Program, a Medicaid Waiver Program designed to allow individuals to stay in their homes instead of entering a nursing home. Keip admitted to falsely billing the program between June 30, 2012 and January 29, 2013, when he purportedly rendered personal assistant services to an individual, his mother, when he, in fact, did not. Keip improperly received $24,000.00 in payments for services not performed. 14
Case Overview Skilled Nursing Facility Background George Houser owned and managed three nursing homes in the state of Georgia Rhonda Washington (George s girlfriend who later became his wife) assisted in managing the three homes Complaints of poor care Residents and families Employees and medical professionals 15
Leads Established numerous business entities Listed others as owners on his businesses Excessive number of bank accounts History of payment issues taxes, wages, vendors Administrators hired had no financial control E-mail from an Administrator 16
Medicare Requirements The care provided at a nursing home must provide an environment that promotes the quality of life of each resident and meets recognized standards of Health Care. They must provide services in compliance with all applicable federal, state and local laws and regulations. 17
Beginning of the end Visit from Doug Colburn, IG for Office of Regulator Services (ORS). Resulted in changed survey team In June 2007, the ORS gave notice that it was terminating the provider agreements for Mt. Berry and Moran Lake September 2007, ORS gave notice that it was closing Wildwood Conditions at Nursing Homes Lack of quality and quantity of food weight loss, healing impaired Labs not being done - resulted in at least one patient being hospitalized Garbage not being collected rodents, smells Roof not being repaired properly and water pouring in - ceiling tiles falling, mold Vendors were not being paid Paychecks were bouncing staff shortages Inspections not being done for sprinklers and fire systems Cleaning supplies not being provided Food spoilage food poisoning HVAC not working resulting in extremely cold or hot conditions pneumonia, dehydration Hot water heater not working - cold baths 18
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Worthless Services A worthless services claim stands for the unexceptional proposition that an entity may not bill the Government for products or services no value to the resident, or are totally undesirable. Worthless services are services that are so inadequate, deficient, and substandard, that they lack value. 20
Judge Murphy During the course of the conspiracy, the evidence shows that the services that Defendant actually provided were of no value WORTHLESS. Autopsy Photo of Resident 21
Autopsy Photo of Resident Sentencing George Houser was found Guilty on all counts one count of conspiracy to commit Health Care Fraud and 10 tax counts August 13, 2012 George was sentenced to 20 years in federal prison and ordered to pay $6,742,807.88 in restitution to Medicaid and Medicare, 22
Case Statistics There were 1,197 government exhibits, 678 exhibits admitted There were 13 exhibits admitted for defense 82 Witnesses for the government two of them took the stand twice 2 witnesses for defense 2,922 transcript pages 471 page verdict written by Judge Murphy 23
Ritecare This case was initiated following complaints from RiteCare office manager, Latonya Robertson. Robertson alleged RC paid vagrants, the mentally challenged, and drug addicts to come into the clinic and then billed Medicare for services not rendered, or for treatment that was not required 24
Ritecare On July 24, 2012, Emilio Haber was sentenced in the Eastern District of Michigan to 60 months in prison related to his guilty plea to one count of Conspiracy to Commit Health Care Fraud. Following his release, Haber was ordered to serve three years probation. The judge also ordered the forfeiture of $99,247.05 previously seized from various Chase Bank accounts; restitution of $6,341,000 (joint and several with co-defendants) and a $100 special assessment. On July 26, 2012, Alejandro Haber was sentenced in the Eastern District of Michigan to 40 months in prison related to his guilty plea to one count of Conspiracy to Commit Health Care Fraud. Following his release, Haber was ordered to serve three years probation. The judge also ordered the forfeiture of $99,247.05 previously seized from various Chase Bank accounts; restitution of $5,333,906 (joint and several with co-defendants) and a $100 special assessment. Ritecare On March 18, 2011, Hans Lobato was sentenced in United States District Court, in the Southern District of Florida, to one year in prison, followed by three years of supervised release. Home detention with electronic monitoring was ordered for the first 18 months of supervised release. Additionally, Lobato was ordered to perform 200 hours of community service. The Judge also ordered joint and several restitution in the amount of $5,336,000.00, and a $100 Special Assessment. On May 9, 2011, Genna Yates was sentenced in United States District Court, in the Eastern District of Michigan, to one year in prison, followed by two years of supervised release. The Judge also ordered joint and several restitution in the amount of $630,506.00, and a $100 Special Assessment. On June 21, 2011, Maria Haber was sentenced in U.S. District Court, in the Eastern District of Michigan to 15 months in prison, followed by three years supervised release. The Judge also ordered joint and several restitution in the amount of $1,004,343.81, and a $100 Special Assessment. 25
Eyes and Ears 26