OIG Work Plan and Enforcement Actions

There are a couple of powerful auditors looking at fraud, waste, and abuse in the healthcare arena with whom you hope to never have the pleasure of interacting. One is the Health and Human Services (HHS) Office of Inspector General (OIG). It is the largest inspector general’s office in the Federal Government and the majority of their resources and activities are focused upon the Medicare and Medicaid programs. The OIG operates under a Work Plan (OIG Work Plan). The Work Plan, which is updated monthly, advises the public about various projects including OIG audits and evaluations that are underway or planned to be addressed during the fiscal year and beyond by OIG's Office of Audit Services and Office of Evaluation and Inspections. Of course, those audits and evaluations could include time consuming activities on the part of providers and suppliers.

OIG Work Plan Audits

In the November 2021 Work Plan, the OIG has decided, among other issues, to tackle inpatient hospital claims for both Medicare and Medicaid. Specifically, through the Office of Audit Services, the OIG plans to address payment issues relating to Medicare mechanical ventilation claims and Medicaid inpatient claims for severe malnutrition.

In Report Number W-00-22-35879, with an expected release date of sometime in 2023, the OIG will review Medicare payments to determine the appropriateness of Medicare Severity Diagnosis Related Group (MS-DRG) coding assignments and subsequent Medicare payments for inpatient hospital claims that require mechanical ventilation. For certain MS-DRGs to qualify for Medicare coverage, a beneficiary must have received more than 96 hours of mechanical ventilation. In previous OIG reviews they identified improper payments made because hospitals inappropriately billed for beneficiaries who did not receive at least 96 hours of mechanical ventilation. This new OIG review will include claims for beneficiaries who received more than 96 hours of mechanical ventilation, determining among other issues whether the hospital needed to utilize mechanical ventilation in the first instance as the use of a ventilator is specifically designed to take over the active breathing process for a patient. Another issue the OIG may address is that mechanical ventilation is currently the only exception to the application of the two-midnight rule for inpatient stays, and if the use of mechanical ventilation is found to be inappropriate for a beneficiary the claim itself could be subject to application of the two-midnight rule.

Covered in Report Number W-00-22-31558, also with an expected release date in 2023, the OIG will address the issue of proper coding by hospitals for Medicaid claims for severe malnutrition through statewide reviews. Since malnutrition can be categorized as either mild, moderate, or severe and severe malnutrition is classified as a major complication or comorbidity (MCC), a hospital can add an MCC to a malnutrition claim which may result in an increased payment by causing the claim to be coded in a higher diagnosis-related group. The OIG will be reviewing claims to determine whether hospitals complied with Medicaid billing requirements when assigning severe malnutrition diagnosis codes to inpatient hospital claims.

OIG Enforcement Actions

The OIG also performs Enforcement Actions, activities that include criminal, civil and administrative legal actions relating to fraud and other illegal activities that can result in jail time, the repayment of wrongfully acquired money and other assets, and exclusion from the Medicare and Medicaid Programs. Most often these activities are referred to the Department of Justice. Here are some notable Enforcement Actions (OIG Enforcement Actions ), notable because they were addressed against individuals, small companies, and large companies alike, with a variety of different penalties. All of the actions listed below took place in November and can be found by filtering for Criminal and Civil Actions:

• The U.S. Attorney filed a civil fraud lawsuit against a non-profit company and settled fraud claims against its founder for inflating Medicaid reimbursements by falsely reporting millions of dollars in costs. In connection with the filing of the lawsuit and settlement, the United States joined a private whistleblower lawsuit that had previously been filed under seal pursuant to the False Claims Act. In addition to payment for the false claims, the defendant also agreed never to work for or accept payments from any entity that receives funds from a federal healthcare program and entered into a Voluntary Exclusion Agreement with HHS-OIG, which prohibits the doctor from participating in Medicaid and other federal healthcare programs for 15 years.
• A home health agency agreed to pay $4.2 million to settle False Claims Act allegations. The company and its affiliated entities agreed to the payment to resolve allegations that they submitted claims for home health services that were not covered by the Medicare and Medicaid programs, and that they failed to refund overpayments that they had received from Medicare and Medicaid in a timely manner. This settlement resolves a lawsuit originally filed in the U.S. District Court for the Northern District of Georgia by a Relator under the qui tam or whistleblower provisions of the False Claims Act. Under the False Claims Act, private citizens may bring suit for false claims on behalf of the United States and share in any recovery obtained by the government. The Relator will receive over $700,000.00 from the settlement.
• A Wisconsin doctor was sentenced to 54 months for a $13 million scheme to defraud Medicare. The doctor wrote thousands of fraudulent orders for Durable Medical Equipment (DME). Other participants in the scheme used the doctor’s fraudulent orders to bill Medicare $26,000,000 of which Medicare paid $13,000,000.

With the abundance of audit activity, especially focusing on fraud, waste, and abuse in the healthcare arena, it’s no wonder that providers and suppliers are scrambling to take action to submit correct and proper claims, including ensuring they have the documentation to support the medical necessity of the item or service being billed, coding claims properly, and pushing back against auditors that are not themselves properly applying the rules and regulations when adjudicating and auditing claims. One of the best ways to make sure you are maintaining claim integrity is to conduct regular internal audits of your process and operations and adjust, as needed, to ensure the submission of proper claims. And, if you find your organization is being pursued by the OIG or other government watchdog, seek appropriate professional assistance to address any alleged fraud, waste, or abuse.