In late 2016, the Office of Inspector General (OIG) for the U.S. Department of Health and Human Services (HHS) released its 2017 Work Plan. The plan lists the topics in which it sees the greatest potential for fraud under federal health care programs, primarily Medicare and Medicaid. The OIG updates its Work Plan throughout the year as conditions warrant.

The plan is extensive, and for that reason we are presenting the information in several topical parts.  In this first installment, we provide an overview of the OIG's role in maintaining provider compliance with federal health care programs, since any of the specific work areas addressed in the bulk of the report can become the focus of investigation and enforcement activity.

Investigations

OIG investigates allegations of fraud, waste, and abuse in all of HHS's programs, often in conjunction with other investigative agencies, including the FBI, U.S. Attorneys' Offices, State agencies, and State police forces. One of those collaborative efforts is HEAT (Health Care Fraud Prevention and Enforcement Action Team), which was formed in 2009 and currently operates in nine major cities. Individually, and as a part of these collaborations, OIG investigates, among other matters:

  • Billing for services not rendered
  • Medically unnecessary and misrepresented services
  • Patient harm, i.e. quality-of-care and failure-of-care issues
  • Illegal billing, sale, diversion and off-label marketing of prescription drugs
  • Solicitation and receipt of kickbacks
  • Illegal referral arrangements

Any entity participating in an HHS program is a potential target for an OIG investigation.

Enforcement

Persons or entities that are found to have participated in schemes to defraud Medicare, Medicaid, or other federal health care programs may face heavy fines, jail time, and exclusion from the programs. The OIG plays a role in civil and administrative health care fraud cases through:

  • Exclusions from program participation – OIG may exclude individuals and entities from participation in Medicare, Medicaid, and other federal health care programs for a number of reasons, including program-related convictions, patient abuse or neglect convictions, and licensing board or disciplinary actions.
  • Imposition of civil monetary penalties – OIG is empowered to pursue and impose civil monetary penalties for false claims, kickbacks, and other conduct.
  • Pursuit of False Claims Act cases – OIG often works hand-in-hand with the Department of Justice (DOJ) in the pursuit of False Claims Act cases against persons or entities that defraud federal health care programs.
  • Implementation and monitoring of Corporate Integrity Agreements (CIAs) – OIG, at times in conjunction with DOJ, requires defendants in health care fraud cases to agree to CIAs as part of settlement agreements.  Under a CIA, OIG assesses a provider's compliance with the terms of the agreement via site visits and the review of many types of information submitted by the provider.  A failure to adhere to the terms of a CIA can result in stipulated penalties or exclusions. 

But it isn't all stick and no carrot. OIG also issues advisory opinions and other industry guidance documents in order to foster compliance. Advisory opinions are provided in response to requests for interpretation on how the anti-kickback and other statutes apply to specific fact situations. Fraud alerts and compliance guidance documents are issued regularly and speak to the OIG's positions on problematic or suspect practices.