The Office of the Inspector General (OIG), U.S. Department of Health & Human Services (HHS), recently issued its Semiannual Report (the Report) to detail the OIG’s most noteworthy findings and activities for the 6-month period from April 1, 2011 to September 30, 2011.  The Report contains four parts (Part I: Medicare Reviews; Part II: Medicaid Reviews; Part III: Legal and Investigative Activities Related to Medicare and Medicaid; and Part IV: Public Health and Human Services Reviews and Other HHS-Related Issues) and includes the following OIG findings, among many others:

  • During Fiscal Year 2011, Medicare Fraud Strike Force Teams implemented nationwide actions that lead to charges against 91 defendants for their alleged participation in Medicare fraudulent billing schemes involving approximately $295 million.
  • Noting that since 2005, Medicare spending on hospice care for residents of nursing facilities has grown by almost 70 percent, the OIG reported its recommendations to CMS to “monitor hospices that depend heavily on nursing facility residents and modify the payment system for hospice care in nursing facilities.” 
  • After reviewing the professional component of diagnostic and radiology services conducted in hospital outpatient emergency departments (ED) in 2008, the OIG found that Medicare allowed close to $40 million in payment for interpretation and reports of diagnostic and radiology services that did not have physicians’ orders documented in the medical record or documentation showing that interpretation and reports were performed.  Also noting that some physicians’ interpretations and reports were performed when the patient was no longer at the hospital outpatient ED and that many interpretations and reports did not follow guidelines promoted by the American College of Radiology, the OIG recommended provider education, uniform policies, and collecting overpayments paid for claims lacking required documentation.
  • In its review of Medicare payments for outpatient services, the OIG noted provider error (such as incorrect codes or units of service or inadequate documentation to support the service) after reviewing outpatient line items for which Medicare payment amounts exceeded billed charges by a significant amount.   The OIG recommended that Medicare contractors: recover overpayments, implement system edits to identify line item payments that exceed billed charges by a prescribed amount, and educate providers.

The entire Report is available on the OIG website by clicking here.