The U.S. Department of Health and Human Services (HHS) is the federal agency that runs the Medicare and Medicaid programs. Within the Department, the Office of the Inspector General (OIG) is charged with preventing fraud on the Medicare and Medicaid programs, and identifying and holding accountable those that have abused their role as healthcare providers. OIG conducts audits, investigations, and evaluations of Medicare and Medicaid, and works closely with attorneys within HHS and at the U.S. Department of Justice to bring civil and criminal charges against those who violate federal healthcare laws.

OIG’s task is enormous. In roughly the last year, more than four thousand individuals and entities were barred from participating in federal healthcare programs; nearly one thousand criminal cases were launched against individuals or entities that engaged in crimes against HHS programs; and nearly seven hundred civil actions were filed seeking millions in restitution and monetary damages.

Every year, OIG publishes a work plan that details the focus of its fraud prevention efforts for the year ahead. Congress mandates certain OIG activities, but OIG otherwise prioritizes its audits and investigations in the areas where HHS’s healthcare programs have most recently suffered from fraud, waste and abuse. In this way, OIG’s work plan is a roadmap of the trouble spots in the Medicare and Medicaid programs. When you work in the healthcare industry, paying attention to what OIG is saying and doing is critical.

OIG’s work plan for 2016 is focused on identifying and preventing Medicare and Medicaid waste, fraud and abuse in many areas. Feel free to review OIG’s entire work plan for 2016 by clicking on this link. We highlight key areas below.

• Billing by acute care hospitals under Medicare Part B for outpatient services that were actually performed while the patient was still in the hospital.

• Actual costs of therapy services provided by Skilled Nursing Facilities, more commonly known as nursing homes. Prior OIG reviews revealed Medicare payments far in excess of the actual costs of therapy.

• Medical necessity of certain hospice services. When a patient elects hospice care, she is limited to receiving palliative care, and may not receive curative care. OIG will examine whether hospice facilities provide for or bill curative care services.

• Proper use of mechanical ventilation on patients in a hospital. Medicare covers the costs of mechanical ventilation only when it is used for more than 96 hours. Previous OIG reviews revealed hospitals that billed and were paid by Medicare for patients who were treated with a mechanical ventilator for less than 96 hours.

• Outpatient dental care. Medicare covers outpatient dental care only in very limited circumstances. Prior OIG audits revealed significant overpayments to hospitals for dental services not covered by Medicare.

• Medical necessity of durable medical equipment, prosthetics and orthotics.

• Questionable billing and medical necessity of certain ambulance services. Medicare pays for emergency and non-emergency ambulance services. Emergency services are reimbursed at a significantly higher rate. Prior OIG reviews found that ambulance service providers billed for emergency services that were neither medically necessary nor what was actually provided to the patient.

• Medical necessity of outpatient chiropractic and physical therapy services.

• Medical necessity of and payments to doctors for prolonged evaluation and management of patients. Doctors may submit claims for prolonged evaluations when they spend additional time with patients, but the need for such prolonged evaluations is rare and unusual.

• Illegal billing, sale, diversion and off-label marketing of prescription drugs.

OIG doesn’t have the resources to identify all of the fraud and abuse in the Medicare and Medicaid programs, estimated to be tens of billions of dollars every year. That’s where the False Claims Act comes in. The False Claims Act empowers an individual to sue on behalf of the government any doctor, hospital or other health care provider who submits a false claim for payment to Medicare or Medicaid, or uses or makes false statements or records material to a false claim. Such individuals are sometimes referred to as whistleblowers, as they “blow the whistle” on the wrongful conduct.

The False Claims Act empowers whistleblowers to file what is known as a civil qui tam action, in which the whistleblower acts as a “relator” and pursues a fraud claim against the Medicare or Medicaid provider in the name of the U.S. government. If the case results in a recovery for the government, the statute provides for the whistleblower to receive a portion of the money recovered.

If you have information about a doctor, hospital or other health care provider that has filed false claims with the Medicare or Medicaid programs or is using or making false statements related to Medicare or Medicaid claims, we can help you figure out what to do with that information and how to protect yourself while bringing the misconduct to light.