OIG: Fraud risks need to be re-examined in face of reform
New payment and healthcare delivery models require a fresh examination of fraud and abuse risk, according to Daniel R. Levinson, inspector general of the Department of Health and Human Services (HHS), during his keynote address at the Healthcare Compliance Association's Annual Compliance Institute last month.
According to Levinson, compliance professionals should be asking questions focused on transparency, quality and accountability as they prepare for healthcare reform. “Are you prepared to operate in a more transparent healthcare system [and is] your organization prepared for greater accountability?” the inspector general asked.
The Patient Protection and Affordable Care Act of 2010 (PPACA) contains numerous provisions that encourage the evolution of delivery and payment models designed to improve quality and introduce new efficiencies through greater integration, collaboration and coordination among providers, according to Levinson.
“Our mutual goal should be to develop solutions as may be necessary to strike the right balance between protecting the integrity of the healthcare programs and fostering innovation that increases quality, efficiency and cost effectiveness,” Levinson said.
Levinson went on to say that many provisions in PPACA are consistent with the Office of the Inspector General’s (OIG) five-principle strategy for combating fraud, waste and abuse:
The PPACA increases funding for the HealthCare Fraud and Abuse Control (HCFAC) program, which is OIG’s primary funding stream; drawing funds from the Medicare Trust Fund to finance OIG fraud-fighting activities. Historically, according to Levinson, the HCFAC program has proven a wise investment.
“From its inception in 1997 through 2008, HCFAC program activities have returned more than $13.1 billion to the federal government through audit and investigative recoveries, with a return-on-investment of $6 for every $1 invested in OIG, Department of Justice (DoJ) and HHS activities through the HCFAC account,” stated Levinson.
An additional initiative among many Levinson noted was that OIG is involved with the HealthCare Fraud Prevention and Enforcement Action Team (HEAT), a joint effort by HHS and DoJ to leverage resources, expertise and authorities to prevent fraud and abuse in Medicare and Medicaid. “OIG contributes its expertise to HEAT by analyzing data patterns of fraud, conducting investigations, supporting federal prosecutions of providers who commit criminal and civil fraud, and pursing administrative remedies, including program exclusions, as well as making recommendations to HHS to remedy program vulnerabilities and prevent fraud and abuse,” stated Levinson.
Using a strike force model has resulted in approximately 270 convictions, indictments of more than 500 defendants and more than $240 million in court-order restitution, fines and penalties, according to Levinson.
As part of HEAT, OIG is planning to conduct compliance training for providers in selected locations, noted Levinson. “We are in the early stgtes of planning for this initiative, which will unfold over the next year, so stay tuned for further announcements about this exciting initiative,” he said.
To access Levinson's list of questions compliance professionals should ask as they prepare for healthcare reform, click here.
According to Levinson, compliance professionals should be asking questions focused on transparency, quality and accountability as they prepare for healthcare reform. “Are you prepared to operate in a more transparent healthcare system [and is] your organization prepared for greater accountability?” the inspector general asked.
The Patient Protection and Affordable Care Act of 2010 (PPACA) contains numerous provisions that encourage the evolution of delivery and payment models designed to improve quality and introduce new efficiencies through greater integration, collaboration and coordination among providers, according to Levinson.
“Our mutual goal should be to develop solutions as may be necessary to strike the right balance between protecting the integrity of the healthcare programs and fostering innovation that increases quality, efficiency and cost effectiveness,” Levinson said.
Levinson went on to say that many provisions in PPACA are consistent with the Office of the Inspector General’s (OIG) five-principle strategy for combating fraud, waste and abuse:
- Enrollment: Scrutinize individuals and entities that want to participate as providers and suppliers prior to their enrollment in healthcare programs;
- Payment: Establish payment methodologies that are reasonable and responsive to changes in the marketplace and medical practice;
- Compliance: Assist healthcare providers and suppliers in adopting practices that promote compliance with program requirements;
- Oversight: Vigilantly monitor the programs for evidence of fraud, waste and abuse; and
- Response: Respond swiftly to detected fraud, impose sufficient punishment to deter others, and promptly remedy program vulnerabilities.
The PPACA increases funding for the HealthCare Fraud and Abuse Control (HCFAC) program, which is OIG’s primary funding stream; drawing funds from the Medicare Trust Fund to finance OIG fraud-fighting activities. Historically, according to Levinson, the HCFAC program has proven a wise investment.
“From its inception in 1997 through 2008, HCFAC program activities have returned more than $13.1 billion to the federal government through audit and investigative recoveries, with a return-on-investment of $6 for every $1 invested in OIG, Department of Justice (DoJ) and HHS activities through the HCFAC account,” stated Levinson.
An additional initiative among many Levinson noted was that OIG is involved with the HealthCare Fraud Prevention and Enforcement Action Team (HEAT), a joint effort by HHS and DoJ to leverage resources, expertise and authorities to prevent fraud and abuse in Medicare and Medicaid. “OIG contributes its expertise to HEAT by analyzing data patterns of fraud, conducting investigations, supporting federal prosecutions of providers who commit criminal and civil fraud, and pursing administrative remedies, including program exclusions, as well as making recommendations to HHS to remedy program vulnerabilities and prevent fraud and abuse,” stated Levinson.
Using a strike force model has resulted in approximately 270 convictions, indictments of more than 500 defendants and more than $240 million in court-order restitution, fines and penalties, according to Levinson.
As part of HEAT, OIG is planning to conduct compliance training for providers in selected locations, noted Levinson. “We are in the early stgtes of planning for this initiative, which will unfold over the next year, so stay tuned for further announcements about this exciting initiative,” he said.
To access Levinson's list of questions compliance professionals should ask as they prepare for healthcare reform, click here.