Dive Brief:
- The HHS’ Office of the Inspector General is expected to recover more than $3.44 billion in fiscal year 2023 as a result of investigations into fraud and misspent funds in Medicare, Medicaid and other government health programs, according to the agency’s latest report.
- The semiannual report tallied 707 criminal enforcement actions and 746 civil actions — including false claims, unjust-enrichment lawsuits and civil monetary penalty settlements — from Oct. 1, 2022 through Sept. 30, 2023. The OIG also banned more than 2,000 people and entities from participating in federal healthcare programs.
- Some of the audits and investigations included Medicare improperly paying providers for psychotherapy, regulators not accurately reporting safety and quality issues in nursing homes and access disparities for opioid use disorder medications in Medicaid.
Dive Insight:
The HHS’ OIG oversees over a hundred health programs that provide services for more than 150 million Americans, including the senior health insurance offering Medicare and the safety-net Medicaid program.
The federal government has recouped similar amounts for healthcare fraud before, announcing last year it was projecting to recoup nearly $4 billion in its 2022 fiscal year.
The recent report highlighted fraud risks like emerging technologies, even as the tech can offer significant benefits for patients in federal healthcare programs, according to OIG Inspector General Christi Grimm.
The HHS OIG highlighted criminal charges brought against 78 defendants earlier this year for allegedly falsely billing $2.5 billion to federal programs, in part using a software platform that auto-generated orders.
The agency also found providers frequently didn’t meet requirements for billing for psychotherapy services in Medicare, including for care provided via telehealth.
The OIG estimated that, out of the $1 billion the program paid, providers received $580 million in improper payments, including $348 million for virtual care. Telehealth use soared during the COVID-19 pandemic as providers and patients shifted to virtual care to prevent the spread of the disease.
Cybersecurity is another major focus for the regulator, as healthcare data breaches increase and expose patients’ sensitive information. In the spring, the OIG found multiple security controls at the CMS were not running effectively, and that the agency didn’t consistently find threats that could lead to a potential breach.
The OIG is also keeping an eye on Medicare Advantage and Medicaid managed care, according to the report. MA, where private insurers are paid by the federal government to administer seniors’ plans, has grown significantly over the past decade, and now includes more than half of eligible Medicare beneficiaries.
Managed care, a similar arrangement in Medicaid, is also the predominant payment model in the safety-net program, according to the report. The OIG highlighted a review published this summer that found managed care organizations denied one out of every eight requests for prior authorization in 2019, and many beneficiaries had limited options for appeal.
