Washington, DC—America’s taxpayers could see nearly $5.9 billion in misspent Medicare, Medicaid, and other health and human service program dollars returned to the government as the result of fiscal year 2019 work by the Department of Health and Human Services, Office of Inspector General, according to a recently released report.
The Semiannual Report to Congress summarizes OIG activities for all of FY 2019 and highlights specific achievements in the second half of the year.
“In this reporting period, OIG continued to produce outstanding results for the American people through independent, objective oversight,” said Joanne M. Chiedi, Acting Inspector General for HHS-OIG. “OIG continued its enterprise-wide oversight of HHS’s over $1 trillion portfolio and its bold pursuit of those who cheat HHS programs or harm HHS beneficiaries.”
Of the billions of dollars in savings and recoveries in FY 2019, more than $819 million is expected to be recovered from audits and approximately $5.04 billion is expected from investigative recoveries. Investigative receivables include expected recoveries from criminal actions, civil and administrative settlements, civil judgments, and administrative actions by OIG.
In FY 2019, OIG brought 809 criminal actions against individuals or organizations engaging in crimes against HHS programs and the beneficiaries they serve and an additional 695 civil actions, including false claims and unjust-enrichment lawsuits filed in Federal district court, civil monetary penalty settlements, and administrative recoveries related to provider self-disclosure matters.
The agency also excluded 2,640 individuals and entities from participation in Medicare, Medicaid, and other Federal health care programs.
In addition to summarizing the full year’s achievements, the Semiannual Report reviews OIG activities for the reporting period comprising the last half of the fiscal year from Apr. 1 through Sept. 30, 2019.
During this period, OIG focused on protecting unaccompanied children in the Department’s care; preventing opioid misuse and promoting access to treatment; fighting fraud to protect the Medicare and Medicaid programs; ensuring appropriate use of Medicaid funds; protecting beneficiaries from abuse, neglect, and unsafe conditions; promoting access to high-quality care; and safeguarding the security and integrity of medical research. The report highlights multiple OIG activities in each of these areas.
An example of the agency’s work to protect the health and safety of unaccompanied children in the Department’s care included a report released in September 2019, in which OIG found that the Office of Refugee Resettlement’s care provider facilities faced challenges in addressing the mental health needs of children. ORR facilities reported several challenges in addressing children’s mental health needs, especially for children who have experienced significant trauma. Facility staff described challenges such as difficulty recruiting and retaining clinicians and resulting high caseloads, trouble accessing external mental health care providers, and difficulty transferring children to facilities within ORR’s network that provide specialized treatment. Policy changes in 2018 exacerbated these concerns, as they resulted in a rapid increase in the number of children separated from their parents after entering the United States, many of whom were younger, and longer stays in ORR custody. The Administration for Children and Families, ORR’s parent organization, agreed with OIG’s recommendations for practical steps that ORR can take to assist facilities caring for children and minimize barriers to appropriate mental health treatment. (See report OEI-09-18-00431.)
OIG continued an extensive body of work focused on preventing opioid misuse and promoting access to treatment in FY 2019, frequently partnering with the Department of Justice. Multiple investigations, evaluations, and audits addressed this public health crisis. An example of a successful OIG-DOJ partnership included a pharmaceutical company agreeing to pay $700 million to settle allegations that it illegally marketed an opioid treatment drug. The pharmaceutical company entered into a $700 million False Claims Act settlement with the United States to resolve allegations that it illegally marketed and promoted the opioid treatment drug Suboxone. The allegations included knowing promotion of Suboxone to physicians who were prescribing it in an unsafe manner, as well as making false and misleading claims to physicians, State Medicaid agencies, and the Food and Drug Administration to increase sales and delay generic competition.
A significant portion of OIG’s efforts focused on fighting fraud to protect the Medicare and Medicaid programs, two of the largest Federal programs in the United States. OIG helped lead a multidistrict law enforcement takedown targeting a massive genetic testing fraud scheme. In September 2019, OIG and Federal and State law enforcement partners announced efforts to dismantle one of the largest health care fraud schemes ever charged. The takedown resulted in charges in five Federal districts against 35 defendants-including nine doctors-associated with dozens of telemedicine companies and laboratories. The defendants are charged with fraudulently billing Medicare more than $2.1 billion for cancer-related genetic tests as part of a scheme involving payment of illegal kickbacks and bribes.
OIG reviews of how the Centers for Medicare & Medicaid Services and States administer Medicaid are vital to ensuring appropriate use of Medicaid funds. For example, in FY 2019, OIG found that Florida made hundreds of millions of dollars in unallowable Medicaid payments to a hospital under a waiver program. As part of its Medicaid reform waiver, Florida established the Low Income Pool program to compensate hospitals for providing care to low-income patients. OIG found that during State FYs 2010 through 2014, Florida paid $686 million to Jackson Memorial Hospital under the LIP program in excess of the hospital’s allowable costs. OIG recommended that Florida refund the $412 million Federal share of the unallowable payments, improve its oversight of the LIP program, and make other procedural changes. (See report A-04-17-04058.)
Protecting beneficiaries from abuse, neglect, and unsafe conditions is at the core of OIG’s mission. OIG’s work to protect vulnerable populations in FY 2019 included a pair of reports in which OIG highlighted the prevalence of quality-of-care deficiencies among hospice providers and gaps in Medicare protections for hospice patients. Three out of four hospices inspected in 2016 were cited with at least one deficiency, such as poor care planning or inadequate patient assessments. Additionally, over 300 hospices had at least one serious deficiency or at least one substantiated severe complaint. OIG also described cases of serious harm that reveal gaps and vulnerabilities in Medicare’s protections for hospice patients. OIG recommended that CMS take a number of actions to more effectively protect hospice beneficiaries from harm. (See reports OEI-02-17-00020 and OEI-02-17-00021.)
In the focus area of promoting access to high-quality care, one example of OIG’s work to ensure that vulnerable populations receive high-quality care is a report in which OIG found that many Medicaid-enrolled children who were treated for attention deficit hyperactivity disorder did not receive recommended followup care. Followup care is an important part of treatment for ADHD as the disorder can affect all aspects of a child’s academic and health outcomes. OIG found that over 500,000 Medicaid-enrolled children who were newly prescribed an ADHD medication and over 3,500 children hospitalized with a primary diagnosis of ADHD did not receive followup care within the timeframes outlined in the national quality measures. CMS agreed with our recommendations to work toward improving health outcomes by developing strategies to increase the number of children who receive timely followup care for ADHD. (See report OEI-07-17-00170.)
OIG focused on safeguarding the security and integrity of medical research. With a $5 million appropriation, OIG conducted oversight work to address concerns about foreign and other threats to the integrity of taxpayer-funded research and intellectual property. Two reports examined the National Institutes of Health’s financial conflict of interest processes. OIG found that NIH has improved its review of FCOIs that institutions report to it, but it has limited controls in place to ensure that institutions report everything that they should. OIG found that NIH has made strides in its oversight of FCOIs reported by institutions. Specifically, NIH has strengthened its reporting requirements and developed an online system for collecting, reviewing, and storing the FCOIs that institutions report. However, NIH could do more to ensure the quality of the reviews of FCOIs that its staff performs. In another review, OIG found that NIH has limited policies, procedures, and controls in place to ensure that institutions report all sources of research support, financial interests, and affiliations. More than half of the 1,875 institutions that received NIH funding in FY 2018 and were required to have FCOI policies did not have such policies posted on their websites. NIH agreed with OIG’s recommendations to help address these issues. (See reports A-03-19-03003 and OEI-03-19-00150.)