The U.S. Department of Health and Human Services, Office of Inspector General (OIG) recently released its Semiannual Report (SAR) covering the period October 1, 2024 to March 31, 2025. The SAR is a must-read because it identifies a wide array of risk areas, which will undoubtedly help providers modify their own risk assessments and audit work plans to stay ahead of government regulators in the ongoing fight against fraud, waste, and abuse.
Recognizing that it faces “increasingly sophisticated and complex schemes”, OIG again highlighted its use of “cutting-edge data and investigative techniques” to identify, prioritize, and mitigate risks such as:
- manipulation of Medicare Advantage’s risk adjustment program to receive inflated payments by using invalid or incorrect diagnosis codes, particularly for payments that solely used health risk assessments (HRAs) and chart reviews linked to HRA visits;
- improper payments for over-the-counter COVID-19 test kits during the public health emergency, as well as those for catheters, genetic testing, and durable medical equipment;
- inappropriate Part D prescription drug payments for skilled nursing facility patients that were otherwise covered under Part A, as well as payments for outpatient hospital services that were otherwise covered under the hospice benefit; and
- Medicaid payments for applied behavior analysis services for autistic children that did not adequately document patient sessions or that used staff who lacked appropriate credentials.
Despite considerable upheaval in the Federal workforce this year, OIG nevertheless reported over 740 criminal convictions, civil settlements, and civil judgments, as well as the exclusion of more than 1,500 individuals and entities. These enforcement actions resulted from issues such as:
- billing for home health services that were never provided; billing for genetic testing services and durable medical equipment where a provider never saw, spoke to, or treated beneficiaries;
- paying kickbacks in a wide-ranging scheme involving a pharmacy owner and marketers who recruited physicians to prescribe expensive compounded drugs; and
- failing to secure Medicare enrollee data without individually encrypting the files to protect them against exposure in the event of a breach.
OIG reserved some of the stiffest penalties for individuals who abused or neglected disabled children and nursing home residents.
OIG is also scrutinizing spending on diabetes and weight-loss drugs, especially since Medicaid spending on certain of these drugs has increased 540 percent since 2019. Medicare Part D spending on these drugs over the same timeframe increased by more than 360 percent.
Given the sheer volume of OIG’s oversight and investigative activities, providers should reassess their current risk assessments, audit work plans, and overall compliance efforts.
A copy of the complete Semiannual Report can be found here.
Should you have any questions regarding the above or would like guidance on strengthening your existing compliance efforts, please contact the authors, the Garfunkel Wild attorney with whom you regularly work, or contact us at [email protected].
