OIG Announces New Inquiries into Fraudulent Billing


On July 17, 2017, the U.S. Department of Health and Human Services Office of Inspector General (OIG) announced their review of 14 possible instances of Medicare and Medicaid billing fraud. These new inquiries join over 200 pending inquiries already being conducted. The most recent investigations include:

  • Whether certain states made payments in accordance with Federal and state regulations for Consumer-Directed Personal Assistance programs;
  • Whether nonresidential adult care centers comply with applicable health and safety standards;
  • Whether Medicare Parts A and B are being billed appropriately by ambulance companies for services provided to skilled nursing facilities;
  • Whether states are meeting Federal requirements in setting payment rates for those treated for severe and persistent mental illness at Assertive Community Treatment programs;
  • Whether states calculated incorrectly the number of children enrolled in Medicaid, causing unallowable bonus payments made to States under the Children’s Health Insurance Program Reauthorization Act of 2009;
  • Identifying, using data from the Comprehensive Error Rate Testing (CERT) program, the common characteristics of “at risk” Home Health Agency providers that could be used to target pre- and post-payment review of claims, as the CERT program concluded “the 2016 improper payment error rate for home health claims was 42%, or about $7.7 billion;”
  • Whether states reported and returned the Federal Government’s share of settlement and judgment amounts received by states resulting from harm to the states’ Medicaid programs;
  • Whether hospitals that adopted electronic health record technology were overpaid Medicare incentive payments;
  • Further review of overpayments received by hospital outpatient providers for non-physician services;
  • Whether state agencies complied with Federal and State requirements when claiming Medicaid reimbursement for Opioid Treatment Program services;
  • Whether states made Medicaid payments for targeted case management services in accordance with certain Federal and state requirements;
  • Whether Medicare claims for telehealth services met Medicare requirements;
  • Whether duplicate Medicare payments were made regarding home health claims and Part B claims; and
  • Whether duplicate Medicare payments were made regarding hospice claims and Part B claims.

Related Practices:   Healthcare Law

Related Attorney:   Riza I. Dagli, Lani M. Dornfeld