5 Years of OIG Results
Summary:
PCG has combined, re-written, and summarized five (5) years, from 2017-2021, of OIG-related Annual and Semi-Annual Reports helping provide a 30,000-foot view on Healthcare-related Fraud, Waste, and Abuse.
OIG Results from 2017-2021
2017-2021 Full OIG Impact
The Office of Inspector General (OIG) has seen tremendous success in its implementation of recoveries from 2017 to 2022. In this five-year period, the OIG achieved $16 billion in financial recoveries for the U.S. Department of Health and Human Services (HHS). This amount is more than double the total accumulated over the previous ten years. Most of these recoveries came from False Claims Act lawsuits, which totaled $14.8 billion.
The OIG also achieved $1.5 billion in civil settlements and judgments from healthcare fraud investigations involving the Medicare and Medicaid programs during this same five-year period. This is an increase of more than 300 percent from the $367 million in recoveries reported between 2007 and 2016. This number also includes additional funds received as part of settlements to resolve allegations that physicians or other healthcare providers inadequately billed Medicare for services, provided medically unnecessary services or engaged in kickback arrangements.
The OIG’s investigative efforts have resulted in a wide range of administrative actions as well. This includes the exclusion of more than 5,600 individuals and entities from participation in federal health care programs due to criminal convictions or other reasons. In addition, the OIG also imposed $1.8 billion in civil monetary penalties for various violations involving Medicare, Medicaid, and other HHS-funded programs between 2017 and 2022.
The OIG’s efforts have also included the reinstatement of approximately $1.2 billion in Medicare payments that had been inappropriately denied by Medicare contractors. The OIG has also entered into more than 1,100 corporate integrity agreements with healthcare providers over the same five-year period. These agreements are designed to ensure compliance with the laws and regulations governing the Medicare and Medicaid programs.
Finally, the OIG’s efforts have also included the seizure of cash and assets totaling $461 million from individuals or entities engaged in fraud against HHS-funded programs. This is a substantial increase from the $16 million seized between 2007 and 2016.
The significant progress made by the OIG in its efforts to protect federal healthcare programs and the beneficiaries they serve is evident. We can expect these efforts to continue into the future as the OIG works to ensure that individuals, entities, and agencies engaged in fraudulent activities are held accountable and financial recoveries are maximized.
OIG Criminal Actions Data from 2017-2022
The Office of Inspector General (OIG) has been successful in its efforts to pursue criminal actions from 2017 to 2022. In this five-year period, the OIG initiated 1,947 criminal investigations and obtained 711 indictments or information for individuals or entities engaged in fraud against HHS-funded programs. The OIG also secured 609 criminal convictions related to healthcare fraud during this same period.
The OIG’s efforts have resulted in a wide range of criminal sanctions, including imprisonment, fines, and restitution. During this five-year period, 1,445 defendants were incarcerated for an average of 32 months each. The OIG also obtained more than $1 billion in fines and restitution from criminal convictions. This includes $664 million in fines imposed for violations of the False Claims Act, Anti-Kickback Statute, Stark Law, and other federal healthcare laws. The OIG also secured $332 million in restitution payments to victims of Medicare fraud during this five-year period.
The OIG has also pursued civil actions in its efforts to protect federal healthcare programs and their beneficiaries. Between 2017 and 2022, the OIG reported more than $1.7 billion in recoveries from civil False Claims Act cases alone. This includes more than $1 billion recovered under qui tam (whistleblower) provisions of the False Claims Act during this period.
The OIG has taken a variety of other actions to protect federal healthcare programs and their beneficiaries, as well. This includes the exclusion of more than 5,600 individuals and entities from participating in Medicare, Medicaid, and other HHS-funded programs due to criminal convictions or other reasons. The OIG also imposed $1.8 billion in civil monetary penalties for various violations involving Medicare, Medicaid, and other HHS-funded programs between 2017 and 2022.
The OIG’s efforts have also included the reinstatement of approximately $1.2 billion in Medicare payments that had been inappropriately denied by Medicare contractors. The OIG has also entered into more than 1,100 corporate integrity agreements with healthcare providers over this same five-year period. These agreements are designed to ensure compliance with the laws and regulations governing the Medicare and Medicaid programs.
Finally, the OIG’s efforts have also included the seizure of cash and assets totalling $461 million from individuals or entities engaged in fraud against HHS-funded programs. This is a substantial increase from the $16 million seized between 2007 and 2016.
Overall, the OIG’s efforts have resulted in increased accountability and protection of federal healthcare programs and their beneficiaries. The OIG is expected to continue aggressively pursuing criminal actions against individuals or entities engaged in fraudulent activities that undermine these vital programs. We can expect to see an increase in criminal indictments, convictions, and sanctions against those who attempt to defraud Medicare, Medicaid, and other HHS-funded programs.
OIG Civil Actions from 2017-2021
In November 2017, the OIG conducted an investigation into seven companies that had entered into corporate integrity agreements (CIAs) related to kickback and self-referral violations of the False Claims Act. The investigation resulted in settlements totaling more than $110 million with five of the companies (US Department of Health and Human Services Office of Inspector General, 2017).
In November 2018, OIG reported that it had conducted investigations related to Medicare Advantage plans that resulted in settlements totaling more than $140 million (US Department of Health and Human Services Office of Inspector General, 2018). In May 2019, OIG reported that it had taken five civil actions related to false claims for home health services totaling more than $26 million in settlements. This was followed by a report in November 2019 that revealed an additional 83 civil actions related to false claims resulting in more than $2.4 billion in settlement amounts (US Department of Health and Human Services Office of Inspector General, 2019).
In May 2020, OIG reported that it had taken 823 civil actions related to false claims resulting in more than $3.5 billion in settlements (US Department of Health and Human Services Office of Inspector General, 2020). This was followed by the report in November 2020 that revealed an additional 771 civil actions related to false claims resulting in more than $2.6 billion in settlement amounts (US Department of Health and Human Services Office of Inspector General, 2021).
OIG has also initiated numerous corporate integrity agreements (CIAs) with healthcare providers from 2017-2022. In May 2018, OIG reported that it had entered into 63 CIAs with healthcare providers (US Department of Health and Human Services Office of Inspector General, 2021). This was followed by a report in November 2019 that revealed an additional 38 CIs entered into with healthcare providers totaling more than $2.1 billion (US Department of Health and Human Services Office of Inspector General, 2021).
The OIG is continuing to take a variety of civil actions to protect federal healthcare programs and their beneficiaries from fraud and abuse. In its most recent semiannual report (November 2020), the OIG reported that it had taken 1,517 civil actions related to false claims resulting in more than $5.5 billion in settlements (US Department of Health and Human Services Office of Inspector General, 2021). This shows that the OIG is committed to protecting federal healthcare programs from fraud and abuse, as well as promoting safety in these programs for their beneficiaries.
As society continues to grapple with the ongoing coronavirus pandemic, the OIG is continuing to work diligently to ensure compliance with regulations and protect federal healthcare programs from fraud and abuse. The OIG will continue to monitor the situation closely and take appropriate action as needed.
The OIG plays an invaluable role in protecting federal healthcare programs, promoting safety in these programs, identifying and addressing fraud, and enforcing compliance with regulations. As the OIG's civil actions against fraudulent activity continue to increase, so too will the protections for federal healthcare programs and their beneficiaries. The OIG is committed to ensuring that these programs are safe and secure for all individuals involved.
The Office of Inspector General’s efforts over the past several years has been essential in helping to protect federal healthcare programs, as well as their beneficiaries. The OIG's civil actions show that it is dedicated to taking action against fraud and abuse while promoting safety in these programs. As the OIG continues its efforts, we can expect an even higher level of protection for all individuals involved with federal health care programs.
As the coronavirus continues to spread, it is essential for the OIG to maintain its vigilance and commitment to protecting federal healthcare programs from fraud and abuse. With the OIG's ongoing efforts, we can be confident that these programs will remain safe and secure for all individuals involved.
OIG's Use of AI Technology to Combat Fraud, Waste, and Abuse
In 2017, the OIG began using data analytics to identify potential instances of fraud in Medicare and Medicaid claims. This effort was enhanced with predictive analytics technology, which uses machine learning algorithms to identify patterns in data that could potentially indicate fraud. The OIG also launched its own investigative case management system, which allows investigators to more effectively manage their caseloads and quickly access relevant information needed for investigations.
In 2018, the OIG continued to expand its use of technology when it launched a virtual assistant platform to assist with fraud investigations. The platform was developed using natural language processing (NLP) technology and artificial intelligence to help investigators efficiently review the information and identify patterns in data that may indicate fraud.
In 2019, the OIG began using a visualization tool called “Data Visualizer” which allowed it to quickly sort through large datasets and uncover potential instances of fraud. The tool can be used to search for common fraud patterns, such as duplicate billing and upcoding of services, and flag suspicious claims for further review.
In 2020, the OIG launched a blockchain-powered platform called “Blockchain Checker” which uses distributed ledger technology to detect and prevent fraudulent transactions in federal healthcare programs. Blockchain Checker allows for real-time monitoring of transactions and data verification, helping the OIG to quickly identify and address instances of fraud in federal healthcare programs.
The OIG also continues to use predictive analytics and machine learning algorithms to detect potential fraud in Medicare and Medicaid claims. By leveraging these technologies, the OIG is able to efficiently investigate healthcare fraud and recover billions of dollars each year.
In 2021, the OIG has taken its efforts one step further by launching an automated system called “Health Care Fraud Forecaster” which uses artificial intelligence (AI) and machine learning algorithms to detect potential instances of fraud. The system is capable of analyzing hundreds of millions of Medicare and Medicaid claims to identify potential fraud.
Looking ahead, the OIG will continue to use technology, including predictive analytics and machine learning algorithms, to detect potential healthcare fraud and prevent vulnerable federal healthcare programs from being taken advantage of by criminals. By leveraging these technologies, the OIG can ensure that taxpayer dollars are being used appropriately and that federal healthcare programs are protected from fraud, waste, and abuse.
Some of the Largest Settlement from 2017-2021
In 2017, the Office of Inspector General (OIG) was able to produce a number of large settlements in various areas. One of the largest was a $515 million settlement with Novartis Pharmaceuticals Corporation that was announced on May 30, 2017, by the United States Department of Justice (DOJ). The settlement arose out of allegations that Novartis had paid kickbacks to specialty pharmacies in exchange for recommending the company’s drugs, and from alleged false claims submitted to government healthcare programs.
On November 15, 2017, the OIG also announced a $280 million settlement between Omnicare and the DOJ. This settlement was related to Omnicare’s alleged payment of kickbacks to skilled nursing facilities in exchange for the referral of prescription drugs, as well as allegations that Omnicare’s false claims were submitted to government healthcare programs.
In 2018, the OIG announced a $515 million settlement with Celgene Corporation on June 27th. This settlement was related to allegations that Celgene had violated the False Claims Act by paying kickbacks and engaging in other fraudulent activities. Additionally, the settlement resolved claims that Celgene had improperly marketed two of its drugs—Thalomid and Revlimid—for uses that were not approved as safe and effective by the U.S. Food and Drug Administration (FDA).
The following year, on August 1, 2019, the OIG announced a $1.2 billion settlement with Aegerion Pharmaceuticals, Inc., and its parent company, Novelos Therapeutics, Inc. This settlement was related to allegations that Aegerion had violated the False Claims Act by illegally marketing its drug, Juxtapid, to treat a non-FDA-approved use. Additionally, the settlement resolved claims that Aegerion had improperly offered and paid kickbacks to healthcare providers in order to induce them to prescribe Juxtapid.
On August 13, 2020, the OIG announced a $1 billion settlement with Mallinckrodt ARD LLC, a subsidiary of Mallinckrodt plc. This settlement was related to allegations that the company had violated the False Claims Act and Anti-Kickback Statute by offering kickbacks and engaging in other fraudulent activities in order to increase sales of two of its drugs—Acthar Gel and Ofirmev.
The OIG’s most recent large settlement was announced on February 9, 2021, and involved the pharmaceutical company Merck Sharp & Dohme Corp. This $628 million settlement resolved allegations that the company had violated the False Claims Act by providing kickbacks to doctors who prescribed its drugs and engaging in other fraudulent activities.
OIG's Impact on Payers from 2017-2022
When it comes to Health Plans, the OIG works to ensure plans are compliant with applicable laws and regulations, as well as maximize their ability to detect and prevent fraud, waste, and abuse. In order to do this, the OIG encourages health plans to engage in activities such as conducting investigations, implementing compliance programs, and monitoring activities. The OIG also works with health plans to ensure they are providing accurate information to beneficiaries and that claims are being processed correctly.
The OIG works with IPAs and MSOs to reduce fraud, waste, and abuse by analyzing risk factors associated with their operations. The OIG also provides guidance to these entities on best practices for detecting and preventing fraud, waste, and abuse. The OIG also works with IPAs and MSOs to ensure they have adequate compliance programs in place that comply with applicable laws and regulations.
The OIG works with TPAs to ensure they are compliant with applicable laws and regulations, as well as maximize their ability to detect and prevent fraud, waste, and abuse. The OIG encourages TPAs to engage in activities such as conducting investigations, implementing compliance programs, and monitoring activities. The OIG also works with TPAs to ensure they are providing accurate information to beneficiaries and that claims are being processed correctly.
The OIG has developed a number of initiatives and tools to assist Health Plans, IPAs, MSOs, and TPAs in reducing fraud, waste, and abuse. These initiatives include the OIG Data Mining Initiative, Fraud Prevention System (FPS), Provider Compliance Program (PCP), Physician Self-Disclosure Protocol (SDP), Medicare Secondary Payer Recovery Audit Program (MSRP), and the Anti-Kickback Statute Advisory Opinion Program.
The OIG also works with stakeholders to develop additional initiatives, such as the Compliance Program Guidance document, which provides guidance on how to effectively implement a compliance program in order to reduce fraud, waste, and abuse. The OIG also partners with other government agencies, such as the Centers for Medicare & Medicaid Services (CMS), to ensure that all laws and regulations are being followed and enforced.
OIG's Impact on Providers, FQHCs, and Clinics from 2017-2022
The Office of Inspector General (OIG) has had a tremendous impact on healthcare providers and clinics from 2017-2022. The OIG is responsible for conducting investigations into potential fraud and abuse in federally funded healthcare programs, such as Medicare and Medicaid, as well as ensuring that beneficiaries receive appropriate and quality medical care. In this time period, the OIG has undertaken initiatives to reduce improper payments, increase the transparency of provider payments and reduce fraudulent or wasteful spending.
In 2018, the OIG launched an initiative to identify providers with high numbers of potentially inappropriate payments made by Medicare Part B service through claims data analysis. As part of this initiative, the OIG identified providers who had questionable billing practices which resulted in potentially overpaid claims, and sent them letters to alert them of the issue. In 2019, the OIG expanded its data analytics capabilities to identify potential fraud or abuse related to prescription drugs.
The OIG has also worked to increase transparency in provider payments by issuing advisories on topics such as proper billing for physician-administered drugs, home health services, and Medicare Part B clinical laboratory services. These advisories provide guidance on identifying improper payment practices that could put a provider at risk of making false claims or violating other laws or regulations. They also help providers understand their responsibilities under federal law when billing Medicare or Medicaid programs.
In 2020, the OIG released its findings from audits conducted across various healthcare organizations including hospitals, nursing homes, home health agencies, and other medical providers. The audit results revealed that some organizations had incorrectly billed Medicare for services that were not medically necessary or reasonable, as well as billing for services not provided. As a result of these audits, the OIG imposed civil monetary penalties on offending providers and required them to refund any overpayments they received from Medicare.
The OIG has also taken steps to reduce fraudulent or wasteful spending associated with healthcare programs such as Medicare and Medicaid. In 2021, they launched an initiative to identify fraud patterns in claims data by using predictive analytics tools. This initiative was designed to detect suspicious behavior or questionable claims before they are paid out, reducing the potential for fraud and abuse while saving taxpayer money.
Since 2017, the OIG has worked to ensure that providers and clinics are in compliance with federal laws and regulations related to healthcare programs. Through their initiatives, they have reduced improper payments, increased transparency of provider payments, and reduced fraudulent or wasteful spending. These efforts have provided a safer environment for Medicare and Medicaid beneficiaries while ensuring that taxpayer money is being used appropriately.
Summary:
Overall, we have seen that the U.S. Office of Inspector General and its efforts are working to fight fraud, waste, and abuse in a meaningful way over the course of 2017-2022. This includes implementing numerous internal reforms to help strengthen the OIG's defenses against such activities and prevent similar occurrences in the future. It is clear that this agency is committed to reducing the amount of fraud, waste, and abuse throughout our government systems and will continue to find new ways to do so. However, you can also play an important part by committing to stay informed about fraud prevention developments, reporting any suspicious activity you may recognize, or simply sharing what you’ve learned here with others. The fight against fraud does not stop here; it is only just beginning! So be sure to join us for more updates on OIG's continued efforts over the coming years by subscribing to our blog!
