The Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (DHHS) released its Semiannual Report to Congress (Report) last week summarizing health care fraud investigation activities for the second half of fiscal year 2014 and the full year’s achievements. OIG reported expected recoveries of over $4.9 billion for fiscal year 2014 consisting of nearly $834.7 million in audit receivables and $4.1 billion in investigative receivables. In fiscal year 2014 OIG reported 971 criminal actions against individuals or entities engaged in crimes against DHHS programs, 533 civil actions for false claims lawsuits, civil monetary penalties settlements and administrative recoveries, and the exclusion of 4,017 individuals and entities from participation in Federal health care programs.The Health Care Fraud Prevention and Enforcement Action Team (HEAT) and Medicare Fraud Strike Force teams continue to invest in new technologies to prevent and combat health care fraud, waste, and abuse in the Medicare and Medicaid systems. Medicare Fraud Strike Force investigations during fiscal year 2014 resulted in charges against 90 individuals, involved in a total of approximately $260 million in false claims billed to Medicare. The health care fraud schemes were based on a variety of fraudulent activities, including conspiracy to commit health care fraud, violations of the anti-kickback statute, money laundering, and providing medically unnecessary treatments to Medicare beneficiaries.

The OIG referenced reports published earlier this year which identified questionable billing practices in the Medicare Part D prescription drug program. The Report also highlighted limited compliance among home health agencies with respect to the Medicare face-to-face encounter rule, improper payments for evaluation and management services, and inappropriate hospital inpatient claims subject to the post-acute care transfer policy.

In addition, the Report addressed how the OIG is implementing and overseeing various aspects of the Patient Protection and Affordable Care Act, including the Health Insurance Exchanges, Medicaid expansion, and the use of State establishment grants. The Report noted a number of issues with internal controls in the Health Insurance Exchange programs which limited the ability to prevent the use of inaccurate or fraudulent information in determining the eligibility of applicants for enrollment in qualified health plans. The Health Insurance Exchanges were also unable to resolve inconsistencies with applicant data due to operational issues with the CMS eligibility system.

The Report highlights the broad range of health care fraud activities that OIG is engaged in, and the significant financial return that OIG stands to gain from its investigative work. The Report amplifies the importance of provider compliance with the requirements of the Medicare and Medicaid programs and the need for providers to continuously monitor their compliance efforts.