Detecting fraud, waste and abuse has become more important than ever with the U.S. Department of Health and Human Services Office of Inspector General (OIG) recently announcing a new legal team dedicated to the enforcement effort. This team will enforce OIG industry guidance by affirmatively litigating against providers who commit fraud through the use of civil monetary penalties and exclusion from federal health care programs.

According to Lisa Re, the Chief of the Civil Remedies Branch, in her remarks at the Annual Meeting of the American Health Lawyers’ Association on June 30^th, there are four main goals of the program:

1. Holding individuals accountable
2. Enforcing the OIG’s industry guidance
3. Filling enforcement gaps by enforcing cases the U.S. Department of Justice does not pursue
4. Amplifying other OIG component work. The team will consist of at least 10 lawyers working for these goals 100% of their time and will be headed by Deputy Chief Robert Penezic.

The team was created after Congress doubled the funding for health care fraud enforcement programs for this year. Before the start of the new team, the OIG in its last Semiannual Report to Congress which can be found at https://oig.hhs.gov/reports-and-publications/semiannual/index.asp, reported expected recoveries of over $1.8 billion, 326 civil actions including false claims and civil monetary penalties settlements, and 1735 exclusions of individuals and entities from participation in Federal health care programs. The new legal team will undoubtedly increase these actions and monetary recoveries.

The team will get their cases from multiple sources including individual outliers found from data analysis, providers who breach their Corporate Integrity Agreements, and providers involved in False Claim Act cases. The team’s emphasis will be on individual providers who commit fraud. Providers and provider-owned entities are cautioned to review their compliance programs.

Context⁴ Healthcare's ClaimsEditor® Online (CEO) helps providers strengthen their compliance programs by providing visibility to problems and actionable insight for resolution before problems leave the business office. Context takes identifying audit risk seriously as all payer entities, both public and private, are stepping up claim audits as a way to save money. CEO can help protect you from today’s increased audit activity. The Context team monitors Medicare, Medicaid, Medicare Administrative Contractor (MAC) and Recovery Audit Contractor (RAC) policies at the local, state, and national level, while also identifying key guidelines set forth by the Office of the Inspector General (OIG).

• Rules are updated weekly and are automatically deployed so edits are always up to date
• Monitor utilization across the patient’s history to identify patterns and potential audit risks
• Professional and facility bill types supported—identify overlaps across bill type for same encounter
• All patient coverage types supported—Commercial, Medicare

Subscribe to FWA Briefs today! Receive more articles on this topic, such as: Compliance Reports Identify 7 Billing Issues to Monitor for Fraud Risk