OIG Touts Nearly $3B In Medicare, Medicaid Fraud Recoveries

December 3, 2018, Alex Spanko, Skilled Nursing News - The Department of Health and Human Services’ top fraud watchdog recovered nearly $3 billion from providers in fiscal 2018, a figure that included more than $18 million in improper payments at nursing homes.  

The HHS Office of the Inspector General (OIG) touted its $2.91 billion haul in its most recent semiannual report to Congress, released at the end of last week, tallying 764 criminal actions and the removal of more than 2,700 providers from the approved Medicare and Medicaid rolls.

“OIG continues to fulfill its crucial mission for the American people by providing objective, actionable information and recommendations to improve fiscal stewardship and quality of services provided by HHS programs and by holding those who harm HHS programs accountable,” inspector general Daniel Levinson wrote in the report.

The OIG’s actions in fiscal 2018, which ended September 30, included flagging $18.4 million in Medicare spending on durable medical equipment related to skilled nursing facility stays that didn’t qualify for Medicare coverage.  In some cases, the OIG found, Medicare paid for equipment at nursing homes that were only approved to handle Medicaid residents.

The Centers for Medicare & Medicaid Services (CMS) agreed to increase oversight of such payments going forward, as well as determine the potential costs and benefits of tracking the level of care provided in Medicaid-only buildings.

“CMS requires facilities to provide DME as a standard part of nursing care, and does not permit separate Medicare payment for DME except when Medicaid-only nursing facilities serve as beneficiary homes,” the OIG noted in its report.  “CMS uses two payment edits designed to identify and reject inappropriate claims, but neither edit rejected the claims because SNFs and DME suppliers did not submit full and accurate information required for processing.”

The six-month reporting period — which stretched from April to September — also included the $30 million settlement that provider Signature HealthCARE agreed to pay in June to resolve allegations of fraudulent billing for rehab therapy services, as well as the capture of an OIG Most Wanted Fugitive with nursing-home ties. 

Etienne Allonce was accused of billing Medicare for wound care supplies that his Hicksville, N.Y.-based durable medical equipment company didn’t actually provide.  Allonce and his wife, Helene Michel, allegedly stole patient medical records from nursing homes in order to further their scheme, according to the OIG.

Allonce is currently being held pending formal charges, while Michel was sentenced to 12 years in prison after being convicted in 2013.

Phone tag

Each report to Congress features a breakdown of how the OIG receives tips regarding potential fraud at health care facilities, with HHS logging 60,390 calls to its confidential free tip line between April and September. 

Of that total, the OIG evaluated more than 11,000 tips, with 8,000 referred for further action.  In all, the department estimates that the hotline alone pulled in $27 million in recovery funds during the six-month reporting period.

That’s a significant uptick in calls from the mid-1990s, when the hotline was first established; writing in a 1996 semi-annual report to Congress, the OIG reported about 23,600 calls between June 1995 and March 1996.