The Department of Health and Human Service, Office of Inspector General has released two recent reports:
The first report is titled, "Less Than Half of Part D Sponsors Voluntarily Reported Data on Potential Fraud and Abuse." You can download the report here.
The report examines data from 2011.
As a result, the IG recommending that CMS:
- amend regulations to require sponsors to report to CMS their identification of and response to potential fraud and abuse;
- provide sponsors with specific guidelines on how to define and count incidents, related inquiries, and corrective actions;
- review data to determine why certain sponsors reported especially high or low numbers of incidents, related inquiries, and corrective actions; and
- share sponsors' data on potential fraud and abuse with all sponsors and law enforcement.
CMS did not concur with the first recommendation, partially concurred with the second and fourth recommendations, and concurred with the third recommendation.
The second report is the IG's "Medicaid Fraud Control Units Fiscal Year 2013 Annual Report."
To download the full report, click here.
This Annual Report highlights statistical achievements from the investigations and prosecutions conducted by 50 MFCUs nationwide. The OIG compiled information from Quarterly Statistical Reports (QSRs) submitted by each MFCU, as well as supplemental data gathered by OIG.
The report is divided into various categories:
- MFCU Criminal Case Outcomes
- MFCU Civil Case Outcomes
- Provider Exclusions
- Other Observations
- OIG Oversight
A few report finding include:
- MFCUs reported 1,341 criminal convictions with criminal recoveries of nearly $1 billion in 2013.
- Home health agencies were most prominent providers in criminal cases.
- MFCUs reported 879 civil settlements and judgments in 2013 with civil recoveries of more than $1.5 billion. It should be noted that most recoveries came from multistate, global settlements.
- Civil settlements and judgments involved many provider types, although pharmaceutical companies were strongly represented.
- As an observation, the OIG offered that provider payment suspension rule (stemming from the ACA) demand more coordination between MFCUs and state Medicaid agencies.