The focus on fraud in the delivery of health care gained importance with the passing of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Among HIPAA’s many provisions it established a national Health Care Fraud and Abuse Control Program which is jointly managed by the U.S. Attorney General and the Secretary of the Department of Health and Human Services. The law specified both criminal and civil enforcement actions as well as provided the financing to expand the government’s efforts to focus on health care fraud. ① Since the passing of HIPAA, the government has continued to add resources to strengthen their efforts to identify and eliminate abuse in the health care system. Strike Force teams were established In 2007 and now operate in nine locations: Miami, Florida; Los Angeles, California; Detroit, Michigan; Houston, Texas; Brooklyn, New York; southern Louisiana; Tampa, Florida; Chicago, Illinois; and Dallas, Texas. These are multi-agency teams consisting of federal, state, and local investigators that use Medicare data analysis techniques and focus on community policing.
In support of Strike Force operations the OIG:
- investigates individuals, facilities, or entities that submit false claims, for example, bill or are alleged to have billed Medicare and/or Medicaid for services not rendered, manipulate payment codes to inflate reimbursement amounts, etc.
- investigates business arrangements that allegedly violate the Federal health care anti-kickback statute and the statutory limitation on self-referrals by physicians
- examines quality-of-care and failure-of-care issues in nursing facilities, institutions, community-based settings, and other care settings and instances in which Federal programs may have been billed for services that were medically unnecessary, were not rendered, or were not rendered as prescribed or in which the care was so deficient that it constituted “worthless services.” ②
Strike Force Statistics as of December 31.2014③
Criminal Actions: 1,227
Indictments: 1,773
Fines $1,579,830,247
The government is reporting that its recovery efforts in fiscal year 2104, including program audits and investigations resulted in recovering nearly $5 billion dollars. The Office of the Inspector General (OIG) also reported 971 actions against individuals or entities for crimes against HHS programs as well as 533 civil actions during the fiscal year. Medicare Strike Force efforts by OIG and the Department of Justice resulted in the filing of charges in 232 criminal actions and the negotiation of more than 40 corporate integrity agreements. ④
The demand for a cardiovascular independent review organization is evident from the increasing scrutiny the OIG is placing on the reviews of cardiovascular procedures. Each year the OIG publishes a work plan that identifies the where the federal focus will be placed to reduce waste and fraud in the Medicare and Medicaid programs. In 2015 the work plan announced the nationwide review of right heart catheterizations (RHC) and endomyocardial biopsies. The OIG states that their reviews identified inappropriate payments when hospitals were paid for separate RHC procedures when the services were already included in payments for endomyocardial biopsies. ⑤ The 2015 work plan continues the focus on cardiac procedures that began in 2005 when the reviews focused on inpatient and outpatient claims involving arterial stent implantation. The 2005 focus was initiated to determine if the services submitted for Medicare payments were medically necessary and supported by adequate documentation. Furthermore, they reviewed claims for beneficiaries who had stent implantations during multiple procedures to determine if the implantations should have been performed simultaneously. ⑥
Page 1 Source:
- The Department of Health and Human Services And The Department of Justice Health Care Fraud and Abuse Control Program Annual Report For FY 1999; January 2000).
- Source: Work Plan Fiscal Year 2015 ; OIG U.S. Department of Health and Human Services, October 20, 2014.
- http://oig.hhs.gov/fraud/strike-force and Medicare Fraud Strike Force Charges 89 Individuals for Approximately $223 Million in False Billing; Office of Public Affairs (202) 514-2007/TDD (202)514-1888
- http://oig.hhs.gov/newsroom/podcasts/2015/review14-trans.asp
- http://oig.hhs.gov/reports-and-publications/archives/workplan/2014/work-plan-2014.pdf
- http://oig.hhs.gov/reports-and-publications/workplan/index.asp
Cardiovascular Peer Review, LLC
Cardiovascular Peer Review LLC (CPR) is an Independent Review Organization specializing in cardiovascular services with the mission to provide an unbiased external review service to fulfill the needs of hospitals and physicians who must comply with the oversight requirement of a Corporate Integrity Agreement (CIA) or similar reviews as mandated by the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) or other regulatory body.