The Department of Health & Human Services (HHS) and the Office of Inspector General (OIG) announced on December 15, 2010 successes in the fight against fraud, waste, and abuse. OIG reported savings and expected recoveries of $25.9 billion of all of fiscal year 2010. OIG’s $25.9 billion in savings and expected recoveries includes: $21 billion in implemented recommendations to put funds to better use, $3.8 billion in investigative receivables, and $1.1 billion in audit receivables.


These 2010 successes are due largely in part to the partnerships between HHS and the Department of Justice through the Health Care fraud Prevention and Enforcement Action Team (HEAT), reported Inspector General Daniel R. Levinson. OIG’s Special Agents were responsible for the unprecedented healthcare fraud takedown that spanned seven (7) cities resulting in charges against 94 doctors, healthcare company owners, executives, and others for more than $251 million in alleged false billing. In addition, 3,340 individuals and organizations were excluded from participation in Federal healthcare programs with 647 criminal actions against individuals or organizations that engaged in crimes against HHS programs and 378 civil actions. OIG work also prevents fraud and abuse through deterrence and by recommending actions to remedy program vulnerabilities.


Analysis of Errors Identified in Medicare Comprehensive Error Rate Testing Program (CERT)


This analysis found that six (6) types of Medicare healthcare providers account for $4.4 million or 94% of the $47 million in improper payments identified by the CMS’s CERT contractor for 2009; (1) inpatient hospitals; (2) durable medical equipment suppliers; (3) hospital outpatient departments; (4) physician; (5) skilled nursing facilities; and (6) home health agencies. The CERT contractor found that about 98% of the improper payments attributable to the six (6) types of providers had insufficient documentation, miscoded claims, and medically unnecessary services and supplies.


Nine Healthcare Employees Sentenced After Death of At-Risk Child.


Nine (9) employees at MultiEthnic Behavioral Health Services, Inc., (MEBH) we sentenced to prison terms ranging 15 months to 17 ½ years with restitution ranging from $316,000 to $1,216,000 resulting from charges related to healthcare fraud and the death of an at-risk child. Federal and local investigators found MEBH’s employees did not provide any services to the at-risk child as the child suffered from severe bed sores and extreme weight loss as she slowly starved to death. MEBH employees attempted to conceal the incident by destroying old records and creating new false records. Moreover, the defendants’ created false documentation, forging guardian signatures, destroying records, and fabricating other medical documents.


Businesses Agree To Pay $7.3 Million to Settle Stark Law Violations.


Physician-owned United Shockwave Services, Ltd.; United Urology Centers, LLC; and United Prostate Centers, LLC, (collectively United) agreed to pay $7,359,500 and along with United Therapies, LLC, enter into a 5-year CIA to resolve their Civil Monetary Penalties Law liability. The settlement resolves allegation that United violated the Anti-Kickback statute by soliciting remuneration from hospitals in exchange for patient referrals, to the extent of threatening to refer to competing hospitals if said hospital did not contract with United.