OIG: Fraud crackdown nets record-breaking recoveries

Cardiovascular, musculoskeletal surgeries resulted in $63M in wasteful Medicare spending
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The Office of Inspector General is on its way to setting a record in recoveries of about $6.9 billion this fiscal year, according to its semiannual report submitted to Congress yesterday.

With "significant progress over the past year," according to Inspector General Daniel Levinson, OIG reported $923.8 million from audits and $6 billion from investigations, as well as $8.5 billion in estimated savings resulting from legislative, regulatory or administrative actions from OIG's recommendations.

OIG's crackdown has focused on reports of healthcare fraud, waste and abuse, most recently, at mental health centers, nursing homes and hospitals.

OIG said it excluded 3,131 individuals and entities from the federal health programs. It also reported 778 criminal actions against individual criminals or entities and 367 civil actions regarding false claims, civil monetary penalties and provider self-disclosure issues.

In Medicare, specifically, efforts by the federal program's Fraud Strike Force resulted in charges against 305 individuals or entities, 181 convictions and $151 million in investigative receivables.

Two audits earlier this year focused on cardiovascular and musculoskeletal surgeries, in which the evaluation and management services (E/M) payments did not reflect the services actually provided. The 2012 reports found that cardiovascular and musculoskeletal surgery claims in 2007 revealed $63 million in wasteful Medicare spending in E/Ms not provided. OIG attributed it to a faulty global physician fee schedule that doled out payments related E/M services before the day of surgery, the day of the surgery and the 90 days after the day of the surgery--regardless of whether the E/M services were actually provided, OIG found.

In a separate report, OIG found flaws in how providers record adverse and temporary harm events with "present-on-admission" conditions at a 3 percent error rate in October 2008 claims. Although OIG determined it was relatively low, present-on-admission indicators provide an opportunity for monitoring hospital care quality.

For more information:
- see the OIG announcement and report on recoveries
- check out the OIG cardiovascular report and musculoskeletal report (.pdfs)
- here's the OIG summary and report (.pdf) on POA indicators

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