OIG Helping to Crack Down on Health Care Fraud
In cities large and small across America, the healthcare industry has been celebrated as the COVID-19 pandemic has played itself out. However, before we hand out medals and begin the process of deification, we must recognize that not everyone who purports to be in the business of saving, improving and extending lives, is a hero.
In fact, the Office of the Inspector General or OIG, associated with Health & Human Services has just issued a report for the period from October 1, 2019 to March 31, 2020. So far they reported $605 million in expected recoveries for Healthcare and close to $290 million in what is known as “questioned costs.” It will mount to $1.5 billion total when all is said and done.
Questioned costs essentially mean that the charges were wholly unreasonable considering the paltry documentation.
The purpose of the OIG is to identify “illegal activity that can unnecessarily raise costs for the Medicare program or put beneficiaries at risk.” Of the money recovered in the first half of the fiscal year, we must remember that the 900 providers who were caught committing fraud against federal healthcare programs were hardly making minor, inadvertent accounting mistakes. These constitute nearly 450 criminal cases and civil actions against hundreds of scammers of the Medicare and Medicaid system.
Healthcare Fraud
The OIG reported that much of the fraud abused Medicare Part D eligibility information. Part D is that supplemental portion that helps pay for drugs. Not surprisingly, one of the entities caught was a pharmaceutical company entering nearly $12 million in false claims.
However, they were hardly alone. Included in the mix were: 60 hospitals that received excessive payments; New Jersey claims for $63 million in unallowable Medicaid school-based administrative costs; a Medicare audit identifying nearly $55 million for acute care (emergency clinics) filings for improper claims; numerous, improper childcare facility claims. Other cases underscored ongoing fraud in the opioid industry including bribes and kickbacks.
Obviously, hospitals, clinics, schools, pharmacies and pharmaceutical companies are not “things,” or buildings. They are people. Many of those people are healthcare professionals, administrators, insurance filing experts and additional claims experts.
Fraud cannot exist in the midst of ethical behavior, but requires the vacuum of unethical conduct. Someone in the chains-of-command of the entities above, approved overcharges, kickbacks, bribes, false filing and misinformation and the OIG is identifying them.
How could this happen to such a widespread extent? How could the healthcare fraud in just the first six-months of the fiscal year be as high as an estimated $1.5 billion? It only takes three elements.
The Game
Fraud needs opportunity and usually, a lack of oversight. That chain-of-command referred to above as well, has experts on hand who frequently look to bend or stretch the rules. They are so convinced the system is flawed, that they have to “game the system” to squeeze out every penny they can. The more they feel they can legally get, the more they can get paid. It is a fine line and a contentious line between the ethical and the unethical, and yes, that line is pushed too hard. Sometimes, the patients themselves are screwed in the process. If not with opportunity, certainly with need.
Then there is the need. In this case, the more money an unethical practice feels it can take in the better. It is sometimes worth the risk for them to get greedy. There is a disconnect between the government paying out higher amounts of money, and tax increases and rising healthcare costs by those who can least afford it.
Finally, there is rationalization. Those who game the system will often protest that they do it, because everyone does it. But there is no race to the unethical finish line; it is a matter of integrity and making ethical choices.
In the first six months of the current fiscal year, the government reclaimed about $1.5 billion as the result of fraudulent healthcare claims. It is clear that there is an ethics problem in healthcare. It is long past time for it to happen.
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