Feds seek $4 billion in health care fraud for the year

Federal investigators hope to net almost $4 billion in health care fraud for fiscal year 2022, which ended Sept. 30, 2022.

Christi A. Grimm, MPA
_{U.S. Department of Health and Human Services Office of Inspector General}

The figure was included in the semiannual report published Dec. 5 by the U.S. Department of Health and Human Services’ (HHS) Office of Inspector General (OIG). That office’s goal is to fight fraud, waste, and abuse, while promoting quality, safety, and value in programs and for beneficiaries, while advancing excellence and innovation.

“HHS-OIG continues to provide essential, data-driven oversight and enforcement to drive positive change in HHS programs and for individuals they serve,” OIG’s Inspector General Christi A. Grimm said in a news release.

"This report describes pragmatic and meaningful progress resulting from the diligent work and unwavering dedication of HHS-OIG’s workforce,” Grimm said. “I am confident that the effects of our efforts during the reporting period – which include recommendations to improve nursing home life safety and emergency preparedness, recovery of over a billion dollars in taxpayer funds, and the exclusion of 1,290 individuals and entities from participating in federal health care programs – resonate throughout all of HHS.”

Telehealth in the spotlight

This year, OIG identified 1,714 providers whose billing for telehealth services during the first year of the COVID-19 pandemic posed a high risk to Medicare.

“Each of these 1,714 providers had concerning billing on at least one of seven measures we developed that may indicate fraud, waste, or abuse of telehealth services,” the HHS-OIG news release said. “In addition, more than half of the high-risk providers we identified are part of a medical practice with at least one other provider whose billing poses a high risk to Medicare. Further, 41 providers whose billing poses a high risk appear to be associated with telehealth companies.”

OIG acknowledged there are about 742,000 providers and the “high-risk” group is a small proportion of the total. But “these findings demonstrate the importance of strong, targeted oversight of telehealth services,” the news release said.

Despite the small group, HHS this year published a special advisory to physicians on spotting telehealth fraud. That notice came shortly after HHS-OIG announced its investigators won or negotiated more than $5 billion in health care fraud judgments and settlements – a record amount – for the year ending Sept. 30, 2021.

Other enforcement

The report covered enforcement actions from April 1 to Sept. 30, 2022. It projected nearly $4 billion in expected recoveries resulting from HHS-OIG audits and investigations from October 2021 to the end of September 2022. OIG expects to collect more than $1 billion based on program audit findings, and about $3 billion based on investigative work.

In its fiscal year 2022, HHS-OIG reported:

• 710 criminal enforcement actions against individuals or entities that engaged in crimes that affected HHS programs.
• 736 civil actions, which include false claims and unjust-enrichment lawsuits filed in federal district court, civil monetary penalty settlements, and administrative recoveries related to provider self-disclosure matters.
• 2,332 individuals and entities excluded from participation in federal health care programs.