Compliance is a tough job. It is thankless and often seen as the watchful eye. However, if ever there was a time to highlight the importance of compliance in healthcare, 2017 is the time. Why? Well, just look at it from the perspective of the OIG or Department of Justice (DOJ).
The OIG reported that in 2016, fraud and abuse was the number one problem facing healthcare when it comes to fines and punishment. Cases stemming from False Claims Act, poor quality of care, fraudulent billing, and Stark violations dominated the news. In the latest report on Fraud and Abuse in 2016, the combined efforts of the HHS OIG and DOJ won or negotiated over $2.5 billion in health care fraud judgments and settlements 2 , and it attained additional administrative impositions in health care fraud cases and proceedings. As a result of these efforts, as well as those of preceding years, in FY 2016 over $3.3 billion was returned to the Federal Government or paid to private persons.
In FY 2016, investigations conducted by HHS’ Office of Inspector General (HHS-OIG) resulted in 765 criminal actions against individuals or entities that engaged in crimes related to Medicare and Medicaid, and 690 civil actions, which include false claims and unjust-enrichment lawsuits filed in federal district court, civil monetary penalties (CMP) settlements, and administrative recoveries related to provider self-disclosure matters. HHS-OIG also excluded 3,635 individuals and entities from participation in Medicare, Medicaid, and other federal health care programs. Among these were exclusions based on criminal convictions for crimes related to Medicare and Medicaid (1,362) or to other health care programs (262), for patient abuse or neglect (299), and as a result of licensure revocations (1,448). HHS-OIG also issued numerous audits and evaluations with recommendations that, when implemented, would correct program vulnerabilities and save program funds.