Does HHS OIG investigate Medicare frauds?
HHS-OIG has encountered a variety of scams in which fraudsters are preying upon people across the U.S., including Medicare and Medicaid beneficiaries. Criminal, civil or administrative legal actions relating to fraud and other alleged violations of law, initiated or investigated by HHS-OIG and its law enforcement partners.
What happens if you are investigated by the OIG?
On first glance, investigations by a federal agency’s Office of Inspector General, or OIG, may seem like no big deal. An inspector general has no criminal authority. He can’t charge you with a crime or throw you in jail.
What kind of legal action does HHS OIG take?
Criminal, civil or administrative legal actions relating to fraud and other alleged violations of law, initiated or investigated by HHS-OIG and its law enforcement partners. HHS-OIG Hotline Operations accepts tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement in HHS programs.
What are the laws against Medicare fraud?
In addition to Medicare Part A and Part B, Medicare Part C and Part D and Medicaid programs prohibit the fraudulent conduct addressed by these laws.
What does the OIG assist with in the healthcare industry?
Since its 1976 establishment, the Office of Inspector General (OIG) has been at the forefront of the Nation's efforts to fight waste, fraud and abuse and to improving the efficiency of Medicare, Medicaid and more than 100 other Department of Health & Human Services (HHS) programs.
What does the anti kickback statute prohibit?
The AKS is a criminal law that prohibits the knowing and willful payment of "remuneration" to induce or reward patient referrals or the generation of business involving any item or service payable by the Federal health care programs (e.g., drugs, supplies, or health care services for Medicare or Medicaid patients).
What is the OIG self disclosure protocol?
OIG's contractor self-disclosure program enables contractors to self-disclose potential violations of the False Claims Act and various Federal criminal laws involving fraud, conflict of interest, bribery or gratuity.
What is the OIG SNF compliance guidance?
OIG has developed a series of voluntary compliance program guidance documents directed at various segments of the health care industry, such as hospitals, nursing homes, third-party billers, and durable medical equipment suppliers, to encourage the development and use of internal controls to monitor adherence to ...
What is the difference between the Stark Law and the Anti-Kickback Statute?
The Anti-Kickback Law covers referrals for all services from anyone including physicians or pharmaceutical companies. Conversely, the Stark Law is for referrals from physicians only and covers a set list of “Designated Health Services” (DHS).
Which of the following actions is legal under the Anti-Kickback Statute?
Under the provisions of the Anti-Kickback Statute, the law prohibits the soliciting, receiving, offering, or paying any remuneration (including any kickback, bribe, or rebate) directly or indirectly, overtly or covertly, in cash or kind.
What does Stark law prohibit?
The Physician Self-Referral Law, also known as the “Stark Law,” generally prohibits a physician from making referrals to an entity for certain healthcare services, if the physician has a financial relationship with the entity.
What is a referral under the Anti-Kickback Statute?
The federal Anti-Kickback Statute (AKS) (See 42 U.S.C. § 1320a-7b.) is a criminal statute that prohibits the exchange (or offer to exchange), of anything of value, in an effort to induce (or reward) the referral of business reimbursable by federal health care programs.
What disclosure protocol should be used by providers when disclosing a stark violation?
Self-Referral Disclosure Protocol (SRDP)Stark- only conduct should be disclosed to CMS through its Self-Referral Disclosure Protocol (SRDP), which can be found at: http://www.cms.gov/PhysicianSelfReferral/. OIG reserves the right to determine whether an arrangement is appropriate for resolution in the SDP.
What are the seven OIG elements of an effective compliance plan?
They are as follows:Designation of a compliance officer and compliance committee. ... 2. Development of compliance policies and procedures, including standards of conduct. ... Developing open lines of communication. ... Appropriate training and education. ... Internal monitoring and auditing. ... Response to detected deficiencies.More items...•
What is OIG exclusion list?
Exclusions. The Office of Inspector General's List of Excluded Individuals/Entities (LEIE) provides information to the health care industry, patients and the public regarding individuals and entities currently excluded from participation in Medicare, Medicaid, and all other Federal health care programs.
How does the OIG impact healthcare?
The Office of Inspector General (OIG) for the U.S. Department of Health & Human Services has created the educational materials to assist in teaching physicians about the Federal laws designed to protect the Medicare and Medicaid programs and program beneficiaries from fraud, waste, and abuse.
What is the OIG exclusion statute?
Section 1320a-7, requires the OIG to exclude individuals and entities convicted of any of the following offenses from participation in all Federal health care programs:
What is the OIG?
The OIG protects the integrity of HHS’ programs and the health and welfare of program beneficiaries. The OIG operates through a nationwide network of audits, investigations, inspections, evaluations, and other related functions. The Inspector General is authorized to, among other things, exclude individuals and entities who engage in fraud or abuse from participation in all Federal health care programs, and to impose CMPs for certain violations.
What is the Stark Law?
Section 1395nn, often called the Stark Law, prohibits a physician from referring patients to receive “designated health services” payable by Medicare or Medicaid to an entity with which the physician or a member of the physician’s immediate family has a financial relationship , unless an exception applies.
What is CMPL 1320A-7A?
The CMPL, 42 U.S.C. Section 1320a-7a, authorizes OIG to seek CMPs and sometimes exclusion for a variety of health care fraud violations. Different amounts of penalties and assessments apply based on the type of violation. CMPs also may include an assessment of up to three times the amount claimed for each item or service, or up to three times the amount of remuneration offered, paid, solicited, or received. Violations that may justify CMPs include:
What is the OIG self disclosure protocol?
The OIG Provider Self-Disclosure Protocol is a vehicle for providers to voluntarily disclose self-discovered evidence of potential fraud. The protocol allows providers to work with the Government to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation.
What is the role of third party payers in healthcare?
The U.S. health care system relies heavily on third-party payers to pay the majority of medical bills on behalf of patients . When the Federal Government covers items or services rendered to Medicare and Medicaid beneficiaries, the Federal fraud and abuse laws apply. Many similar State fraud and abuse laws apply to your provision of care under state-financed programs and to private-pay patients.
What is heat in Medicare?
The DOJ, OIG, and HHS established HEAT to build and strengthen existing programs combatting Medicare fraud while investing new resources and technology to prevent and detect fraud and abuse . HEAT expanded the DOJ-HHS Medicare Fraud Strike Force, which targets emerging or migrating fraud schemes, including fraud by criminals masquerading as health care providers or suppliers.
Grant Fraud
HHS is the largest grant-making organization in the federal government, and its funding of health and human services programs touches the lives of almost all Americans. Fraud or misconduct related to the receipt or expenditure of HHS grants should be reported to our Hotline.
Contract Fraud
HHS-OIG is responsible for conducting investigations into fraud, waste, and abuse involving HHS programs, including HHS contracts. Any suspected fraudulent activities by participants on HHS contracts should be reported to our Hotline.
Whistleblower Protection Coordinator
Whistleblower disclosures by HHS employees can save lives and taxpayer dollars. These individuals play a critical role in keeping our government honest, efficient, and accountable.
Fraud Risk Indicator
HHS-OIG assessment of future risk posed by persons who have allegedly engaged in civil health care fraud.
Operation CARE
HHS-OIG has a long history of protecting the health and well-being of HHS beneficiaries, including residents in long-term care facilities such as nursing homes. HHS-OIG collects and investigates tips and complaints about fraud, waste, and abuse in these facilities.
What is an OIG investigation?
Many criminal investigations of private companies start with OIG investigations. For example, the OIG for Health and Human Services investigates Medicare fraud; that can easily lead to a False Claims Act case or criminal charges.
How are OIG investigations made public?
The results of an OIG investigation may be made public through published reports. Each OIG has its own practice with respect to publishing investigation results. Some offices publish only a summary of the investigatory findings and others publish redacted final reports.
How are OIG subpoenas enforced?
OIG subpoenas will be enforced by the federal courts as long as they (1) are issued for a lawful purpose, and (2) are reasonably relevant to that purpose, and (3) are not unduly burdensome. Some agencies have internal regulations that govern the issuance of subpoenas, as well.
Why do federal agencies have an OIG hotline?
Federal agencies have an OIG hotline to allow for reporting of complaints. The complaints can be made anonymously. This anonymous reporting process serves a legitimate purpose—to encourage employees to report problems without fear of retribution, particularly if the alleged wrongdoer is a supervisor.
What is an OIG?
In short, OIGs investigate waste, fraud and abuse within government agencies and report to Congress about their findings. OIGs are independent from the agency and the inspector general reports only to Congress. In other words, the Secretary of Defense cannot stop or direct a DoD OIG investigation.
What is the purpose of the Inspector General Act?
It defined three purposes: (1) to conduct and supervise audits and investigations relating to the programs and operations of the establishments listed in section 12 (2);
Can an OIG lawyer hear out defense counsel?
Defense counsel are not part of the process as they are in a standard white collar investigation. Although an employee can bring counsel to the interview , it is rare that the OIG lawyers will engage with or hear out defense counsel in the same way that an AUSA would during an attorney proffer.
What happens if you don't file a Medicare exclusion?
If the Medicare exclusion was in error, you will be reinstated.
What happens if you are excluded from Medicare?
Once you have been notified that you are excluded from Medicare, you must cease billing all federally funded health programs and consult with an experienced Medicare exclusion attorney.
How long does it take for Medicare to reinstate?
It can take up to six months or more for the OIG to rule on your Medicare reinstatement application.
Why should the proposed length of exclusion be modified?
Reasons, if applicable, why the health or safety of Medicare beneficiaries does not warrant exclusion. If you do not file a timely request for a hearing, you lose your right to appeal.
How long do you have to appeal Medicare exclusion?
You only have 60 days from your notice of ...
Why is Medicare exempt?
Reasons for Medicare Exclusion. You can be excluded from Medicare for a variety of reasons outlined in 42 U.S.C. §1320a-7. Some Felony convictions can result in Medicare exclusion, especially those arising from health care fraud, or the unlawful manufacture, distribution or prescription of dispensing controlled substances (drug trafficking).
Is Medicare reinstatement automatic?
Medicare reinstatement is not automatic. If you have been notified of exclusion from Medicare by the HHS OIG, you must understand that you are prevented from working for any individual or entity that contracts with Medicare, Tricare or other Federally funded programs until you receive notice of reinstatement.