Have a Claim?

Click here for a confidential contact or call:


OIG Identifies Fraud as Top Challenge in 2023 HHS Annual Report - Bring on the Whistleblowers

Posted  November 21, 2023

The Department of Health and Human Services (HHS) Office of the Inspector General (OIG) just released its 2023 Annual Report on its Top Management and Performance Challenges for the past year.  Among the key challenges OIG identified is better protecting HHS programs — Medicare and Medicaid being chief among them — from fraud, waste, and abuse.  No big surprise as this is a perennial challenge for the federal government’s top healthcare administrator.

What is surprising is the staggering amount of annual losses OIG projected from this recurring misbehavior in our healthcare system.  For last year, that amounted to roughly $131 billion in improper payments for Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP) alone.  With an annual spend last year of roughly $2.4 trillion, it would be virtually impossible to eliminate all improper payouts under the HHS umbrella.  But according to OIG, there is a lot more the agency can do to shore up its system.

Included among the healthcare areas OIG pointed to of particular concern are hospice, home health, hospitals, skilled nursing facilities, testing labs, genetic testing, durable medical equipment, substance abuse treatment, and COVID-19 testing.  OIG also highlighted the continued growth of managed care, which covers more than half of Medicare enrollees and more than 80 percent of Medicaid enrollees.  The Medicare Advantage program (Medicare Part C) has been an especially prolific area of fraud with Medicare Advantage organizations making their enrollees appear sicker than they actually are to maximize Medicare reimbursement.

Other than pointing to the need for improved monitoring and controls to address this fraud and abuse of the system, OIG did not provide much in the way of specific details or guidance.  Even more notable was the absence of any mention of what is perhaps the government’s most effective fraud-fighting tool — whistleblowers bringing suit under the False Claims Act.

The False Claims Act was enacted during the Civil War to go after war profiteers trying to defraud the Union Army.  It authorizes private individuals to bring lawsuits on behalf of the government against those that commit fraud against the government.  Over the past two decades, the government has recovered tens of billions of dollars under the statute, largely against companies that have defrauded the Medicare and Medicaid systems.  The vast majority of those recoveries came from lawsuits initiated by whistleblowers.

Another unique feature of the statute is that successful whistleblowers are entitled to recover up to 30 percent of any government recovery.  This has amounted to billions of dollars of whistleblower awards that have followed from the massive recoveries the government has secured under the False Claims Act.

OIG highlighted the importance of whistleblowers to the government’s fraud enforcement efforts by calling out the OIG Hotline and encouraging knowledgeable insiders to use it:

OIG Hotline Operations accepts tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement in HHS programs. Hotline tips are incredibly valuable, and we appreciate your efforts to help us stamp out fraud, waste, and abuse. . . .  Every complaint helps OIG carry out its mission of overseeing HHS programs and protecting the individuals they serve.  By reporting your concerns to the OIG Hotline, you help us safeguard taxpayer dollars and ensure the success of our oversight efforts.

But OIG failed to mention the critical role whistleblowers can also play by bringing actions under the False Claims Act.  Indeed, history has shown that it is whistleblowers and the False Claims Act that has been the most effective mechanism for detecting and deterring healthcare fraud.  Definitely important to know if you think you might have information relating to potential Medicare or Medicaid fraud.  And definitely something for OIG to highlight and promote going forward in its continuing efforts to stamp out fraud and abuse in our healthcare system.

If you think you have information of potential healthcare fraud and would like to speak to an experienced member of the Constantine Cannon whistleblower team, please do not hesitate to contact us for a free and confidential consult.

Read More

Tagged in: Healthcare Fraud, Medicaid, Medicare,