Audit and medical review are terms that understandably put a lot of nursing homes on edge. The newsmakers in the Medicare/Medicaid billing arena are the U.S. Department of Justice (DOJ) and the Office of Inspector General (OIG) at the U.S. Department of Health and Human Services (HHS), which lead some significant collaborative efforts.
On the civil side, DOJ and the OIG regularly work with other agencies and law enforcement to coordinate False Claims Act (FCA) lawsuits, accruing more than $2.8 billion in FCA settlements and judgments just in fiscal year (FY) 2018 ending Sept. 30, 2018. It’s fairly common for nursing homes to be targeted in FCA lawsuits. For example, skilled nursing facilities (SNFs), their executives, and even their consultants paid more than $41 million to resolve FCA allegations in FY 2018, mostly related to rehabilitation therapy services that weren’t reasonable, necessary, and skilled, as well as for grossly substandard quality of care. In addition, there were several FY 2018 FCA cases tangentially involving nursing homes (e.g., a company facing FCA allegations related to paying nursing homes kickbacks).
On the criminal side, the now 11 DOJ/OIG-led Medicare Strike Force teams based in high-fraud areas nationwide have charged more than 3,700 defendants who submitted over $14 billion in false Medicare billings since the program’s inception in 2007 under the interagency Health Care Fraud Prevention and Enforcement Action Team (HEAT). In June 2018, the Strike Forces led the nation’s largest-ever healthcare fraud enforcement action (aka Takedown Day), charging more than 600 doctors, nurses, and other licensed medical professionals in fraud cases worth more than $2 billion in false billings.
The Strike Forces partner U.S. Attorney’s Offices, the FBI, and the OIG with other federal and local law enforcement agencies and state Medicaid Fraud Control Units. Using advanced data analysis techniques to find aberrant billing levels, suspicious billing patterns, and emerging schemes, the Strike Forces investigate and prosecute cases involving fraud, waste, and abuse in federal healthcare programs, including Medicare and Medicaid. Thus far, nursing homes haven’t been a significant target of the Strike Forces. In FY 2018, Strike Force teams brought only one case indirectly involving nursing homes.
The Center for Program Integrity (CPI) runs point on healthcare fraud, waste, and abuse at the Centers for Medicare & Medicaid Services (CMS). These efforts start with a focus on improper billing and move all the way up to outright fraud and abuse, including working with the DOJ/OIG civil and criminal teams. Here are the key CMS contractors that could send nursing homes an additional documentation request (ADR) letter related to Medicare or Medicaid claims.