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Home healthcare leads Medicaid fraud convictions; DME suppliers, pharma provide highest recoveries

OIG reports dive into fraud activity, compliance oversight guidance for governing boards

Home healthcare aides represented 30 percent of the criminal convictions by Medicaid Fraud Control Units (MFCU) in 2014, according to an Office of Inspector General (OIG) report. This marks a slight increase from 2013 and remains well ahead of any other provider type.

Of the 1,318 criminal convictions reported by MFCUs in 2014, 413 were home healthcare aides who were frequently convicted for rendering services that weren't provided or falsifying timesheets. Although durable medical equipment (DME) suppliers accounted for just 33 criminal convictions last year, they represented the largest monetary recovery in criminal cases, totaling $26.6 million. By comparison, home healthcare aide convictions brought in $12.5 million.

FierceHealthPayer: Antifraud has previously reported on the importance of efficiency, particularly when it comes to recoveries from state-run MFCUs

Additionally, MFCUs reported 874 civil settlements and judgements, 52 percent of which came from pharmaceutical manufacturers that led to a whopping $1.3 billion in recoveries. Over the last several years, pharmaceutical companies have been frequently embroiled in high-paying settlements linked to fraud allegations. By comparison, the next most profitable industry, home health agencies, made up just 3 percent of civil settlements and judgments but brought in $186.6 million in recoveries.

Last week, OIG also released updated guidelines regarding the healthcare governing board's involvement in audits, compliance and regulatory risk. In it, OIG recommended utilizing an "experienced regulatory, compliance, or legal professional" in order to stay abreast of compliance issues, and urged the governing board to improve its awareness of emerging risks and the efficacy of the organization's compliance program. A 2012 study showed that a quarter of hospital CEOs thought their boards were too large to be efficient, FierceHealthcare previously reported.

The guidelines place particular emphasis on involving the board in internal audits. High-risk fraud areas that may need special attention include "referral relationships and arrangements, billing problems (e.g., upcoding, submitting claims for services not rendered and/or medically unnecessary services), privacy breaches and quality-related events," OIG said.

For more:
- here's the OIG MFCU report (.pdf)
- read the OIG's governing board guidance (.pdf)

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