Office of Inspector General. Regional Enforcement Efforts and Priorities in Florida. South Atlantic Regional Conference January 28, 2011

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1 Office of Inspector General Regional Enforcement Efforts and Priorities in Florida Health Care Compliance Association South Atlantic Regional Conference January 28, 2011 Felicia Heimer, Esq. Office of Counsel to the Inspector General

2 OIG s Florida Region Office of Investigations Regional Office located in Miami, and Field Offices in Jacksonville and Tampa. OI employs more than 60 special agents and investigative support staff throughout the region. Office of Audit Services Locations in Tallahassee, Jacksonville and Miami employing more than 30 auditors. Office of Counsel One regional counsel based in Miami, more than 60 attorneys based in Washington, D.C., many of whom handle cases throughout Florida.

3 Mission of OIG Components Office of Investigations conducts and coordinates investigative activities relating to allegations of fraud, waste and abuse in HHS Programs. Serves as investigative liaison to DOJ, Attorney General, CMS and State Licensing Boards. Office of Audit Services conducts and oversees audits of HHS programs, including investigative audit work performed in conjunction with other OIG components. Office of Counsel imposes and litigates civil money penalty and program exclusion cases within the jurisdiction of the OIG, handles civil False Claims Act cases with DOJ, resolves voluntary self-disclosures, negotiates and monitors Corporate Integrity Agreements, and handles and litigates EMTALA cases.

4 Top Healthcare Fraud Schemes in Florida Home Health, Durable Medical Equipment, CORFs, ORFs, Part A and Part B Billing Medicare for services or items that were never provided to a patient Billing Medicare for medically unnecessary services Upcoding billing Medicare for a higher level of service than was actually provided Paying/receiving kickbacks for patient referrals

5 How Schemes are Identified CMS data mining, referrals, hot line calls, proactive work and data reports were you can see aberrations Government investigations (OIG, FBI, State Investigators) Qui tam relators (whistleblowers) OIG Hotline complaints Congressional inquiries Provider Self-Disclosure

6 OIG s Administrative Sanctions - Civil Monetary Penalties Administrative remedy for fraud False or fraudulent claims Billing while excluded Kickbacks Remedy 3 times amount claimed Up to $10,000 per item or service Six year statute of limitations OIG negotiates money and exclusion/cia Testimonial Subpoenas

7 OIG s Administrative Sanctions - Exclusion from Federal Health Care Programs In most cases for which the OIG may seek CMPs, the OIG may also seek exclusion from participation in all Federal health care programs Mandatory Exclusion (5 year minimum) conviction of program related crime conviction of patient abuse & neglect felony conviction of health care fraud felony conviction relating to controlled substances

8 OIG s Administrative Sanctions - Exclusion from Federal Health Care Programs (continued) Permissive Exclusion 15 authorities, including: certain misdemeanor convictions loss of state license to practice failure to repay health education loans failure to provide quality care Effect of Exclusion No program payment for any item or service Provided directly or indirectly List of Excluded Entities and Individuals available on the OIG s website

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10 Corporate Integrity Agreements The OIG may waive its exclusion authority in exchange for a CIA Standard Provisions Develop written standards of conduct, policies and procedures Designate a compliance officer or representative Educate and train staff to ensure competency in positions Retain an Independent Review Organization (IRO) to review contracts, claims, etc. Respond to improper activities, correct them, and report them, if necessary More CIAs are requiring complex IRO Reviews More CIAs are requiring Board-level involvement and oversight

11 For More Information Florida Fraud Hotline OIG Hotline HHS-TIPS