Monthly Archives:' January 2017


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The HHS OIG issued its work plan for 2017.  This is significant to False Claims Act attorneys, relators and litigants because healthcare fraud continues to make up the largest share of FCA recoveries. The Office of Inspector General (OIG) is responsible for maintaining the integrity of the Health and Human Services (HHS) programs, including the Centers for Medicare and Medicaid Services (CMS). It does this by trying to identify, investigate and reduce improper payments and healthcare fraud, waste and abuse.

Here are some of the new and revised issues OIG will be focusing on in 2017:

Medicare Parts A and B

  • Hyperbaric Oxygen Therapy Services – Provider Reimbursement in Compliance with Federal Regulations
  • Incorrect Medical Assistance Days Claimed by Hospitals
  • Inpatient Psychiatric Facility Outlier Payments
  • Case Review of Inpatient Rehabilitation Hospital Patients Not Suited for Intensive Therapy
  • Nursing Home Complaint Investigation Data Brief
  • Skilled Nursing Facilities – Unreported Incidents of Potential Abuse and Neglect
  • Skilled Nursing Facility Reimbursement
  • Skilled Nursing Facility Adverse Event Screening Tool
  • Medicare Hospice Benefit Vulnerabilities and Recommendations for Improvement, A Portfolio
  • Review of Hospices Compliance with Medicare Requirements
  • Hospice Home Care — Frequency of Nurse On-site Visits to Assess Quality of Care and Services
  • Comparing HHA Survey Documents to Medicare Claims Data
  • Part B Services during Non-Part A Nursing Home Stays: Durable Medical Equipment
  • Medicare Market Share of Mail-Order Diabetic Testing Strips: April 1–June 30, 2016 –Mandatory Review
  • Positive Airway Pressure Device Supplies – Supplier Compliance with Documentation Requirements for Frequency and Medical Necessity
  • Intensity-Modulated Radiation Therapy
  • National Background Checks for Long-Term-Care Employees – Mandatory Review
  • Ambulance Services – Supplier Compliance with Payment Requirements
  • Inpatient Rehabilitation Facility Payment System Requirements
  • Histocompatibility Laboratories – Supplier Compliance with Payment Requirements

Medicare Parts C and D

  • Medicare Part C Payments for Service Dates After Individuals’ Dates of Death
  • Extent of Denied Care in Medicare Advantage and CMS Oversight
  • Medicare Part D Rebates Related to Drugs Dispensed by 340B Pharmacies
  • Questionable Billing for Compounded Topical Drugs in Part D
  • Medicare Part D Payments for Service Dates After Individuals’ Dates of Death


  • States’ MCO Medicaid Drug Claims
  • Data Brief on Fraud in Medicaid Personal Care Services
  • Delivery System Reform Incentive Payments
  • Accountable Care in Medicaid
  • Third-Party Liability Payment Collections in Medicaid
  • Medicaid Overpayment Reporting and Collections
  • Overview of States’ Risk Assignments for Medicaid-only Provider Types
  • Health-Care-Related Taxes: Medicaid MCO Compliance with Hold-Harmless Requirement
  • Health Care-Acquired Conditions – Medicaid Managed Care Organizations

CMS: Health Insurance Marketplaces

  • CMS Oversight and Issuer Compliance in Ensuring Data Integrity for the ACA Risk Adjustment Program
  • CMS Monitoring Activities for Consumer Operated and Oriented Plan Loan Program

For more information read


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The U.S. Department of Justice announced False Claims Act Recoveries totaling $4.7 Billion in 2016 from successful False Claims Act cases. Of this overall amount, $2.5 billion came from the health care industry, primarily pharmaceutical companies, medical device equipment & equipment companies, hospitals, nursing homes, laboratories, and physicians. The second largest recoveries came from the financial services industry, with $1.7 billion, mainly involving underwriting and lending fraud in the residential mortgage markets.

According to DOJ, whistleblowers filed 702 qui tam suits under the False Claims Act in fiscal year 2016, and DOJ recovered $2.9 billion from these and earlier filed qui tam lawsuits. As a result, whistleblowers were awarded $519 million for cases that settled or were decided in court during 2016.

For more information read