The Department of Health and Human Services (HHS), Office of Inspector General (OIG) expects to recoup billions of dollars in misspent Medicare, Medicaid, and other health and human services funds according to their news release on December 1, 2023. Their latest report, the Fall 2023 Semiannual Report to Congress (SAR), highlights over $3.44 billion in expected recoveries resulting from HHS-OIG audits and investigations conducted during fiscal year (FY) 2023.
In FY 2023, HHS-OIG reported 707 criminal enforcement actions against individuals and entities suspected of engaging in crimes targeting HHS programs and the people they serve. HHS-OIG also reported 746 civil actions, which include false claims and unjust-enrichment lawsuits filed in federal district court, civil monetary penalty settlements, and administrative recoveries related to provider self-disclosure matters. They also excluded 2,112 individuals and entities from participation in federal healthcare programs.
According to the report, a top priority for the OIG is improving nursing home quality of care. The OIG has 29 ongoing audits and evaluations of nursing home issues. They are continuing to monitor identified areas of concern, promote unimplemented recommendations, and issue new recommendations as they identify problems and solutions.
In the report, they list their three-part strategy:
- Performance: Understanding what drives nursing home performance, and in particular what contributes to poorly performing nursing homes.
- Residents First: Ensuring that nursing homes prioritize quality of care and quality of life for residents.
- Oversight: Ensuring that entities responsible for nursing home oversight—CMS and States—detect problems quickly and effect rapid remediation.
You can access the SAR here.
Compliance Perspective
Issue
Misuse of allocated public funds can be seen as fraud, waste, and abuse of government funds. The Centers for Medicare & Medicaid Services (CMS) requires skilled nursing facilities to have a compliance and ethics program that is effective in preventing and detecting criminal, civil, and administrative violations under the Social Security Act, and in promoting quality of care. Routine audits should be conducted at each facility on monetary transactions and the results of the audits should be reported to the compliance and ethics committee and to the governing body. The audits should have a corrective action plan to address any identified discrepancy, and all discrepancies should be investigated and rectified immediately.
Discussion Points
- Review your policies and procedures for operating an effective compliance and ethics program. Ensure that your policies are reviewed at least annually and updated when new information becomes available.
- Train all staff on your compliance and ethics policies and procedures upon hire and at least annually, including their responsibility to identify and report any concerns of fraud, waste, or abuse of government funds in a timely manner. Document that these trainings occurred and file the signed document in each employee’s education file.
- Periodically perform audits to ensure all staff are aware of the importance of identifying compliance and ethics concerns and their responsibility to report them to their supervisor, the compliance and ethics officer, or via the anonymous hotline.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
