The Department of Health and Human Services (HHS), Office of Inspector General (OIG), is expected to recover over $7 billion in healthcare fraud during fiscal year 2024, according to the Fall 2024 Semiannual Report to Congress (SAR), issued on December 4, 2024. The report highlights recoveries resulting from HHS-OIG audits and investigations conducted during the fiscal year.
In FY 2024, HHS-OIG reported 1,548 criminal and civil enforcement actions against individuals and entities suspected of crimes targeting HHS programs. These actions include criminal convictions and settlements resulting from civil monetary penalties. Additionally, 3,234 individuals and entities were excluded from participation in federal healthcare programs.
The report identifies over $4 billion in expected recoveries and receivables from investigations and audits conducted between April 1, 2024, and September 30, 2024. During this period, HHS-OIG made 239 new audit and evaluation recommendations, and 187 prior recommendations were implemented.
OIG also reviewed 100 for-profit nursing homes nationwide and found that 24 did not meet federal requirements for infection preventionists, who are responsible for infection control and prevention. Based on this sample, OIG estimates that 2,568 (approximately 1 in 4) for-profit nursing homes nationwide may not have complied with federal infection preventionist requirements, potentially increasing health and safety risks for residents and staff.
The report also identifies five significant management and performance challenges facing HHS:
- Public Health
- Financial Integrity
- Medicare and Medicaid
- Beneficiary Safety
- Data and Technology Security
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. This training should include their responsibility to identify and report any concerns regarding fraud, waste, or abuse of government funds in a timely manner. Document all training sessions and maintain signed documentation 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, Inc. for informational purposes only and is not intended to provide legal advice.*
