Posted and filed under Fraud, FWA, Healthcare, Medical Record Auditing.

Peggy Glynn, a former OIG Field Agent returns in this week’s guest blog post. Her friendship, insights, and experiences in the OIG are incredible tools for those looking to learn more about fighting healthcare fraud, waste, and abuse.

What is the USDHHS?

Who is the OIG?

Why do you care about the OI?

What:

USDHHS (HHS) is the United States Department of Health and Human Services.

HHS has 11 operating divisions, including eight agencies in the U.S. Public Health Service and three human services agencies. These divisions administer a wide variety of health and human services and conduct life-saving research for the nation, protecting and serving all Americans.

The 2020 budget for HHS is $1,286,434 billion.

Who:

One of the divisions within HHS is the Office of Inspector General (OIG).

The OIG’s mission is to protect the integrity of Department of Health & Human Services (HHS) programs as well as the health and welfare of program beneficiaries.  Since its 1976 establishment, OIG has been at the forefront of the Nation’s efforts to fight waste, fraud and abuse in Medicare, Medicaid and more than 100 other HHS programs.

HHS OIG is the largest inspector general’s office in the Federal Government, with approximately 1,600 individuals dedicated to combating fraud, waste and abuse and to improving the efficiency of HHS programs.  Most OIG’s resources go towards the oversight of Medicare and Medicaid… OIG’s government oversight extends to programs under other HHS institutions, including the Centers for Disease Control and Prevention, National Institutes of Health, and the Food and Drug Administration.

One of the components within the OIG is the Office of Investigations (OI).  OI is responsible for conducting criminal, civil, and administrative investigations of fraud and misconduct, involving the 100+ programs funded and operated by HHS.  OI is comprised of 11 regions.  OI agents are sworn federal law enforcement officers, with the authority to carry firearms, make arrests, execute search warrants and swear oaths.

These investigations are conducted by Special Agents (SA) with the assistance of analysts, auditors and evaluators.  Although responsible for protecting all the programs within HHS, OI focuses much of its attention on investigations concerning the Medicare and Medicaid program as these programs comprise 85% of the HHS budget (see below):

Why:

Why is it important to understand the role of OI and particularly the OI SAs? Understanding OIs mission and the SAs who facilitate that mission, will prevent companies, entities and individuals from claiming ignorance of the enforcement capabilities of the OIG, denial of appropriate compliance and regulatory methodologies and overtly skirting the policies, procedures and regulations in place to ensure that HHS programs remain financially viable.

So, see what makes OI SAs unique and different.

All OI SAs go through rigorous training that includes a total of 12 weeks of training.  Much of the initial training is conducted at the Federal Law Enforcement Training Center (FLETC) in Glynco, Georgia.  The training received at FLETC includes classrooms, physical fitness, firearms, tactical training, and practical exercises, such as investigating, surveillance, arrests, issuing subpoenas, and interviewing witnesses and subjects.

Upon completion of the Special Agent training program, OIG SAs receive 3 weeks of additional training at FLETC specifically focused on overall OIG operation and program administration.  This training, however, is not solely focused on the role of the OIG-OI SAs.  HHS-OIG is one of many OIGs within the federal government.

For example, the Veterans Administration, the Department of Justice, the Food and Drug Administration, the Department of Education, and the Social Security Administration (to name a few) all have OIGs and OI SAs.  The OIG specific training teaches the SAs the role of the OIG, and the impact in investigating fraud and waste within their departments.

For example, the OIG has administrative subpoena power, i.e. besides a Grand Jury subpoena, and OIG agent can issue an administrative subpoena which can be used in both criminal and civil investigations.  Issuance of an IG subpoena bypasses the Grand Jury secrecy rule and allows information collected to be shared with other law enforcement partners, such as the Federal Bureau of Investigations.

Upon completion of the OIG training, HHS OI SAs attend specialized training at the HHS training facility, the National Training Operations Center (NTOC).  During the SAs training at NTOC, the agent receives an in-depth review of the Medicare and Medicaid programs and ways in which to dedicate fraud and abuse to those programs.  The training also examines fraud and abuse to many of the other programs funded by HHS, such as grant fraud.   Additionally, the agents receive firearms and tactical training.

HHS-OIG-OI SAs are the leading investigators in combating fraud for Medicare and Medicaid, and healthcare programs generally.  The SAs are afforded access to auditors and evaluators who conduct reviews of the many HHS programs.  This access grants the SAs to on-the-spot experts.

Many SAs work in conjunction with other federal, state and local partners, because it has been widely demonstrated that fraud perpetuated on Medicare and Medicaid usually means fraud perpetuated on other healthcare insurers, such as Blue Cross and Blue Shield.

In conclusion, HHS OI SAs are highly trained unique individuals who protect the integrity of your tax funded HHS programs.

Thoughts for your Consideration:

  • If you are part of a Special Investigation Unit (SIU) and not currently working with a healthcare fraud task force, consider joining one or if need be creating one. Cross communication is the fastest and most effective way to combat fraud.
  • Know who in your area is responsible for investigating healthcare fraud, reach out and introduce yourself. Throughout my career, I was contacted by local healthcare providers, insurers, and SIU investigators to exchange information and facilitate investigations.  Contrary to popular belief reaching out, does not put you in the SAs “cross hairs”.  In fact, it helps to establish ongoing lines of communications.
  • Consider joining the healthcare fraud prevention partnership. This public/private consortium is designed to facilitate information sharing and data analysis across the spectrum of insurers and helps to “meld” data that would otherwise be invisible to individual insurers.

Advize Health LLC is a healthcare advisory and consulting company that provides a breadth of healthcare industry services in the payer, provider, and legal communities. Contact Eric Rubenstein for more information on our Fraud Spotlight series.