Retired OIG Special Agent and Advize’s Director of Litigation & FWA Support will be stepping in each week to examine current fraud trends from the lens of an investigator. Stay tuned for weekly insights, updates, and information on healthcare’s most expensive crimes.

Last week, the CMS Administrator made some comments that outlined some new initiatives (or really more of a reiteration of what is and has been happening) to combat fraud, waste and abuse in the Medicare program. These comments are not the same as the new rules that will take effect on November 4.  The five points made highlighted the already known issues that are at the heart of FWA in the program. Although some with whom I have spoken have commented that the statements were a waste of time, I would argue that it is important to continually reiterate the fact that FWA will be at the forefront of the industry, and that there can never be enough publicity and awareness about the issue.

As an OIG agent, I always felt we could have done much more to publicize our brand. The OIG is the primary agency for Medicare related FWA investigations, and is often overshadowed by other, larger agencies with better known acronyms.  Most of the general public does not know who the OIG is, and even more, who CMS is.  The healthcare provider community does, which is much more important to me.  In fact, in retirement, when I meet and speak to people and tell them I came from the OIG, it is exciting to have people ask about aspects of the job that only people in the FWA community would know to ask.  I waved the OIG flag proudly for an entire career and am always extremely happy to talk about the important work the OIG does.

Stopping bad actors and preventing fraud were two of the main points espoused by the Administrator.  When I read that, I was a bit perplexed, as I was of the understanding for my entire career that was already the point of the OIG and CMS’ Center for Program Integrity (CPI).  CPI and the OIG have a great relationship, and the current Director is a huge fan of the OIG and really gets the mission. The FWA issues will always, in my estimation, be more about: not enough OIG agents to work the cases, the pay and chase system that is inherent in the US healthcare system, the lack of absolute buy in by the FWA community to join the Healthcare Fraud Prevention Partnership (which is making some great strides in developing partnerships) and the simple fact that unscrupulous providers will always find a way to “build a better mousetrap.”  There are a multitude of other issues, but these come to mind immediately.

As the ProPublica article about the Texas based provider who bilked millions from healthcare insurers demonstrated, there is a lot that needs to be done to get the industry, and those that pay into it, to collectively say enough is enough.  I spent my career working hard to combat FWA and continue to enjoy working in that space.  I’m guardedly optimistic that there are enough like-minded people out there who read the CMS Administrator’s comments, and instead of taking them with a grain of salt, or making negative comments, saw them as a reiteration of our collective opinion that the FWA community is always looking to move forward (even when moving forward is more of a crawl).

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.