healthcare whack-a-mole

Posted and filed under FWA.

With all of the money that has been going out the door as a result of COVID, many are asking what, if any collaborate efforts will be undertaken by the law enforcement communities?  The answer is going to lay with the Offices of Inspectors’ General (collectively known as the OIGs).  As part of the recent financial relief, a large amount of money was specifically earmarked for investigative efforts. 

The newly formed, and short-term entity, Pandemic Response Accountability Committee (PRAC) was created to specifically navigate through the fraud schemes that are out there.  This work is squarely in the wheelhouse of the OIG community, as the mission of an OIG is to ferret out fraud, waste and abuse (FWA) in its respective programs.  With more OIGs out there than many are aware of, this will be an amazing effort to identify those intent on defrauding the various relief programs.  As a retired HHS-OIG agent, I am obviously most concerned about how the Medicare program was adversely affected by the fraud committed during COVID.

Whether it be through the various vaccination scams, the unbelievable amount of telemedicine fraud, or the myriad of frauds associated with laboratory testing, I was extremely happy to hear that HHS-OIG is playing a tremendous role in leading the charge.  I know of at least two of my former co-workers who are helping to coordinate the massive investigative efforts.  What many may not realize is that if an individual is defrauding one area, there is likely more to be found in other areas.  As I had written about previously, there are charges pending against healthcare providers who were not only committing healthcare fraud, but also seeking to defraud the Paycheck Protection Program (PPP). 

Sadly, this physician just could not apparently stop himself.  Under indictment for healthcare fraud, he also submitted a false PPP loan application.  Sometimes, well more than sometimes, those intent on committing fraud, do not believe there is a ramification; particularly when the fraud goes on for many years.   In my consulting role at Advize, I have spoken to numerous providers who refuse to institute basic, and strongly recommended compliance measures (just read the HHS-OIG model compliance guidance—it is only seven points).  I often times sound like a broken record when I state that many providers seek to be “a penny wise and a pound foolish.”  Spending some money upfront for proper basic compliance would have prevented me as an OIG Agent from meeting many of the defendants in my career.  I will provide one caveat, which is that those who intent on committing fraud will never heed that advice.  Those who ultimately end up engaging in waste, abuse or a general failure to properly maintain a compliance plan, are the ones that could have ended up in the proper side of the fence. 

I am excited to read about the successes that the PRAC will have.  Joining forces with many other OIGs will be a force multiplier.  More data and more information will lead to ferreting out those who unjustly received the fruits of the pandemic.