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Health Care Fraud Investigations

Richard P. Kusserow Former Inspector General President Strategic Management Systems, Inc. (SMSInc). Health Care Fraud Investigations. Fraud Investigations Update. OFFICE OF INSPECTOR GENERAL Office of Audit Services Office of Investigations Office of Evaluations and Inspections

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Health Care Fraud Investigations

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  1. Richard P. Kusserow Former Inspector General President Strategic Management Systems, Inc. (SMSInc) Health Care Fraud Investigations

  2. Fraud Investigations Update OFFICE OF INSPECTOR GENERAL • Office of Audit Services • Office of Investigations • Office of Evaluations and Inspections • Office of Counsel to the IG

  3. OIG Office of Investigations • Fraud against Medicare/Medicaid programs • Individuals, facilities, or entities • Billing Medicare for services not rendered • False claims • Joint efforts with FBI, U.S. Postal Inspection Service, IRS, State Medicaid Fraud Control Units

  4. Fraud Investigations Update • OIG 2001 Semi-Annual Report • Over $18 billion fines, savings, & restitution • Collected $1billion + investigative receivables • Excluded 3,756 individuals and entities

  5. How are the savings achieved? • TAP Pharmaceutical Products Inc. • $875 million fraudulent pricing & marketing • CIA: Government oversight marketing & pricing • $560 million for fraudulent Medicare, Medicaid claims

  6. Other Settlements/Cases • Bayer AG • $14 million settlement for allegations of fraudulent Medicaid claims • Glaxo Wellcome • Nov. 2001 sued for fraudulently inflating the AWP of certain drug • 28 pharmaceutical companies • Dec. 2001 alleged to have overcharged Medicare $800 million by overstating AWP

  7. Future of Fraud Investigations OIG Work Plan for FY 2002 • Major Focus on Quality Issues • Many new Pharmaceutical Initiatives • Increased Funding for Investigations

  8. OIG Work Plan Initiatives • Medicare • Nebulizer inhalation drugs • Epogen Use in Renal Dialysis • Drug Coverage Variances Among Carriers • Medicare, Medicaid, & DVA Price Comparison • Appropriateness of payments for Clinical Trials

  9. Work Plan Initiatives Cont.. • Medicaid • Compare AWP of drugs to actual costs for providers and DVA • Analyze effects of new versions of existing drugs on Medicaid drug rebate program • Evaluate prices of mental health drugs compared to other government payers

  10. Work Plan Initiatives Cont.. • Gifts to Providers • Study the amount and nature of drug companies’ gifts and payments to physicians • Clinical Trials • Determine if producers of drugs/devices appropriately monitor clinical trials they sponsor

  11. Office of Investigation Initiatives • Focus Areas as stated by OI in Work Plan • Pharmaceutical Fraud • Quality of care issues for beneficiaries residing in care facilities • Business arrangements that violate the anti-kickback statute

  12. Funding for Fraud and Abuse HIPAA • Revolving Fund to Support OIG, FBI, and DOJ Investigative Costs • Funding to increase in 2002 and 2003

  13. Summary • Expect continued scrutiny of the pharmaceutical industry, especially in the area of sales and marketing • Providers should also be concerned about inappropriate gifts or benefits from Rx companies • Quality of care issues will continue to be investigated

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