Blog: OIG Reports Targeting Medicare Part D Fraud Issued on the Heels of National Medicare Fraud Sweep

by Cooley LLP
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The Health and Human Services (HHS) Office of Inspector General (OIG) released two reports yesterday related to Medicare Part D fraud. The OIG report, Ensuring the Integrity of Medicare Part D, “synthesizes numerous OIG reports that have identified weaknesses in Part D program integrity, and provides updates on Departmental efforts to address these weaknesses.” The report also identifies a number of recommendations made in previous reports that the Centers for Medicare & Medicaid Services (CMS) has not yet implemented, and encourages CMS to do so in order to protect the Part D program from fraud, waste and abuse.

The second OIG report, Questionable Billing and Geographic Hotspots Point to Potential Fraud and Abuse in Medicare Part D, summarizes OIG reviews that have revealed questionable billing associated with pharmacies, prescribers, and beneficiaries involving controlled and noncontrolled substances. These reviews were conducted because of the OIG’s ongoing concerns regarding abuse and diversion of Part D drugs. Notably, the report concluded that more than 1,400 pharmacies had questionable billing for Part D drugs in 2014 that “warrant further scrutiny.” Additionally, “geographic hot spots” for certain drugs in Los Angeles, CA; McAllen, TX; Miami, FL; New York, NY; and San Juan, PR suggest potential fraud and abuse.

These OIG reports were released on the heels of a nationwide takedown of suspected Medicare and Medicaid fraud schemes announced last week by the U.S. Attorney General and HHS. The three-day sweep was the largest ever conducted by the Medicare Fraud Strike Force, part of the Health Care Fraud Prevention & Enforcement Action Team (HEAT) between HHS and U.S. Department of Justice, which resulted in charges against 243 individuals, including doctors, nurses and other licensed health care professionals. The charges, which were brought in 17 federal districts around the country, included health care fraud, conspiracy to commit health care fraud, violations of the federal anti-kickback statute, money laundering, and aggravated identity theft, and allegedly resulted in $712 million in false billing to the Medicare and Medicaid programs.

This blog post was co-authored by Amy Westergren, a 2015 summer associate in Cooley’s New York office.

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DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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