How did healthcare compliance fare in 2015? Overall, it was quite a busy year for the OIG and various organizations, with noteworthy settlements and enforcement activities beginning as early as January. The OIG excluded 4,112 individuals and entities from participation in Federal healthcare programs in FY 2015.
The Health Care Compliance Association will hold a web conference on January 21, 2016 for a more in-depth review on the past year’s fraud and abuse history. In the meantime, let’s take a brief look at some of 2015’s OIG compliance highlights.
Successful Health Care Fraud Takedown
Last June 18, a nationwide sweep led by the Medicare Fraud Strike Force in 17 districts resulted in charges against 243 individuals for their alleged participation in Medicare fraud schemes. Some important facts and figures in the takedown:
- It included 46 doctors, nurses, and other licensed medical professionals
- It involved approximately $712 million in false billings
- The coordinated effort between the Department of Justice and the Department of Health and Human Services resulted in the biggest number of defendants charged and loss amount in the history of the Medicare Fraud Strike Force.
Consequently, the Centers for Medicare & Medicaid Services (CMS) also suspended a number of providers using its suspension authority as provided in the Affordable Care Act.
Settled Cases
Some of the first settlements with the OIG began as soon as the new year rolled around. These included self-disclosure cases, excluded individuals, and fraudulent claims. The following are a few examples of the early settled cases of 2015; for the full list, click here.
- On January 7, 2015, the Healthcare Authority for Medical West (Medical West), Alabama agreed to pay $431,041.28 after a self-disclosed report to the OIG for allegedly employing an excluded individual.
- A Georgia physician named Dennis Conrad Harper agreed to enter into a $305,168.54 settlement agreement (effective January 20, 2015) with the OIG. The OIG charged him in a False and Fraudulent Medicare Claims Case for overbilling in-office urine drug testing.
- On January 30, 2015, Trinity Medical Center of Birmingham, Alabama entered into an agreement with the OIG for $111,969.11 settlement. It was to resolve charges that the hospital employed an individual excluded from participating in any Federal healthcare programs, and for charging Federal healthcare programs with services rendered by said individual.
A Year’s Worth of Criminal and Civil Enforcements
It was also a full year for convicting those who committed health care fraud. From January to December 2015, various individuals and institutions were meted with indictments ranging from paying penalties to being sentenced to prison. Below are some of the more prominent cases that made it to the 2015 Criminal and Civil Enforcements archive.
- As early as March 2015, one of the biggest OIG CMPs – amounting to $12.64 million – was paid by Sandoz, Inc. to settle allegations that it misrepresented drug pricing data to the Medicare program.
- Last September 29, 2015, the owner of an Orlando health care clinic was sentenced to five years in prison for engaging in a $2.4 million health care fraud scheme.
- The owner of two medical clinics in Brooklyn, New York, pleaded guilty last October 2015 to her role in a $55 million health care fraud and money laundering conspiracy.
- In early November, Dr. John Katsetos of Fairfield, Connecticut, was sentenced to 7 years in prison for illegally prescribing narcotics and defrauding government healthcare programs.
Most Wanted Fugitives Arrested
Then there were the fugitives from healthcare compliance – the people who literally ran off with the money. Let’s take a quick look at a couple of the more notorious captured and sentenced individuals, along with the cases they tried to run away from.
For a complete profiles of 2015’s captured fugitives, click here.
- The OIG’s Most Wanted Fugitive, Ubert Guillermo Rodriguez, was captured on October 9, 2015 at the Miami International Airport. He was indicted in July 2013 on 14 counts of health care fraud. Rodriguez was the president of a medical supplies company which he used to submit false claims – resulting in $918,402 of Medicare reimbursement for him.
- On April 16, 2015, Felix Gonzalez was sentenced to 113 months imprisonment and ordered to pay $21 million in restitution, joint, and several. Gonzales pleaded guilty on January 9, 2015, for conspiracy to commit healthcare fraud. He was a fugitive who returned to the United States in September 2014 and was also arrested at the Miami Airport.
$3.35 Billion Expected to Return to Taxpayers
In a recently issued report by the OIG, American taxpayers are expected to see $3.35 billion in improperly spent Federal health care dollars returned to the Government from oversight work, including audits and investigations. The report also mentioned $20.6 billion in estimated savings resulting from legislative, regulatory, or administrative actions that were supported by report recommendations.
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