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Published on October 30, 2007

Author: Mertice

Source: authorstream.com

U.S. Office of Personnel Management Office of Inspector General Office of Investigations:  U.S. Office of Personnel Management Office of Inspector General Office of Investigations Chuck Focarino Deputy Assistant Inspector General for Investigations (202) 606-3809 Charles.Focarino@opm.gov Office of Inspector General Office of Investigations Overview:  Office of Inspector General Office of Investigations Overview Organization and Field Structure of the Office OIG and Health Care Fraud Trends in Cases on Providers Cases on Health Insurance Carriers The Office of Inspector General:  The Office of Inspector General OPM OIG functions as a separate and independent oversight organization whose responsibilities (within agency specific programs) include: The performance of independent and objective audits, investigations and inspections, To prevent and detect waste, fraud and abuse, Promote economy, effectiveness and efficiency, Review pending legislation and regulation, and Keep the Agency Director and Congress fully and currently informed of all agency problems and activities. Office of Investigations Goals & Objectives:  Office of Investigations Goals & Objectives Return of Losses to make the program whole. $$ = ROI Criminal Prosecution – Medical Providers, i.e. Physicians, Chiropractors Civil Enforcement (Prosecution) – Qui Tams, Parallel Proceedings Administrative Sanctions – Suspension or Debarment from Government programs. Office of Investigations:  Office of Investigations October 2000 > 6 agents – DC and San Francisco, CA October 2001 > 6 agents – added Phoenix, AZ October 2002 > 10 agents – added San Diego, CA October 2004 > 22 agents – 14 offices nationwide April 2005 > 28 agents in 21 offices nationwide U.S. Office of Personnel Management Office of Inspector General Office of Investigations :  U.S. Office of Personnel Management Office of Inspector General Office of Investigations NORTHEAST REGION SOUTHEAST REGION Washington, DC Newport News, VA Boston, MA Atlanta, GA Baltimore, MD Tampa, FL New York, NY Raleigh, NC Miami, FL Pittsburgh, PA Philadelphia, PA CENTRAL REGION WESTERN REGION Phoenix, AZ San Francisco, CA Dallas, TX Los Angeles, CA St Louis, MO San Diego, CA Baton Rouge, LA Denver, CO Chicago, IL Portland, OR Houston, TX Agent Backgrounds FEHBP Health Insurance Plan Investigators Pharmacist with FEHBP PBM Pharmacy Auditor with FEHBP PBM State Division of Insurance Fraud Health Care Investigators Medicare Program Integrity Contractor Supervisory Investigators State Medicaid Fraud Investigators HHS OIG Special Agents FBI Agents FDA Office of Criminal Investigations Agents U.S. Postal Inspectors :  Agent Backgrounds FEHBP Health Insurance Plan Investigators Pharmacist with FEHBP PBM Pharmacy Auditor with FEHBP PBM State Division of Insurance Fraud Health Care Investigators Medicare Program Integrity Contractor Supervisory Investigators State Medicaid Fraud Investigators HHS OIG Special Agents FBI Agents FDA Office of Criminal Investigations Agents U.S. Postal Inspectors HOST AGENCIES:  HOST AGENCIES Atlanta Baltimore Baton Rouge Dallas Denver Houston Miami New York Portland Phoenix Santa Ana San Diego St. Louis Tampa HHS OIG Office of Investigations U.S. Attorney for District of Maryland Louisiana State Police FBI DOD Tricare Management Activity FBI Florida Medicaid Fraud Unit U.S. Attorney for Eastern District of NY HHS OIG FBI FBI Defense Criminal Investigative Service FBI FBI U.S. Office of Personnel Management Office of Inspector General Office of Investigations:  U.S. Office of Personnel Management Office of Inspector General Office of Investigations TYPES OF INVESTIGATIONS Slide10:  TYPES OF INVESTIGATIONS COMBINED FEDERAL CAMPAIGN FRAUD (CFC) RETIREMENT FRAUD HEALTH CARE FRAUD SPECIAL INVESTIGATIONS OIG and Health Care Fraud:  OIG and Health Care Fraud Referrals Come From: Department of Justice (False Claims Act Suits, HCF task forces) Other Federal and State Investigative Agencies (FBI, HHS, DCIS, MFCU, DOI) Health Insurance Carriers (under contract) National Health Care Anti-Fraud Association (NHCAA) OIG Healthcare Fraud Hotline OPM Office of Insurance Programs. OIG and Health Care Fraud:  OIG and Health Care Fraud Progress of Typical Investigation Receive Allegation Request Program Exposure Identify Specific Fraud Scheme, additional request to carriers Test Allegation – review claims data, interview patients Criminal Civil or Administrative Subpoena Subpoena Indictment/Conviction Trial or Settlement Negotiations Or Settlement/Plea Trends in Cases on Providers:  Trends in Cases on Providers Outpatient Surgical Centers Diabetic Supplies Drug & Alcohol Treatment Facilities Wheelchairs and Scooters Off Label Promotion of Drugs/Kickbacks to Physicians Pharmacy Benefit Managers/Pricing and Service Issues Cases on Health Insurance Carriers:  Cases on Health Insurance Carriers Defective rating Overcharging on administrative expenses Receiving kickbacks from cost containment vendors Payments to fraudulent providers/plan employee misconduct Overcharging for use of provider networks Questions?:  Questions?

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