OIG Announces $3.44 Billion in Expected Recoveries from Audits, Investigations 

03 Dec, 2023 F.J. Thomas


Sarasota, FL (WorkersCompensation.com) – Earlier this week, the OIG released their Semiannual Report to Congress detailing their audit findings for reporting period April 1 through September this year, which included activity from October 2022 through March of this year. The OIG expects over $3.44 billion in recoveries, with $283 million as a direct result of audit findings, and $3.16 billion the result of investigative work. 

On the investigative front, there were 707 criminal actions taken, 746 civil actions, and 2,112 exclusions. One of the criminal actions included a laboratory owner sentenced to 27 years for submitting more than $463 million in medically unnecessary genetic tests. In another case, a physician was sentenced to 84 months in prison with 3 years of supervised release for requiring patients to schedule clinic visits multiple times a month for unnecessary steroid injections in exchange for prescriptions. The physician was also ordered to pay $1 million in restitution, fined $195,000, and forfeited seized assets worth $900,000.

From October 2022 through March 2023, the OIG evaluated a total of 36,244 tips through their hotline and website. A total of 21,740 tips were referred for further action. 

On the audit front, the OIG issued 127 audit reports, with 42 evaluations. The OIG found $1.5 billion in questioned costs, and $47.2 million in potential savings. 

Auditors found that for some psychotherapy services, providers did not meet Medicare requirements in over 84 percent of the sampled enrollee days. Of the 216 sample enrollee days reviewed, 128 enrollee days the time was not documented, and in 54 enrollee days provider signatures were missing. Based on the results of their review, the OIG estimates that of the $1 billion paid for psychotherapy services, over $580 million was paid out in error. The Auditors estimate that psychotherapy services delivered by telehealth accounts for $348 million of the total. 

Auditors found that Medicare paid out over $44.6 million in overpayments due to pricing at the incorrect place of service. Medicare paid out over $22.4 million in error by paying nonfacility rates for services actually rendered in nursing facility. An additional $22.1 million in overpayments at nonfacility rates were made to physicians for services that were in a facility or hospital. 

Authorizations were another area of interest that auditors reviewed. CMS found that the administrators in their review denied one out of every eight requests for prior authorizations in 2019. In some cases, auditors found that an authorization denial rate as high as 25 percent. 

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    About The Author

    • F.J. Thomas

      F.J. Thomas has worked in healthcare business for more than fifteen years in Tennessee. Her experience as a contract appeals analyst has given her an intimate grasp of the inner workings of both the provider and insurance world. Knowing first hand that the industry is constantly changing, she strives to find resources and information you can use.

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