We’ve made it to a new year – 2019! Last year was filled with quite a lot of updates from HHS OIG, CMS, and DOJ. Last year, around $2.8 billion was collected involving healthcare fraud and false claims. To close out 2018 properly, we’ve wrapped up the latest exclusion data from each state and federal list for Q4.
Our data scientists + automated solutions remain diligent and accurate with matching records and data to give you a complete picture to help make the best decisions when it comes to exclusion monitoring, license verification, sanction screening, and more. Let’s take a look at the most recent trends from Q4 results in the latest edition of the Compliance Healthcare Index Report by ProviderTrust.
2018 Q4 Healthcare Exclusions Takeaways
In Q4 of 2018, the total number of healthcare-related exclusions at the state and federal level surpassed 200,000. This trend of increased state and federal exclusions is indicative of the coordinated efforts of a Medicare Fraud Strike Force and the active state Medicaid Fraud Control Units (MFCU) across the nation.
The shady business of fraud in healthcare continues to involve more elaborate schemes and organized criminals attempting to take advantage of the large sums of federal healthcare dollars. To combat these efforts the OIG, DOJ, DEA and the MFCU’s continue to use smart data and more investigators to take down bad actors. Law enforcement still maintains a positive return on their investment of $7 returned per each dollar spent, according to the OIG Semi-Annual Report.
HHS OIG Requirement of Medicaid Fraud Control Units (MFCU)
Unfortunately, there is a dilemma in timeliness of state reporting to HHS Office of Inspector General (OIG). Did you know that according to Performance Standard 8, OIG calls for all state Medicaid Fraud Control Units to transmit information to the OIG for HHS?
for purposes of program exclusions under section 1128 of the Social Security Act, all pertinent information on MFCU convictions within 30 days of sentencing, including charging documents, plea agreements, and sentencing orders.”
Id. p. 32648.
The discrepancy between state Medicaid lists and federal exclusion data (OIG LEIE) can cause major problems for your organization when it comes to hiring and working with vendors or third parties. When you take the civil and monetary fines imposed in 2017 (including $5.2M for hiring or contracting excluded providers) into account, it’s urgent to understand the importance of ongoing exclusion monitoring as a part of your compliance program.
HHS OIG December 2018 Updates
In December, HHS Office of Inspector General (OIG) released their Semiannual Report to Congress for April 1 – September 20, 2018, complete with fiscal results from 2018. Here are some of the stats that made the list:
- $2.91 billion reported expected investigative recoveries of
- Criminal actions against 764 individuals or entities that engaged in crimes against HHS programs
- Exclusion of 2,712 individuals and entities
- Civil actions against 813 individuals or entities
2018 Q4 Healthcare Exclusions Data
State Medicaid Exclusion Lists
Federal + State Exclusion Lists
2018 Q4 State Medicaid Exclusions Data
Top 5 States with the Most Exclusions
- New York
- New Jersey
Find out more about each state’s excluded individuals and entities by clicking on the map below!
Civil Monetary Penalties
Civil monetary penalties are the fines levied against healthcare organizations for doing business with an excluded individual or entity. The Office of Inspector General (OIG) allows organizations to self-disclose in exchange for a lesser fine. If the above cases had been enforced to their fullest extent by the OIG, the total fines could have exceeded $64,000,000.
Healthcare Exclusions Insights
We are proud to continue to provide insight into how your compliance program is stacking up against the rest, and help you understand the time dilemma between state exclusion reporting to OIG. According to our data, the average time it takes for states to report exclusion issues to OIG is 169 days. To dive deeper into our report and discover the most updated stats on the state of exclusions across the country – visit our CHIRP page!
Written by Michael Rosen, Esq.
Michael brings over 20 years of experience founding and leading risk mitigation businesses, receiving numerous accolades such as Inc. Magazine’s Inc. 500 Award and Nashville Chamber of Commerce Small Business of the Year.