The OIG has become more sophisticated in their detection and fight against fraudulent schemes.
July 6, 2022
In an interview with Health Care Compliance Association (HCCA), the new Inspector General of HHS-OIG, Christi A. Grimm (who has been with the OIG for 22 years) indicated that their focus continues to be around compliance and fraud, waste, and abuse. The OIG has become more sophisticated in their detection and fight against fraudulent schemes.
“We remain wholeheartedly committed to compliance and fraud prevention. What has changed markedly are the types and scope of fraud schemes; the contents of our toolbox; the revolution in technology and science; and the size and complexity of Medicare, Medicaid, and other HHS programs. We must be smart, fast, and nimble to stay ahead of increasingly sophisticated fraud schemes. We use modern data analytics and artificial intelligence to identify potential fraud, outliers, and concerning trends. And we partner with other law enforcement and oversight agencies to share data and trends so we can more holistically detect and target fraud and inefficiency across government programs.”
“We continue to make important strides using data analytics to reveal quality-of-care concerns, potential cost recoveries, and compliance opportunities. A terrific example is our evaluation that used innovative claims analysis to show how some Medicare Advantage companies may be leveraging chart reviews and health-risk assessments to disproportionately drive payments.”
Some of the top priorities for Grimm include:
- Improving oversight of nursing homes
- Ensuring there are adequate resources and infrastructure to manage HHS’ annual spend of $2.4 trillion
- Combat fraud
- Reduce improper payments
- Opioid epidemic
- Risks in managed care
- Ensure alternate modes of care delivery, such as telehealth, have appropriate operational guardrails
Inspector General Grimm stressed the importance for having a Compliance Official within the organization who has the authority to drive the seven elements of a compliance program, including the utilization of OIG’s Health Care Fraud Self-Disclosure Protocol, which is consistently being utilized. A challenge that Grimm recognizes is embedding the culture of compliance across the organization, especially as part of the acquisition process.
As Medicare and Medicaid transition from volume-based-payment to value-based and managed care models, Grimm describes how changes to the Stark Law, Anti-Kickback Statute, and beneficiary inducement regulations (effective January 19, 2021) were impacted by OIG’s and HHS’ collaboration during the development of the new guidelines.