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OIG Unveils Latest Tool for Evaluating Fraud Risk

by admin on November 12, 2018 No comments
OIG fraud risk

https://oig.hhs.gov/compliance/corporate-integrity-agreements/risk.asp

By: Karina Gonzalez

The Office of Inspector General (OIG) announced the launch of a new tool on its website titled the “Fraud Risk Indicator”.  The OIG has stated that the purpose for the tool is to provide guidance on how it has evaluated risk in settling False Claims Act (FCA) cases and to publicize information about where FCA defendants fall on the OIG’s risk spectrum.  This tool can benefit patients, healthcare industry professionals and other individuals who may find this information relevant.   This tool will also benefit the public with information about providers charged under the FCA that are at high risk for committing healthcare fraud. The Indicator shows the Risk Spectrum from Highest Risk to Lower Risk.

The US Government’s civil tool for healthcare fraud is the FCA.  Based on the information that it gathers in a FCA case, the OIG assesses the future trustworthiness of a settling party, to decide whether to take further action or to exclude them from Federal healthcare programs. Often the OIG concludes that exclusion is not necessary to protect the Federal healthcare programs if the person agrees to an appropriate integrity obligation. There are two situations in which the OIG will usually give a person a release of exclusion: (1) when a person or entity self-discloses the potential fraudulent conduct to the OIG, or (2) the person or entity agrees to an integrity obligation with the State or Department of Justice and the OIG.

Greg Demske, Chief Counsel for the OIG explained that the public has been unable to get information about FCA settlements and to learn where an entity or person belonged on the risk spectrum. The Fraud Risk Indicator will provide more transparency in this regard.

Healthcare fraud cases are listed on a continuum with the Highest Risk being those who have refused to enter into Corporate Integrity Agreements despite the Government’s determination that more oversight is needed.  The Lowest Risk are those providers who have cases that the OIG closed without seeking exclusion or signing a Corporate Integrity Agreement.

The RISK CATEGORIES:

Highest RiskExclusion from Federal healthcare programs

High Risk – Heightened Scrutiny these parties have refused to enter into CIAs despite the OIGs conclusion that additional oversight is needed

Medium Risk –  These individuals or entities have signed CIA.

Lower Risk – No Further Action, case closed with the OIG seeking exclusion or requiring a CIA

Low RiskSelf-Disclosure of Party of potential fraud or abuse.

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