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OIG report details fraud, abuse, neglect cases

March 12, 2014
by Lois A. Bowers, Senior Editor
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Criminal convictions resulting from Medicaid fraud and patient/resident abuse and neglect cases involved home health agencies more than any other individual type of provider in 2013, whereas civil settlements and judgments most often involved pharmaceutical companies, according to the recently released 2013 annual report of the U.S. Department of Health and Human Services’ Office of Inspector General (OIG) Medicaid Fraud Control Units (MFCUs). Data for the report were compiled from the MFCUs of all 50 states.

Home healthcare aides were involved in 26 percent of all criminal convictions, and pharmaceutical manufacturers accounted for 62 percent of all civil settlements and judgments, the report noted.

The OIG conveyed a nationwide total of 1,341 criminal convictions for fraud or abuse and neglect, with recoveries totaling almost $1 billion. Nationwide, 879 civil settlements and judgments resulted in more than $1.5 billion in recoveries, the agency added. More than 1,000 convicted Medicaid providers were excluded from participating in all federal healthcare programs, including Medicare, in 2013, the OIG said.

For criminal cases involving abuse and neglect, nursing facilities accounted for 10 convictions and $154,692 in recoveries. The “other long-term care” category, had 21 convictions and $156,538 in recoveries for criminal abuse and neglect cases.

For civil abuse and neglect cases, nursing facilities saw six settlements/judgments and were responsible for $770,845 in recoveries, and other long-term care providers had one settlement/judgment with a $25,000 recovery.

Regarding fraud, the OIG reported 14 criminal case convictions with $1.1 million in recoveries from nursing facilities as well as 11 other long-term care case convictions with $340,562 in recoveries. In civil cases, 16 settlements/judgments involved nursing facilities, with $8.3 million in recoveries, and three other long-term care cases resulted in $2 million in recoveries.

Criminal fraud cases—representing 74 percent of all criminal convictions noted in the report—involved healthcare fraud or conspiracy to commit healthcare fraud, submitting or making false statements related to healthcare or reimbursement matters, grand larceny and violations of anti-kickback statutes, according to the OIG. Criminal abuse and neglect cases include aggravated assaults, injury to an elderly or disabled person or theft of funds from patients/residents, the agency added.