OIG Roundtable (Formerly Retro Fraud)

Eric, Wade and Matt continue their discussion from last week’s podcast to dive a bit deeper into a few of the recommendations that remain as open items for HHS program consideration.  We look at the potential exposure to financial losses to programs from a lack of data coordination in Medicare Part A and Part D, and the implications of HCC risk scores in the Medicare Advantage space.

Eric, Wade and Matt discuss the newly released OIG unimplemented recommendations for 2025.  In total, nearly 1200 recommendations since 2017 have remained outstanding. This is part one of a two part discussion, so make sure you tune in next week as well.

Eric, Wade and Matt discuss a recent OIG study that found duplicate payments being made for certain DME products when the patient was in-patient.  This behavior permeates not only DME, but can also implicate other things such as medications.  We discuss the overall importance of having strong edits and how this type of review can greatly increase ROI, opportunity cost and reduce case backlogs by not needing to perform medical record reviews.

Eric, Wade and Matt discuss the art and science of negotiating a settlement with a provider.  Should there be dedicated investigators that only work settlement negotiations, and what are the follow ups after the settlement is completed?

Eric, Wade and Matt discuss the complexities and pros and cons of using proprietary and common off the shelf tools for SIU work.  There are strong arguments for each, and things to consider when making your decision on what tool or platform to use.

Eric and Matt have a discussion about how device and pharmaceutical firms work to market the difference in cost for the item and how the provider can make a lot of money by using the various devices and drugs to be administered.

Eric and Wade discuss some of the logistics of conducting an onsite for an SIU case.  What do you bring, do you provide notice, and what are you seeking to obtain as a result of the onsite?  All these questions will be answered.

Eric, Wade and Matt discuss the need to have clean data, linked data and the ability to get the visualizations needed to effectively conduct an investigation.

Eric, Matt and Wade discuss the recent additional charges against 12 individuals involved in a larger scheme to obtain nursing licenses under the pretense of completing a degree in nursing.  The individuals received false documents that were then used to allow them to sit for the nursing boards, and become licensed nurses; all based on false documents.

Eric, Matt and Wade take a look at the recent OIG study on Medicaid MCO efforts from the FWA perspective.  A lack of referrals, lack of training and lack of segmented teams can work to create inefficiencies and failures to properly refer FWA to law enforcement.