Don't have a TCI SuperCoder account yet? Become a Member >>

Pain Management Coding Alert


Feds Primed to Find Fraud in Opioid Prescribing

Get all your procedures in place to prevent trouble.

As 2020 kicks off, PM practices find themselves in the crosshairs of the federal government’s fraud investigations for two very different services.

All medical providers that report telemedicine services or prescribe opioids for pain management purposes are in the same boat, though, as the HHS Office of Inspector General (OIG) lists them both as top areas for fraud.

Background: The OIG reports on fraudulent and abusive healthcare behavior that impacts federal healthcare programs in its Semiannual Report to Congress. Its most recent report focuses on incidents, enforcement, and takedowns from April 1, 2019 to Sept. 30, 2019. Opioid abuse, telemedicine fraud, and challenges with unaccompanied minors in HHS custody were among the OIG’s top issues during that time period, says Joanne M. Chiedi, acting HHS OIG inspector general.

Statistics: During the report timeframe, Chiedi says OIG made great strides through audits, enforcement, and recoveries, working in tandem with its partners at the Department of Justice (DOJ), the Medicare Fraud Strike Force, State Medicaid Fraud Control Units, and other federal, state, and local law enforcement. Here’s a breakdown of the report numbers:

  • Audits: OIG released 91 audit reports and 36 evaluations. It expects to recover more than $322.7 million from its audit work. The agency also questioned more than $666.5 million in costs, too.
  • Investigative recoveries: OIG anticipated its investigative recoveries at $2.74 billion during the reporting period.
  • Criminal actions: The federal watchdog brought criminal actions against 388 individuals and entities.
  • Civil actions: OIG levied civil actions against 364 individuals and entities.
  • Exclusions: The feds excluded 1,347 individuals and entities from federal healthcare programs over the time period, maintains the report.

Check Out These Top Cases

The OIG oversees fraud and abuse that impact expenses and beneficiaries serviced by the Centers for Medicare & Medicaid Services (CMS).

According to the report, OIG’s “largest body of work” includes investigating Medicare and Medicaid fraudsters. The investigations range from upcoding, billing for medically unnecessary or never performed services, opioid abuse and fraud, and kickbacks or bribes for referrals. Plus, organized crime surrounding federal healthcare programs is on the rise, too.

“OIG also conducts investigations regarding organized criminal activity, including medical identity theft and fraudulent medical schemes established for the sole purpose of stealing Medicare dollars,” states the report. “Investigators are opening an increasing number of cases against healthcare providers who engage in these healthcare fraud schemes.”

“Those who participate in the schemes may face heavy fines, jail time, and exclusion from participation in Federal health care programs,” OIG warns.

Here are three of the biggest Medicare-related takedowns over the reporting period:

  • Telemedicine: OIG brought charges against 24 defendants who engaged in telemedicine fraud. Telemedicine companies operated in 17 districts and offered kickbacks and bribes to medical professionals to push orthotic braces to beneficiaries who didn’t need them via telemedicine. The scheme resulted in $1.2 billion in Medicare losses.
  • Genetic testing: In this case, “dozens of telemedicine companies and laboratories” bribed medical professionals to push unneeded genetic testing for cancer. The massive fraudulent activity was one of the largest takedowns in OIG history and included 35 defendants — including nine doctors — and $2.1 billion charged to Medicare for the genetic tests.
  • Opioid abuse: In four separate federal districts in Texas, OIG and its “enforcement partners” charged 58 individuals — including 16 doctors or medical professionals — in a massive opioid fraud scheme that included a “networks of ‘pill mill’ clinics resulting in $66 million in losses to public and private insurers and 6.2 million pills,” notes the report.

Review the Semiannual Report to Congress at