# Presentation: 208116

## U.S. Office of Personnel ManagementOffice of Inspector GeneralOffice of Investigations

-  Chuck Focarino
- Deputy Assistant Inspector General for Investigations
- (202) 606-3809
- Charles.Focarino@opm.gov

- OPM's 2005 Carrier Conference

- April 5, 2005

## Office of Inspector General Office of InvestigationsOverview

- Organization and Field Structure of the Office
- OIG and Health Care Fraud
- Trends in Cases on Providers
- Cases on Health Insurance Carriers

- OPM's 2005 Carrier Conference

- April 5, 2005

## The Office of Inspector General

- OPM OIG functions as a separate and independent oversight organization whose responsibilities (within agency specific programs) include:
- The performance of independent and objective audits, investigations and inspections,
- To prevent and detect waste, fraud and abuse,
- Promote economy, effectiveness and efficiency,
- Review pending legislation and regulation, and
- Keep the Agency Director and Congress fully and currently informed of all agency problems and activities.

- OPM's 2005 Carrier Conference

- April 5, 2005

## Office of InvestigationsGoals & Objectives

- Return of Losses to make the program whole. $$ = ROI
- Criminal Prosecution – Medical Providers, i.e. Physicians, Chiropractors
- Civil Enforcement (Prosecution) – Qui Tams, Parallel Proceedings
- Administrative Sanctions – Suspension or Debarment from Government programs.

- OPM's 2005 Carrier Conference

- April 5, 2005

## Office of Investigations

- October 2000 > 6 agents – DC and San Francisco, CA
- October 2001 > 6 agents – added Phoenix, AZ
- October 2002 > 10 agents – added San Diego, CA
- October 2004 > 22 agents – 14 offices nationwide
- April 2005 > 28 agents in 21 offices nationwide

- OPM's 2005 Carrier Conference

- April 5, 2005

## U.S. Office of Personnel ManagementOffice of Inspector GeneralOffice of Investigations

- NORTHEAST REGION			SOUTHEAST REGION
- Washington, DC				Newport News, VA
- Boston, MA				Atlanta, GA
- Baltimore, MD				Tampa, FL
- New York, NY				Raleigh, NC
- 						Miami, FL
- Pittsburgh, PA
- Philadelphia, PA
- CENTRAL REGION			WESTERN REGION
- Phoenix, AZ				San Francisco, CA
- Dallas, TX				Los Angeles, CA
- St Louis, MO				San Diego, CA
- Baton Rouge, LA				Denver, CO
- Chicago, IL				Portland, OR
- Houston, TX

- OPM's 2005 Carrier Conference

- April 5, 2005

## Agent BackgroundsFEHBP Health Insurance Plan Investigators  Pharmacist with FEHBP PBMPharmacy Auditor with FEHBP PBMState Division of Insurance Fraud Health Care InvestigatorsMedicare Program Integrity Contractor Supervisory InvestigatorsState Medicaid Fraud InvestigatorsHHS OIG Special AgentsFBI AgentsFDA Office of Criminal Investigations AgentsU.S. Postal Inspectors

- OPM's 2005 Carrier Conference

- April 5, 2005

## HOST AGENCIES

- Atlanta
- Baltimore
- Baton Rouge
- Dallas
- Denver
- Houston
- Miami
- New York
- Portland
- Phoenix
- Santa Ana
- San Diego
- St. Louis
- Tampa

- HHS OIG Office of Investigations
- U.S. Attorney for District of Maryland
- Louisiana State Police
- FBI
- DOD Tricare Management Activity
- FBI
- Florida Medicaid Fraud Unit
- U.S. Attorney for Eastern District of NY
- HHS OIG
- FBI
- FBI
- Defense Criminal Investigative Service
- FBI
- FBI

- OPM's 2005 Carrier Conference

- April 5, 2005

## U.S. Office of Personnel ManagementOffice of Inspector GeneralOffice of Investigations

**TYPES **
**OF **
**INVESTIGATIONS**

- OPM's 2005 Carrier Conference

- April 5, 2005

## TYPES OF INVESTIGATIONS

- COMBINED FEDERAL CAMPAIGN FRAUD (CFC)
- RETIREMENT FRAUD
- HEALTH CARE FRAUD
- SPECIAL INVESTIGATIONS

- OPM's 2005 Carrier Conference

- April 5, 2005

## OIG and Health Care Fraud

- Referrals Come From:
- Department of Justice (False Claims Act Suits, HCF task forces)
- Other Federal and State Investigative Agencies
-   (FBI, HHS, DCIS, MFCU, DOI)
- Health Insurance Carriers (under contract)
- National Health Care Anti-Fraud Association (NHCAA)
- OIG Healthcare Fraud Hotline
- OPM Office of Insurance Programs.

- OPM's 2005 Carrier Conference

- April 5, 2005

## OIG and Health Care Fraud

- Progress of Typical Investigation
- Receive Allegation
- Request Program Exposure
- Identify Specific Fraud Scheme, additional request to carriers
- Test Allegation – review claims data, interview patients
- Criminal			Civil or Administrative
- Subpoena			Subpoena
- Indictment/Conviction		Trial or Settlement Negotiations
- Or Settlement/Plea

- OPM's 2005 Carrier Conference

- April 5, 2005

## Trends in Cases on Providers

- Outpatient Surgical Centers
- Diabetic Supplies
- Drug & Alcohol Treatment Facilities
- Wheelchairs and Scooters
- Off Label Promotion of Drugs/Kickbacks to Physicians
- Pharmacy Benefit Managers/Pricing and Service Issues

- OPM's 2005 Carrier Conference

- April 5, 2005

## Cases on Health Insurance Carriers

- Defective rating
- Overcharging on administrative expenses
- Receiving kickbacks from cost containment vendors
- Payments to fraudulent providers/plan employee misconduct
- Overcharging for use of provider networks

- OPM's 2005 Carrier Conference

- April 5, 2005

## Questions?

- OPM's 2005 Carrier Conference

- April 5, 2005