Department of Justice Audit Programs
The Department of Justice (DOJ) works with the Office of the Inspector General (OIG) and the Centers for Medicare and Medicaid Services (CMS) to identify instances of fraud and abuse and litigates these cases on behalf of the government.
While the DOJ typically acts in concert with the OIG and CMS based on their investigations, it can undertake its own investigations. The most recent example of this is in the area of implantable cardioverter defibrillators (ICDs). In 2011 hospitals across the country were served subpoenas regarding their billing for implantation of ICDs.
Medicare coverage for the implantation of ICDs is spelled out in a National Coverage Determination (NCD), Chapter 1, Sec. 20.4 of the Internet-Only Medicare National Coverage Determinations Manual (Pub. 100-3). The DOJ suspects that hospitals may be billing inappropriately for these services. The NCD is quite specific in terms of situations where the implantation is not covered by Medicare, regardless of a cardiologist’s clinical judgment of medical necessity. In addition to serving the hospitals, a number of ICD manufacturers received subpoenas pertaining to any potential billing or reimbursement advice they may have furnished to practitioners. The DOJ has not released any formal findings, nor has it filed suit against any hospitals to date. However, in August 2012, hospitals were contacted via e-mail and encouraged to conduct internal audits, using a specially developed “Resolution Model” and medical review guidelines. These will be used by the DOJ to facilitate resolution of concerns raised during the investigation.
HEAT Task Force
The Health Care Fraud Prevention and Enforcement Action Team (HEAT) is an interagency team that both investigates potential fraud, as well as works to prevent it. As part of this interagency collaboration, the government has created the Medicare Fraud Strike Force consisting of investigators from DOJ, CMS and the OIG, as well as from state and local agencies designed to combat Medicare fraud through the use of Medicare data analysis techniques and an increased focus on community policing. Their efforts to date have focused on regions of the country that are considered high fraud areas, including but not limited to California, Florida and New York. Additionally, the HEAT Task Force has developed educational programming for clinicians, physician practices and others to help prevent fraud, waste and abuse.
To learn more about the HEAT Task Force, visit www.stopmedicarefraud.gov.