Office of the Inspector General

Office of the Inspector General

The Office of the Inspector General (OIG) was set up following the Inspector General Act 1978. Its role is to detect fraudulent activity, improper behavior, abuse, maladministration, and waste in the government (Kempf & Cabrera, 2019). They also promote trade and industry growth, performance, and success. The OIG assesses and reviews the goals and objectives of government programs. They evaluate whether the programs are reaching their goals and recommend other ways to improve their performance.

Information about the programs is collected through evaluations and surveys. After collection and compilation of data, results are reported to the program administration that has been evaluated. The administration then gives their opinion about the results and recommended interventions. When the process is complete, the OIG writes an official statement. The statement is distributed to the OIG’s boss and even the community. Employees of the OIG who perform these tasks include program analysts, investigators, accountants, and lawyers.

Role of the OIG in combating healthcare fraud, waste, and abuse

The OIG coordinates local, national, and government law enforcement programs to fight fraudulent activity, waste, and abuse in private and public healthcare schemes. Implementing the statutes and regulations that forbid fraud and abuse by the healthcare industry is the duty of many government, national, and local organizations. Some organizations include government criminal and civil lawyers, healthcare insurance fraud control Units, regulatory organizations, local lawyers, state district attorneys, and licensing boards. Even though these organizations may handle a range of statutory requirements, when it comes to fraudulent activity in public or private health schemes, they all have the same objective: to find and stop healthcare fraud, waste, and abuse.

The OIG conducts analyses, assessments, reviews, and safety checks about healthcare provision in the United States and its financing. The fact-finding phase of each case’s inquiry and evaluation is the core of the crime control effort. Additionally, gathering information is crucial for controlling and supervising the various organizations with authority over different healthcare sector facets. At the government, state, and local levels, law enforcement and regulatory organizations are tasked with conducting surveys, appraisals, and inspections and using the resources at their disposal.

The OIG tries to enhance the ability to gather information in law enforcement and regulatory bodies. It ensures that the administration knows methods of gathering information. Additionally, it provides direction on optimizing the potency of these methods. The office encourages the sharing of information among those who will be collecting the data. It also establishes other guidelines ensuring assessments, appraisals, and inquiries follow the law.

Another role of the OIG in fighting healthcare fraud, waste, and abuse is implementing constitutional, criminal, and managerial laws that apply to healthcare services. Enforcing existing laws is crucial in fighting fraudulent activity in the healthcare sector (Vian, 2020). Criminal laws punish offenders and act as a warning to those intending to commit the crime. Constitutional laws are designed to compensate victims of fraudulent activity, waste, or abuse, whereas managerial laws act as a warning to fraudsters and abusers.

The OIG directs the healthcare industry on what to do in case of fraudulent, abusive, or wasteful well-being practices. It provides admonitory suppositions, safe spaces, and special extortion alarms. For instance, in 1996, the OIG provided direction to citizens before implementing the Health Insurance Portability and Accountability Act (Eisenberg, 2022). They explained safe harbor regulations and particular fraud warnings. It also ensured continuous change was made to existing safe harbors, new safe harbors were made, and specific fraud warnings were reviewed continuously. If any changes are made, the OIG takes appropriate action. Providing direction by the OIG is helpful because it informs healthcare providers about what is lawful or unlawful.

The OIG organizes national data repositories for collecting and disclosing complaints against healthcare service providers (Chang, Rusu, & Kohler, 2021). The ultimate goal is to create a network of information that will enable sharing information about unfavorable actions against providers with relevant stakeholders. Law enforcement and other organizations, including government, national, and local organizations that regulate the healthcare service provider community, would benefit from information exchange in this aspect. Regulations will be implemented to guarantee that the national data repositories gather timely, accurate information and that authorized personnel can and swiftly receive it.

Successes

During the 2019 financial year, the OIG retrieved billions of dollars from fraud investigations. It also investigated fraudulent activity using genetic testing in 2019, which led to a settlement of millions of dollars (Chen et al., 2020). Furthermore, they cited accusations brought against executives and doctors from medical equipment and telemedicine companies for their alleged involvement in a healthcare fraud conspiracy. False Claims Act settlement with the multinational corporation Reckitt Benckiser Group plc (RB Group) was obtained by the OIG and the Department of Justice (DOJ) during a federal investigation into the marketing of opioid addiction treatment (Dyer, 2019). The pharmaceutical company agreed to pay seven hundred million dollars to resolve claims that it improperly advertised an opioid treatment medicine.

The accusations included making false and deceptive promises to healthcare providers, national health insurance agencies, and the Food and Drug Administration to raise sales, stall the entry of generic competition, and knowingly promote the drug to health services providers who were prescribing it unsafely. According to the report, the OIG estimates that billions of dollars will continue to be recovered from intelligence gathering, unlawful conduct, civil and managerial settlements, civil rulings, and disciplinary proceedings by OIG, summarizing OIG activities for the financial year 2019.

Challenges

One of the challenges experienced is a high level of fraudulent activity by health services providers and other healthcare professionals. Health service providers and other individuals know the laws concerning fraud and, therefore, can find ways of hiding their criminal activity (Chen et al., 2020). Community members are unaware of the rules and will not report fraudulent, wasteful, or abusive activities. Even if they are aware, they are unsure where to say criminal activities safely.

Regulatory guidelines on mechanisms that detect fraudulent activity in the healthcare sector are also limited. Different types of fraudulent health service activities exist. The few existing regulatory guidelines are insufficient to cover all fraudulent activities. This means that other providers go unpunished for their criminal activities. Innocent individuals seeking services lose a lot of money and even suffer dire health consequences. It is, therefore, crucial for the government to keep updating regulatory guidelines to improve the provision of health services. Updating laws will also ensure that offenders are rightly punished.

Conclusion

The OIG is crucial in assisting healthcare service providers in preventing fraud. Most healthcare providers perform their services ethically, but lawmakers must pass rules to safeguard their people. The OIG should ensure that all seeking health services know the possibility of experiencing fraud or abuse. They should be taught how and where to report these criminal activities. Furthermore, the OIG reviews and updates laws concerning fraud, abuse, and waste in the healthcare sector.

References

Chang, Z., Rusu, V., & Kohler, J. C. (2021). The Global Fund: why anti-corruption, transparency and accountability matter. Globalization and Health, 17(1), 1-11. https://doi.org/10.1186/s12992-021-00753-w

Chen, Z. X., Hohmann, L., Banjara, B., Zhao, Y., Diggs, K., & Westrick, S. C. (2020). Recommendations to protect patients and health care practices from Medicare and Medicaid fraud. Journal of the American Pharmacists Association, 60(6), e60-e65. https://doi.org/10.1016/j.japh.2020.05.011

Dyer, O. (2019). UK firm pays $1.4 bn to settle US allegations over opioid marketing. https://doi.org/10.1136/bmj.l4715

Eisenberg, M. A. (2022). Clinical Informatics Policy and Regulations. In Clinical Informatics Study Guide (pp. 35-45). Springer, Cham. https://doi.org/10.1007/978-3-030-93765-2_3

Kempf, R. J., & Cabrera, J. C. (2019). The de facto independence of federal offices of inspector general. The American Review of Public Administration, 49(1), 65-78. https://doi.org/10.1177/0275074018783012

Vian, T. (2020). Anti-corruption, transparency, and accountability in health: concepts, frameworks, and approaches. Global health action, 13(sup1), 1694744. https://doi.org/10.1080/16549716.2019.1694744

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Office of the Inspector General

Discuss the role of the Office of the Inspector General (OIG) in combating healthcare fraud, waste, and abuse. Describe the successes and challenges the OIG has faced.