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







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

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Slide 1

U.S. Office of Personnel ManagementOffice of Inspector GeneralOffice of Investigations

Chuck Focarino

Deputy Assistant Inspector General for Investigations

(202) 606-3809

Charles.Focarino@opm.gov

OPM's 2005 Carrier Conference

Slide 2

Office of Inspector General Office of InvestigationsOverview

  • 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

Slide 3

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

Slide 4

Office of InvestigationsGoals & 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

Slide 5

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

Slide 6

U.S. Office of Personnel ManagementOffice of Inspector GeneralOffice 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

Slide 7

Agent BackgroundsFEHBP Health Insurance Plan Investigators Pharmacist with FEHBP PBMPharmacy Auditor with FEHBP PBMState Division of Insurance Fraud Health Care InvestigatorsMedicare Program Integrity Contractor Supervisory InvestigatorsState Medicaid Fraud InvestigatorsHHS OIG Special AgentsFBI AgentsFDA Office of Criminal Investigations AgentsU.S. Postal Inspectors

OPM's 2005 Carrier Conference

Slide 8

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

HOST AGENCIES

OPM's 2005 Carrier Conference

Slide 9

U.S. Office of Personnel ManagementOffice of Inspector GeneralOffice of Investigations

TYPES

OF

INVESTIGATIONS

OPM's 2005 Carrier Conference

Slide 10

TYPES OF INVESTIGATIONS

  • COMBINED FEDERAL CAMPAIGN FRAUD (CFC)

  • RETIREMENT FRAUD

  • HEALTH CARE FRAUD

  • SPECIAL INVESTIGATIONS

OPM's 2005 Carrier Conference

Slide 11

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

Slide 12

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

Slide 13

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

Slide 14

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

Slide 15

Questions?

OPM's 2005 Carrier Conference


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