April 5, 2005 OPM's 2005 Carrier Conference 1 U.S. Office of Personnel Management Office of Inspector General Office of Investigations Chuck Focarino Chuck Focarino Deputy Assistant Inspector General for Investigations (202)

April 5, 2005OPM's 2005 Carrier Conference2 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

April 5, 2005OPM's 2005 Carrier Conference3 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.

April 5, 2005OPM's 2005 Carrier Conference4 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.

April 5, 2005OPM's 2005 Carrier Conference5 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

April 5, 2005OPM's 2005 Carrier Conference6 U.S. Office of Personnel Management Office of Inspector General Office of Investigations NORTHEAST REGIONSOUTHEAST REGION Washington, DCNewport News, VA Boston, MAAtlanta, GA Baltimore, MDTampa, FL New York, NYRaleigh, NC Miami, FL Pittsburgh, PA Philadelphia, PA CENTRAL REGIONWESTERN REGION Phoenix, AZSan Francisco, CA Dallas, TXLos Angeles, CA St Louis, MOSan Diego, CA Baton Rouge, LADenver, CO Chicago, ILPortland, OR Houston, TX

April 5, 2005OPM's 2005 Carrier Conference7 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

April 5, 2005OPM's 2005 Carrier Conference8 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  Defense Criminal Investigative Service  FBI

April 5, 2005OPM's 2005 Carrier Conference9 U.S. Office of Personnel Management Office of Inspector General Office of Investigations TYPESOFINVESTIGATIONS

April 5, 2005OPM's 2005 Carrier Conference10 TYPES OF INVESTIGATIONS 1.COMBINED FEDERAL CAMPAIGN FRAUD (CFC) 2.RETIREMENT FRAUD 3.HEALTH CARE FRAUD 4.SPECIAL INVESTIGATIONS

April 5, 2005OPM's 2005 Carrier Conference11 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) (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.

April 5, 2005OPM's 2005 Carrier Conference12 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 CriminalCivil or Administrative SubpoenaSubpoena Indictment/ConvictionTrial or Settlement Negotiations Or Settlement/Plea

April 5, 2005OPM's 2005 Carrier Conference13 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

April 5, 2005OPM's 2005 Carrier Conference14 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

April 5, 2005OPM's 2005 Carrier Conference15 Questions?