Auditors said the program lost out on $3.2 million that carriers paid to a medical entity in an alleged fraud involving pressuring providers to inflate charges. Image: Shawn Hempel/Shutterstock.com
By: FEDweek StaffIn a series of recent reports, the OPM inspector general’s office said it has identified misspending in the FEHB program, which adds to the cost of premiums both for the enrollees and the government, but that legal barriers prevent the program from recouping some of that amount.
A report covering the last three months of 2023 is typical in noting that the FEHB program is precluded from pursuing cases under the Anti-Kickback Statute, which makes it illegal for health care providers to knowingly and willfully accept bribes or other forms of remuneration in return for activities such as patient referrals.
“Kickbacks can increase FEHB costs and patients can suffer harm if health care providers are tempted to profit off referrals for treatments or procedures that are not medically necessary. The FEHB’s exclusion from the Anti-Kickback Statute can interfere with our ability to protect the FEHB and its members from improper conduct that would constitute a federal crime when committed against any other federally funded health care program. Improperly paid FEHB dollars can go unrecovered because of our exclusion,” it says.
It said that when the Justice Department Justice prosecutes cases primarily or exclusively asserting a violation of that law, “other federal health care programs are identified as victims—but the FEHB is not, regardless of dollars lost. We typically close these cases after a prosecutorial determination excludes the FEHB.”
It said that most recently, the program lost out on potential recovery of $2.7 million in claims that FEHB carriers paid due to an alleged scheme involving the promotion, sale, and marketing of a medication for off-label use; and $3.2 million that carriers paid to a medical entity in an alleged fraud involving pressuring providers to inflate charges.
Similar cases cited in prior recent reports involved inability to recover: $28.8 million for allegedly improper pre-authorizations for a medication; $1.5 million in an alleged fraud involving over-billing for COVID-19 treatments; $4.6 million for alleged billing for services that were medically unnecessary or never provided; and $3.9 million for alleged medically unnecessary procedures.
The reports added, though, that the IG has been able to collect repayment on behalf of the FEHB in cases of fraud in which that particular law was not invoked.
OPM Advises Agencies on Conducting RIFs During Shutdown
Updated Shutdown Contingency Plans Show Range of Impacts
Use Shutdown as Justification for More RIFs, OMB Tells Agencies
Unions Win a Round in Court Disputes over Anti-Representation Orders
Deferred Resignation Periods End for Many; Overall 12% Drop
Senate Bill Would Override Trump Orders against Unions
TSP Adds Detail to Upcoming Roth Conversion Feature
See also,
Legal: How to Challenge a Federal Reduction in Force (RIF) in 2025
How to Handle Taxes Owed on TSP Roth Conversions? Use a Ladder
The Best Ages for Federal Employees to Retire
Best States to Retire for Federal Retirees: 2025
Retention Standing, ‘Bump and Retreat’ and More: Report Outlines RIF Process
