Office of Inspector General of the United States Department of Health and Human Services

Kind of a parallel to it, not necessarily a connection to it, but a parallel to it is a lot of the skepticism that there is for ABA as a practice as far as it's built under Medicaid.

The OIG has an ongoing series of investigations on the billing practices that states are establishing with their payer partners.

Now, the findings don't reflect well on providers either.

But this goes to show that ABA is kind of a punching bag right now and kind of a very easy, and pardon the harsh language, but a whipping boy for a lot of the problems that healthcare is seeing collectively because of its youth, because of its remarkable and frankly explosive growth, but also because of these biases and this misunderstanding.

There's a huge difference between just not being good at billing and doing things that aren't compliant with like billing rules and then going out of your way to defraud a system.

I want to point something out that I picked up over the last couple of years of observing federal actions and state actions when it comes to fraudsters.

A lot of the bad practices that we do see and that are showing up in your federal OIG reports are not fraud.

It's just bad billing.

for PAD.

There was a report that the OIG came out with just a few months ago talking about the fact that Medicare paid more than, I think, $600 million in 2022 for atherectomies and angioplasties and peripheral arterial disease cases.

And so they've just seen an explosion of this sort of work and some other bad articles focusing on a very small handful of bad actors, you know, there's just been a lot of focus.

But, you know, the trade organizations are doing a great job just to provide education and, you know, trying to make sure that atherectomy continues to remain a first line defense.

I head up our health care regulatory group, and the group of attorneys who work with me, we help providers and suppliers make good decisions, try to avoid some of the pitfalls and get them in trouble.

We also have a litigation group so that if somebody gets hit with a Department of Justice or OIG investigation, criminal or civil, or get hit with a whistleblower lawsuit, we can defend that.

We have an employment group that handles what I call the sex, drugs, and rock and roll.

law because they get all the real strange things.

So they floated the idea that it has to be monitored by clinic staff that ordered the remote monitoring.

So CMS, in my view, specifically ties these proposals to concerns identified by the OIG regarding potential fraud, waste, and abuse.

What's interesting here is that here's the mechanism.

CMS is not proposing a new enforcement program.

Our practice is a little different.

I've literally trained and groomed, and we had an administrator for a long time who was a compliance expert, worked with the OIG, and making sure that we fight to get patients the care they deserve.

And so we together have really trained our staff to do that.

So a large part of their day is spent arguing and fighting for what we request for patients' care, whether it's a lab, an MRI, surgery.

I would say the Justice Department, but there's no trust in the Justice Department under Todd Blanche.

And so who knows what would happen there? There used to be a very good OIG at Department of Justice.

I think he is now retired.

He was there when I was with the Bureau of Prisons, and he was a very fair person, and he looked at stuff very clearly.

Right.

But I do think that this should be reopened.

I think, you know, OIGs across the government should relook at this, find out what happened, you know, and recommend to Congress at least some changes to how this stuff gets worked on, especially, I guess, hopefully after January 1st.

January 3rd.

Yeah, I think the takeaway is what I've noticed working healthcare fraud in all of its different forms over the last 17 years, especially in Florida, is when an opportunity arises to commit fraud, there's unfortunately going to be somebody there who's going to take advantage of that opportunity.

The good thing is, is that at HHS OIG, we have become very good at identifying these schemes using predictive data analytics, using predictive modeling, using our just fantastic group of agents around the country to tackle this.

And I think in this case, it goes to show that we have 100% conviction rate.

This is not something that people are getting away with, and we're doing a very good job tackling this type of fraud.

If a CNA's CPR certification lapsed three weeks ago, the scheduling system literally algorithmically blocks them from being placed on the board.

Routine background checks, OIG exclusion checks, and required CEUs, it all tracks on the exact same unified record.

I have to share a specific hypothetical anecdote here because it is the absolute perfect illustration of why this matters so much.

Imagine an LPN, a licensed practical nurse, we'll call her Michelle.