Medicare and Medicaid CMS audits can lead to further and more extensive investigations. For example, auditors looking at overutilization of rehabilitation services, may consult with both OIG or DOJ, and a broader investigation could ensue. If you are investigated by OIG, DOJ or FBI, you should be prepared and know what to do when an inspector walks in the door.
Federal investigations can lead to prosecution. CMS, OIG and DOJ have worked together, through criminal and civil systems, to secure thousands of criminal convictions and obtain civil administrative actions against individuals and organizations committing Medicare and Medicaid program fraud. Further, billions of dollars in health care fraud monies have been recovered under both Federal and State False Claims Act (FCA). Under the FCA, individuals who knowingly submit, or cause another person or entity to submit, false claims for payment of Medicare or Medicaid funds, are liable for three times the government’s damages plus civil penalties. Under the FCA, providers also can be prosecuted for allegedly billing the Medicare and Medicaid programs for “worthless services.”