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Medicare Fraud and Abuse: DOJ's Implementation of False Claims Act Guidance in National Initiatives Varies

HEHS-99-170 Published: Aug 06, 1999. Publicly Released: Aug 06, 1999.
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Highlights

Pursuant to a legislative requirement, GAO reviewed the Department of Justice's (DOJ) and selected U.S. Attorneys' Offices' implementation of the False Claims Act guidance, focusing on: (1) the status of DOJ's work groups efforts and the initiative-specific guidance they prepared; (2) DOJ's efforts to assess U.S. Attorneys' compliance with the guidance; (3) the implementation of the guidance at selected U.S. Attorneys' Offices; and (4) state hospital associations' concerns regarding DOJ's use of the False Claims Act.

Recommendations

Recommendations for Executive Action

Agency Affected Recommendation Status
Department of Justice DOJ should improve its oversight of U.S. Attorneys' Offices participating in national health care initiatives. Specifically, DOJ should: (1) develop guidance for reviewers that includes specific steps for determining whether offices appropriately follow the guidance; and (2) require reviewers to independently determine whether the offices are complying with the guidance.
Closed – Implemented
In meeting the recommendation, DOJ planned to take a combined approach, utilizing national initiative working groups, United States Attorneys' Offices (USAOs), Civil Health Care Fraud Coordinators, and Evaluation and Review Staff. Implementation was scheduled for late 1999. In its March 2000 report, GAO noted that DOJ had, in fact, taken these steps and had improved its method of evaluating the compliance of its USAOs with its False Claims Act guidance. However, at that time, GAO was unable to evaluate the effectiveness of DOJ's changes because, DOJ had not yet completed any evaluations using this new approach. In GAO's subsequent reports, issued in March 2001 and April 2002, GAO reported that these evaluations appear to have promoted compliance with the guidance. These reports also noted that DOJ had taken further steps to strengthen its oversight of USAOs participating in national health care initiatives. They also concluded that DOJ appears to be conducting its two most recent national initiatives in a manner consistent with the guidance.

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Topics

Claims processingHealth insurance cost controlHospitalsInternal controlsInvestigations by federal agenciesMedical expense claimsMedicareOverpaymentsProgram abusesQuestionable billing