U.S. Office of Personnel Management www.opm.gov - Recruiting, Retaining and Honoring a World-Class Workforce to Serve the American People

xposed
Billing
Scheme
Results in $176,955
FEHBP Recovery

By agreeing to pay the federal government the sum of $9 million, UroCor will have resolved its federal liability for the alleged submission of false and fraudulent claims for services it provided to the various victimized federal health insurance programs involved. UroCor is to pay $252,200 to our agency, which represents the amount UroCor owes the FEHBP trust fund. 

Physicians Group Agrees to Settle Fraud Charges

A continuing five-year investigation being conducted by our office in conjunction with the Department of Justice, has culminated in a civil settlement with a corporation representing emergency room physicians. 

Emergency Physicians Medical Group, PC (EPMG), of Michigan, Pennsylvania and Ohio, agreed to pay the federal government $1.9 million. This payment  represents EPMG's liability for its alleged involvement in a billing scheme to defraud federal and state health insurance programs. Under the agreement, the FEHBP is to receive $176,955, representing its portion of the settlement. 

We initiated this investigation based on a referral by a Blue Cross Blue Shield plan that had alleged that an emergency room physicians. billing service (Emergency Physicians Billing Service), routinely charged for high-end services involving emergency room physicians when, in reality, lower-priced basic services had actually been provided. This activity inflated costs charged to the FEHBP and to other federal and state health insurance programs. 

We learned through this investigation how the billing service initially succeeded in its fraudulent billing practices. When billing these federal health insurance 

programs for medical services, the billing service deliberately changed specific treatment codes to indicate higher-priced service. This type of billing fraud is known in the insurance industry as .up coding.. EPMG was a customer of the billing service and willingly participated in this fraud. 

Inasmuch as this is an ongoing investigation of the billing service, we expect to realize additional recoveries from other corporate entities involved in the scheme. These, of course, will be reported  in future semiannual reports.

Retirement Fraud and Special Investigations

In addition to health care fraud, our office works closely with other federal, state and local law enforcement officials to uncover fraud involving OPM's retirement and life insurance program trust funds. 

Our office's proactive efforts to identify fraud against OPM's retirement fund takes two forms: (1) we routinely review Civil Service Retirement System (CSRS) annuity records for indications of unusual circumstances, and (2) we maintain contact with the federal annuitant population, including telephone calls and on-site visits to the homes of annuitants listed in OPM's retirement records. While our fraud recoveries in this area are, for the most part, smaller than in the health care fraud area, criminal prosecutions and sentences tend to be more significant. 

In addition, this office conducts special investigations in other areas having to do with serious criminal violations and misconduct by OPM employees. These cases primarily involve the theft of government funds and property.