Medicare Fraud and Abuse:

DOJ's Implementation of False Claims Act Guidance in National Initiatives Varies

HEHS-99-170: Published: Aug 6, 1999. Publicly Released: Aug 6, 1999.

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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.

GAO noted that: (1) DOJ's national initiative work groups have made further progress in implementing the Department's False Claims Act guidance since GAO issued its February 1, 1999, report; (2) all four work groups have completed their examination of the legal and factual basis for their initiatives and have prepared initiative-specific guidance for the U.S. Attorneys' Offices participating in the initiatives; (3) the guidance prepared by these work groups is consistent with the requirements in DOJ's guidance; (4) while DOJ officials told GAO compliance with its False Claims Act guidance is an ongoing priority for the Department, GAO believes DOJ's process for assessing the U.S. Attorneys' Offices' compliance may be superficial; (5) these assessments appear to involve little more than reviewers asking supervisors what they have done to ensure compliance with the guidance; (6) DOJ's plans for strengthening the assessment process, such as adding more questions, may not be enough to effectively assess compliance; (7) in GAO's view, these additional questions will not provide more substantive information than the original question and are only a starting point for an effective assessment; (8) GAO also found that the implementation of DOJ's False Claims Act guidance varied among the eight U.S. Attorneys' Offices GAO visited that were participating in the national initiatives; (9) five of these offices were participating in the Laboratory Unbundling initiative and had begun their involvement before DOJ's guidance was issued; (10) GAO found that their actions were, to varying degrees, inconsistent with the guidance; (11) GAO's limited review also raised questions about whether four of these offices were promptly incorporating the guidance into their ongoing investigations; (12) restrictions on GAO's access at all offices prevented GAO from conducting a complete and independent review; (13) GAO's survey of state hospital associations indicated that the issuance of DOJ's False Claims Act guidance has lessened their concerns about national initiative investigations; and (14) half of the associations expressing concerns with DOJ's use of the False Claims Act prior to the issuance of the guidance said that the guidance had fully addressed their concerns.

Recommendation for Executive Action

  1. Status: Closed - Implemented

    Comments: 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.

    Recommendation: 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.

    Agency Affected: Department of Justice

 

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