The Office of Inspector General (OIG) has added a new entity, Ridgeview Rehab & Nursing Center, LLC (Ridgeview), to its list of individuals and entities designated as “high risk – heightened scrutiny.” The “high risk – heightened scrutiny” list is part of the OIG’s fraud risk indicator tool, which the OIG made public last year. The fraud risk indicator tool places parties that have settled False Claims Act (FCA) allegations with the government into one of five categories on a risk spectrum.The OIG says it uses this risk spectrum to “assesses the future trustworthiness of the settling parties (which can be individuals or entities) for purposes of deciding whether to exclude them from the Federal healthcare programs or take other action.”

In 2018, the OIG announced that it would start publishing a list of those parties designated as “high risk – heightened scrutiny” on its website. The “high risk – heightened scrutiny” designation is for individuals and entities that the OIG has determined pose a “significant risk” to Federal healthcare programs. According to the OIG, parties on this list have refused to enter into corporate integrity agreements (CIAs) with the OIG, but the OIG believes that they require additional oversight.

The OIG says it is making this information public because “where an FCA defendant falls on [the OIG’s] risk spectrum . . . may be relevant to various stakeholders, including patients, family members, and healthcare industry professionals.”

The OIG’s risk spectrum is based on exclusion criteria published in 2016. The five categories are:

  • “Highest Risk – Exclusion” – for parties that the OIG has determined present the highest risk of fraud and must be excluded from Federal healthcare programs.
  • “High Risk – Heightened Scrutiny” – for parties that the OIG has determined pose “significant risk” and require additional oversight but refuse to enter into CIAs as part of settling an investigation.
  • “Medium Risk – CIAs” – for parties that have signed a CIA with OIG as part of settling an investigation.
  • “Lower Risk – No Further Action” – for parties that the OIG has determined pose a “relatively low risk” and had their case closed without the OIG “evaluating the effectiveness of any efforts the parties have made to ensure future compliance with Federal healthcare program requirements.”
  • “Low Risk – Self-Disclosure” – for parties that have demonstrated they have an effective compliance program by self-disclosing potential fraud and abuse to the OIG.

When the list was first published in October 2018, only two entities (both part of the same settlement) were designated as “high risk – heightened scrutiny.” These entities – both dental practices – were accused of violating the FCA by billing Medicaid for a more expensive procedure than the one actually performed and billing Medicaid for services that were either not performed or not medically necessary.

Similarly, Ridgeview settled allegations in May 2019 that it violated the FCA by billing Medicare for services that were not medically necessary. Ridgeview was one of three nursing facilities involved in the May 2019 settlement, but it was the only party to the settlement that the OIG added to the “high risk – heightened scrutiny” list. It is unclear why the other parties to the settlement were not designated as “high risk – heightened scrutiny.”

Although only two settlements have resulted in parties being added to the “high risk – heightened scrutiny” list since the list was made public last year, the addition of these parties suggests that the OIG plans to use this tool to flag potential bad actors, particularly those accused of billing Medicare of Medicaid for services that were unnecessary or never performed.