OIG Fraud Alert Warns of Marketing Schemes, Prohibited Activities

The Health and Human Services Office of the Inspector General (OIG) issued a special fraud alert on December 11 highlighting the risks posed by MA organizations' (MAO) paying or rewarding healthcare providers in exchange for referrals.

Medicare Advantage regulations related to marketing explicitly state what marketing activities providers can and cannot do related to MA plans. Providers should take note that such payments can come in various forms, including gift cards, goods or services.

OIG said that direct and indirect remuneration-regardless of its form-in exchange for referrals can be a sign of abusive marketing practices and it has observed an uptick in these practices in recent years. The alert outlines a series of "suspect characteristics" that providers should watch out for to avoid legal sanctions. Essentially, health care providers and their staff should not accept any type of remuneration (e.g., bonuses or gift cards) in exchange for referring or recommending patients to a particular plan or MAO.

Providers should be wary of payments from plans that are disguised as payment for legitimate services but are really in exchange for referrals. Providers shouldn't share patient information which could be used for marketing purposes by a plan or MAO including demographics or health status. For example, plans might be interested in current patients who will need long term nursing home care following post-acute care so they can market their institutional special needs plan (ISNP). Providers should review the MA regulations regarding what activities are permissible and which are prohibited, and establish and communicate clear policies on these practices to prevent the organization and staff from running afoul of these situations.