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Report (OEI-07-09-00020)

03-18-2011
CMS's Processing of Complaints Received Through the 1 800 HHS-TIPS Hotline

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Summary

Our review of hotline complaint data and inquiries to staff at each claims processing contractor and program integrity contractor assigned to the sampled complaint(s) revealed that at least 1 year after receiving complaints through the 1-800-HHS-TIPS hotline, CMS had resolved the majority of them, but 12 percent remained unresolved.

Many OIGs operate hotlines to respond to citizen and employee allegations of fraud, waste, or abuse in Federal programs. The Department of Health & Human Services (HHS) OIG maintains such a hotline (1-800-HHS-TIPS) for individuals to provide information that may assist in combating fraud, waste, or abuse in HHS programs (e.g., Medicare, Medicaid, child support enforcement, and Head Start). The availability of the hotline is widely publicized in HHS and CMS publications and on Web sites. Given the hotline's prominence, it is vital that information reported to the hotline be thoroughly reviewed and appropriately addressed in a timely fashion.

Long timeframes and inefficient processes delay starting work on complaints. Contractors reported starting work on 58 percent of complaints within 30 days of CMS's receipt of the complaints from OIG, but for 29 percent of complaints, contractors took more than 4 months to start work. Some CMS and contractor staff described processes that contribute to delays in transmitting complaints from the CMS central office to contractor staff. Such delays add to the time that it takes to resolve complaints. Finally, lack of guidance and an inadequate information system hinder complaint processing. Although CMS provides some guidance to contractors, some CMS and contractor staff stated that guidance is lacking for processing complaints from receipt through resolution. In addition, the status of complaints cannot be tracked in CMS's information system.

We recommended that CMS (1) issue written guidance to its own staff and contractor staff for processing hotline complaints and (2) upgrade its information system for processing complaints.

In its written comments on the report, CMS concurred with our recommendations. CMS stated that it will create written guidance that defines the specific roles and responsibilities for CMS and its contractor staff to achieve greater clarity in administration of its database (i.e., its information system). Where they are not already established, CMS will establish timeframes for assigning, researching, and resolving complaints. CMS stated that it is revising its national contractor list to include contact names and contract numbers associated with the contractors. CMS stated that it is upgrading and updating the database with the following features: auditing mechanisms to track user activity, contractor assignments, and status of complaints; and the capacity to alert CMS when complaints have not been assigned. CMS stated that it will work with OIG to establish an electronic method to deliver hardcopy evidence received from complainants concurrently with the electronic complaint.

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Exclusions Database Report Fraud
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