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HHS-OIG’s Work Could Save Taxpayers Billions of Dollars, New Report Says

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America's taxpayers could see billions in misspent Medicare, Medicaid, and other health and human services dollars recouped as a result of work by the Department of Health and Human Services (HHS), Office of Inspector General (OIG), according to a new report.

The Fall 2020 Semiannual Report to Congress (SAR) highlights more than $4 billion in expected investigative and audit recoveries identified during fiscal year (FY) 2020.

In addition to summarizing the full year's achievements, the SAR provides an overview of OIG’s activities for the reporting period comprising the last half of FY 2020 (April 1 through September 30).

“During this reporting period, the COVID-19 public health emergency posed significant challenges for HHS programs and their capacity to ensure public health and safety. Consequently, oversight of COVID-19-related issues commanded much of OIG’s attention and remains a primary focus,” said Christi A. Grimm, OIG’s Principal Deputy Inspector General. “OIG has been a leader in the fight against COVID-19-related fraud, aggressively pursuing those who seek to exploit the public health emergency, endanger people, and steal public funds. OIG additionally has issued guidance on the application of OIG’s administrative sanction authorities to support health care providers as they have rapidly adjusted to delivering services during the pandemic.”

Of the more than $4 billion in expected recoveries, the report shows that for FY 2020, some $942 million could be returned based on program audit findings and more than $3.14 billion in expected investigative recoveries.

In FY 2020, OIG reported 624 criminal actions against individuals or entities that engaged in crimes that affected HHS programs. OIG also reported 791 civil actions, which include false claims and unjust-enrichment lawsuits filed in federal district court, civil monetary penalty settlements, and administrative recoveries related to provider self-disclosure matters. Our agency also excluded 2,148 individuals and entities from participation in federal health care programs, including Medicare and Medicaid.

Additional highlights of OIG’s work in the SAR include:

OIG rapidly provided information about hospitals’ experiences and perspectives in responding to COVID-19. In a pulse survey conducted in late March 2020 and described in an OIG report issued on April 3, 2020, hospitals nationwide described challenges, mitigation strategies, and the need for assistance in responding to COVID-19. Hospitals reported that their most significant challenges centered on testing and caring for patients with known or suspected COVID-19 infection and keeping staff safe. Hospitals also reported substantial challenges to maintaining or expanding their facilities’ capacity to treat patients with COVID-19. (See report OEI-06-20-00300.)

In April 2020, OIG issued guidance regarding the application of OIG’s administrative fraud enforcement authorities to support providers in delivering needed patient care during the public health emergency. The Policy Statement was in response to the Secretary’s January 31, 2020, declaration of a public health emergency. Under this Policy Statement, OIG will exercise its enforcement discretion to not impose administrative sanctions under the federal anti-kickback statute for certain remuneration related to COVID-19 (See Policy Statement).

Also, in April, OIG identified opportunities where HHS can strengthen its overall IT security program. OIG found that HHS made progress in improving its overall cybersecurity posture, but certain weaknesses persist and pose challenges. OIG found weaknesses in the following domains of the Inspector General Federal Information Security Modernization Act of 2014: risk management, configuration management, identity and access management, data protection and privacy, security training, information security continuous monitoring, incident response, and contingency planning. HHS agreed with OIG’s recommendations to strengthen its cybersecurity program and enhance security controls at HHS. (See report A-18-19-11200.)

In July 2020, OIG determined that Medicaid claim data can be used to identify incidents of potential child abuse or neglect. Based on claim data and medical record review, OIG estimated that 29,260 of the 29,534 children enrolled in Medicaid in our sampling frame were involved with incidents of potential child abuse or neglect. The Centers for Medicare & Medicaid Services (CMS) concurred with OIG’s recommendation to inform states that performing data analysis using Medicaid claims containing diagnosis codes indicative of potential child abuse or neglect could help identify incidents of possible child harm, and also help ensure health care provider compliance with state mandatory reporting laws. (See report A‑01-19-00001.)

In August 2020, OIG found that individual nursing homes’ daily staffing levels did not match their Staffing Star Ratings. In 2018, nursing homes reported that staffing levels often varied on a day-to-day basis, and that staffing levels for 7 percent of nursing homes fell below required federal standards for at least 30 total days. CMS’s Star Rating System ranks nursing homes on their average staffing levels each quarter; as a result, daily staffing variations are not transparent to consumers. CMS did not agree or disagree with recommendations to enhance efforts to ensure that nursing homes meet daily staffing requirements. (See report OEI-04-18-00450.)

Later in August, OIG found that opioid use has steadily declined in Medicare Part D and the use of drugs for medication-assisted treatment (MAT) has increased. The changes in recent years in opioid use and MAT show progress from the efforts of HHS and others to address the opioid crisis. Nonetheless, it is critical to remain vigilant as the COVID-19 pandemic poses additional danger for at-risk populations. Although the number of Part D beneficiaries who received opioids decreased in 2019, OIG determined that almost 34,000 beneficiaries remain at serious risk of opioid misuse or overdose. OIG encourages CMS to also closely monitor opioid use and access to treatment in 2020 and beyond. (See report OEI-02-20-00320.)

In September 2020, the largest national takedown in Department of Justice history was carried out across 51 judicial districts. This takedown resulted in charges against 345 individuals for submitting more than $6 billion in false and fraudulent claims to federal health care programs and private insurers, including more than $4.5 billion connected to prescribing or ordering unnecessary medical items or services by leveraging aggressive marketing tactics (See enforcement action details).

Also, in September, three former caregivers were sentenced on civil rights and obstruction charges related to the death of a disabled resident. The Missouri caregivers were sentenced for their roles in the death of a disabled resident at Second Chance Homes, an organization that provided housing and care for developmentally disabled persons through a Missouri Department of Mental Health initiative. The caregivers pleaded guilty to willfully failing to provide necessary medical care to the victim, resulting in injury to and the death of the victim (See enforcement action details).

OIG issued a Notice of Proposed Rulemaking (NPRM) regarding its new authorities under the 21st Century Cures Act. The NPRM discusses OIG’s new authorities permitting the imposition of sanctions for fraudulent conduct related to HHS grants, contracts, or other agreements, and the investigation of information blocking. The NPRM also sets forth OIG’s expected information blocking enforcement approach and priorities. The NPRM proposes modifying OIG’s civil monetary penalty regulations in accordance with the Bipartisan Budget Act of 2018. OIG will provide an update in a future SAR when OIG issues the Final Rule (See NPRM).

OIG continues to expand its use of data analytics to strengthen oversight efforts. Further, OIG's work highlights the critical role that complete, accurate, timely, and secure data must play in strengthening the performance of HHS programs.

For additional information on HHS-OIG's ongoing and completed work, visit oig.hhs.gov.