HHS-OIG's Efforts Result in $3.44 Billion in Expected Recoveries, According to Latest Report
America’s taxpayers could see recoupment of billions of dollars in misspent Medicare, Medicaid, and other health and human services funds 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 2023 Semiannual Report to Congress (SAR) highlights over $3.44 billion in expected recoveries resulting from HHS-OIG audits and investigations conducted during fiscal year (FY) 2023.
In addition to summarizing the reporting period’s achievements, the SAR details the impact of our work for the entire FY 2023. The report projects over $3.44 billion in expected recoveries resulting from HHS-OIG audits and investigations occurring between October 1, 2022 and September 30, 2023; over $283 million is expected to be returned based on program audit findings, and $3.16 billion is expected to be returned based on investigative work.
In FY 2023, HHS-OIG reported 707 criminal enforcement actions against individuals and entities suspected of engaging in crimes targeting HHS programs and the people they serve. HHS-OIG also reported 746 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 2,112 individuals and entities from participation in federal health care programs.
Additional highlights of HHS-OIG’s work in the SAR include:
Medicare Improperly Paid Providers for Some Psychotherapy Services, Including Those Provided via Telehealth, During the First Year of the COVID-19 Public Health Emergency. Providers did not meet Medicare requirements and guidance when billing for some psychotherapy services, including services provided via telehealth. For 84 of the 216 sampled enrollee days, providers met Medicare requirements. However, for 128 sampled enrollee days, providers did not meet these requirements (e.g., psychotherapy time was not documented). In addition, for 54 sampled enrollee days, providers did not meet Medicare guidance (e.g., providers’ signatures were missing). We did not review 4 sampled enrollee days and treated them as non-errors because they were already part of other OIG reviews. Based on our sample results, we estimated that of the $1 billion that Medicare paid for psychotherapy services, providers received $580 million in improper payments for services that did not comply with Medicare requirements, consisting of $348 million for telehealth services and $232 million for nontelehealth services. (See report A-09-21-03021.)
CMS Did Not Accurately Report on Care Compare One or More Deficiencies Related to Health, Fire Safety, and Emergency Preparedness for an Estimated Two-Thirds of Nursing Homes. For 67 of the 100 sampled nursing homes, CMS did not accurately report on its website, Care Compare, one or more deficiencies that State surveyors identified during yearly and complaint inspections of Medicare- and Medicaid-certified nursing homes. The surveyors inspected the nursing homes for compliance with Federal health, fire safety, and emergency preparedness requirements. The deficiencies consisted of health deficiencies for 34 nursing homes, fire safety deficiencies for 52 nursing homes, and emergency preparedness deficiencies for 2 nursing homes. In addition, for 42 of the 100 sampled nursing homes, CMS did not report on Care Compare the results of all yearly fire safety and emergency preparedness inspections. We estimated that 10,303 nursing homes had 1 or more deficiencies identified during inspections that were not accurately reported on Care Compare. In addition, we estimated that for 6,458 nursing homes, CMS did not report on Care Compare the results of all yearly fire safety and emergency preparedness inspections. (See report A-09-20-02007.)
FDA Could Take Stronger Enforcement Action Against Tobacco Retailers With Histories of Sales to Youth and Other Violations and Supplemental Data on Tobacco Retailer Inspections. FDA conducted more than 1 million inspections from 2010 through 2019, inspecting 74 percent of retailers nationwide at least once. Overall, FDA’s actions against retailers that violated tobacco laws and regulations were in accord with its policies. In some States, inspection activities were correlated with neighborhoods’ socioeconomic conditions, though the direction of the correlation varied. In 18 States, more disadvantaged neighborhoods had more inspection activity, but in 8 States, they had less. FDA uses socioeconomic status to direct its contractor’s activities and to fulfill its requirement to ensure enforcement of restrictions against youth access to tobacco products in minority communities. Retailers with histories of violations were often not subject to the strongest enforcement actions. FDA collected the full amount for only 9 percent of the civil money penalties it issued to these retailers. OIG supplemented this report by publishing data on tobacco retailer inspections, including an interactive map, allowing stakeholders to explore geospatial data that provides insights on differences between states; differences by year; and socioeconomic status. (See reports OEI-01-20-00240 and OEI-01-20-00242.)
Toolkit: Analyzing Telehealth Claims to Assess Program Integrity Risks. This toolkit provides detailed information on methods to analyze telehealth claims to identify program integrity risks associated with telehealth services. It is based on the methodology that we developed for the report Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks (OEI-02-20-00720), which identified Medicare providers whose billing for telehealth services poses a high risk to Medicare. The toolkit is intended to assist public and private sector partners—such as Medicare Advantage plan sponsors, private health plans, State Medicaid Fraud Control Units, and other Federal health care agencies—in analyzing their own telehealth claims data to assess program integrity risks in their programs. The toolkit contained no recommendations. (See report OEI-02-20-00723.)
Many Medicaid Enrollees With Opioid Use Disorder Were Treated With Medication; However, Disparities Present Concerns. Treating opioid use disorder with medication (referred to as MOUD) is essential to reducing overdose deaths. However, we found that one-third of the 1.5 million Medicaid enrollees with opioid use disorder did not receive MOUD in 2021. Certain demographic groups—including Black or African-American enrollees, enrollees 18 years and younger, and enrollees with a disability and/or blindness—were less likely to receive MOUD. In 10 States, less than half of enrollees with opioid use disorder received MOUD. These findings underscore the need for continued efforts to increase the use of MOUD in Medicaid. We recommended that CMS: (1) encourage and support States’ efforts to reduce barriers to MOUD, especially among groups who may be underserved; and (2) encourage States and work with Federal partners to educate Medicaid and CHIP enrollees about access to MOUD. (See report OEI-BL-22-00260.)
The Office of Refugee Resettlement Needs to Improve Its Oversight Related to the Placement and Transfer of Unaccompanied Children. OIG found that the Office of Refugee Resettlement (ORR) faced challenges when making initial placements during an influx period. ORR did not consistently make initial placements within 24 hours during influx periods because of capacity issues and lack of intake specialist staff. Additionally, ORR did not adequately document placement decisions or placement designations for children with special concerns or needs. Furthermore, we determined that: (1) for the statistical sample of transfers of unaccompanied children, some were missing supporting documentation; (2) for the judgmental sample of transfers of children into restrictive placements, some of the required documentation was not completed or missing; (3) ORR did not maintain documentation for the reason(s) each child was denied a transfer; and (4) ORR faced challenges transferring children with both behavioral and mental health needs. These errors occurred because ORR had limited quality control procedures, lacked oversight to ensure that documentation was retained by care providers, and did not have a process in place to track denied transfers. (See report A-06-20-07002.)
During the fall SAR reporting period, HHS-OIG made 464 new audit and evaluation recommendations, which are crucial to encourage positive change in HHS programs. Meanwhile, HHS operating divisions implemented 493 prior recommendations, leading to positive impact for HHS programs and beneficiaries.
For additional information on HHS-OIG's ongoing and completed work, visit oig.hhs.gov.