HHS-OIG's Efforts Result in $7.13 Billion in Expected Recoveries and Receivables, According to Fall 2024 Semiannual 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 2024 Semiannual Report to Congress (SAR) highlights over $7 billion in expected recoveries and receivables resulting from HHS-OIG investigations and audits conducted during fiscal year (FY) 2024.
In FY 2024, HHS-OIG reported 1,548 criminal and civil enforcement actions against individuals and entities suspected of engaging in crimes targeting HHS programs and the people they serve, including settlements resulting from using OIG's civil monetary penalty authorities and criminal convictions. HHS-OIG also excluded 3,234 individuals and entities from participation in Federal health care programs.
The report identifies over $4 billion in expected recoveries and receivables resulting from HHS-OIG investigations and audits occurring between April 1, 2024, and September 30, 2024. During the fall SAR reporting period, HHS-OIG made 239 new audit and evaluation recommendations, which are crucial to encourage positive change in HHS programs. Meanwhile, HHS operating divisions implemented 187 prior recommendations, leading to positive impact for HHS programs and beneficiaries.
Additional highlights of HHS-OIG's work in the SAR include:
Certain For-Profit Nursing Homes May Not Have Complied With Federal Requirements Regarding the Infection Preventionist Position. OIG reviewed 100 for-profit nursing homes nationwide and found that 24 did not meet Federal requirements pertaining to infection preventionists. Infection preventionists are responsible for facility infection prevention and control. Based on our sample results, OIG estimates that 2,568 (approximately 1 in 4) for-profit nursing homes nationwide may not have complied with Federal requirements for infection preventionists during our review period. As a result, there may be increased health and safety risks for the residents and staff of these nursing homes. (See report A-01-22-00001.)
States Could Better Leverage Coverage and Access Requirements To Promote Maternal Health Care Access in Medicaid Managed Care. OIG found that States could better leverage MCO provider coverage requirements and network adequacy standards to promote access to maternal health care. Specifically, OIG found that beyond obstetrician/gynecologist (OB/GYN) physicians and hospitals, many States reported they do not require MCOs to cover important types of maternal health providers and professionals, some of whose services are federally required. Some States are not using network adequacy standards to address important dimensions of maternal health care access. For example, some measure access to specific provider types such as OB/GYNs, but many do not. Some tailor their standards to maternal health care needs (e.g., by varying appointment wait time requirements by pregnancy stage), while others do not. All States reported monitoring MCOs' compliance with network adequacy standards, but they may lack data on the standards' impact on access to maternal health care. (See report OEI-05-22-00330.)
Medicare Improperly Paid Hospitals An Estimated $79 Million For Enrollees Who Had Received Mechanical Ventilation. OIG found Medicare improperly paid hospitals an estimated $79 million for enrollees who had received mechanical ventilation. Hospitals attributed the improper billing to incorrectly counting the hours that enrollees had received mechanical ventilation or clerical errors in selecting procedure or diagnosis codes. (See report A-09-22-03002.)
Medicare and Some Enrollees Paid Substantially More When Stelara Was Covered Under Part D Versus Part B. OIG found that Medicare and some enrollees paid 80 percent more when Stelara injections, a high-cost prescription biologic approved to treat certain autoimmune diseases, were covered under Part D (i.e., self-administered) versus under Part B (i.e., administered by a physician). However, given recent coverage changes, enrollees who once opted to receive Stelara injections in their doctors' offices (i.e., through Part B) must now obtain Stelara through a pharmacy (i.e., through Part D), where they will potentially face much higher out-of-pocket costs. Our findings illustrate how differences in the methods used to set drug payment amounts under Part B (i.e., manufacturers' sales prices) versus under Part D (i.e., negotiations between plan sponsors, manufacturers, pharmacy benefit managers, and pharmacies) result in widely different payment amounts for the same drugs. (See report OEI-BL-19-00500.)
Many States Lack Information To Monitor Maltreatment in Residential Facilities for Children in Foster Care. OIG found that many State child welfare agencies lack information to monitor maltreatment in residential facilities for children in foster care. States reported missing or incomplete information in the following key areas that could support enhanced oversight of residential facilities for children, although collecting and sharing this information is not required by Federal law. Nearly one-third of States could not identify patterns of maltreatment in residential facilities within their State. States had limited awareness of maltreatment that occurred across chains of residential facilities operating in multiple States. States reported challenges monitoring the safety of children placed in out-of-State residential facilities. Thirteen States did not consistently report to the national maltreatment database whether children who experienced maltreatment were living in a residential facility. (See report OEI-07-22-00530.)
Safeguarding the Integrity of HHS Programs. OIG has continued to prioritize investigations in areas particularly vulnerable to criminal schemes, such as durable medical equipment. During this reporting period, our investigators worked with the Department of Justice to prosecute two brothers who used aggressive telemarketing strategies and bribed doctors to order unnecessary durable medical equipment. The brothers were sentenced to jail and ordered to pay more than $424 million in restitution.
For additional information on HHS-OIG's ongoing and completed work, visit oig.hhs.gov.