Does HHS OIG investigate Medicare frauds?
HHS-OIG has encountered a variety of scams in which fraudsters are preying upon people across the U.S., including Medicare and Medicaid beneficiaries. Criminal, civil or administrative legal actions relating to fraud and other alleged violations of law, initiated or investigated by HHS-OIG and its law enforcement partners.
How many complaints does OIG review each year?
HHS-OIG’s Hotline reviews and investigates thousands of complaints each year. We recommend you review Before You Submit a Complaint to understand the type of complaints we do and do not investigate and the complaint process.
How do I file a complaint with HHS OIG?
HHS-OIG’s Hotline reviews and investigates thousands of complaints each year. We recommend you review Before You Submit a Complaint to understand the type of complaints we do and do not investigate and the complaint process. Start your online complaint with HHS-OIG by selecting an option below.
What is the Office of OIG Hotline operations?
OIG Hotline Operations accepts tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement in the U.S. Department of Health and Human Services’ programs. HHS-OIG has encountered a variety of scams in which fraudsters are preying upon people across the U.S., including Medicare and Medicaid beneficiaries.
What is OIG hotline?
OIG Hotline Operations accepts tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement in the U.S. Department of Health and Human Services’ programs.
What is the HHS OIG?
HHS-OIG has a long history of protecting the health and well-being of HHS beneficiaries, including residents in long-term care facilities such as nursing homes. HHS-OIG collects and investigates tips and complaints about fraud, waste, and abuse in these facilities.
What Types of Common Complaints are NOT Accepted by OIG?
Allegations of identity theft unrelated to HHS programs (please Contact the Federal Trade Commission ).
What is HHS OIG Hotline Operations?
OIG Hotline Operations is a component of the OIG, Office of Investigations, overseeing several hotlines through which complaints and information are received. OIG Hotline Operations reviews and processes complaints which may or may not result in an investigation, audit, or inspections performed by the OIG, or administrative action by an Operating Division of Staff Division of HHS. As a result, the OIG Hotline helps ensure the proper and efficient use of taxpayer dollars and Government resources for the American people.
What Are the Privacy Safeguards Concerning Hotline Complaints?
§552a. OIG Hotline Operations complaint referrals are provided to non-OIG offices for review and response on an official-need-to-know basis only , and must not be released to the subjects of complaints. Although additional information may be received during the course of a complaint such items are part of the OIG Hotline file, and its release is subject to OIG approval.
Can You Appeal an OIG Hotline Operations Complaint Decision?
There are no appeal rights to a decision by OIG Hotline Operations as to the actions taken on a particular complaint. OIG Hotline Operations is not a statutory entity, court, or other administrative body. The IG Act gives the Inspector General sole discretion regarding the processing and investigation of hotline complaints.
How long do you have to wait to file a complaint with OIG?
Remember to phrase your request in terms of a search for records pertinent to your complaint, not status. You should wait at least six months before filing such a request.
What is the IG Act?
The Inspector General Act (IG Act) protects an employee of HHS. The IG Act prevents disclosure of an HHS employee’s identity outside HHS/OIG unless the Office of Inspector General, on rare occasions, determines that release of the complainant's identity is essential to investigate the allegation. To avoid disclosure, the confidential employee complainant should provide a contact address and telephone number off HHS facility premises.
Can OIG take further action?
Take No Further Action. OIG Hotline Operations administratively close the complaint, taking no further action on matters which are not within HHS or OIG's jurisdiction, are outside referral criteria identified by HHS and OIG management, or are too trivial, stale, or vague to warrant further review. For example, anonymous complaints that lack sufficient information are too vague to warrant further review. Whenever possible, OIG will attempt to refer the complaint to the appropriate authorities.
What is the OIG report?
The Office of Inspector General (OIG) for the Department of Health and Human Services (HHS) has published the findings of an investigation into claims denials for members of Medicare Advantage Plans. The report concluded that there is a profit motive, stating specifically, “A central concern about the capitated payment model used in Medicare ...
How many Medicare denials were overturned in 2016?
The OIG study found that during 2014-2016, Medicare Advantage plans overturned 75% of their own preauthorization and payment denials, overturning approximately 216,000 denials each year. Even more, denials were overturned when the beneficiaries went further into the appeals process, beyond the first stage. The report states, “The high number of overturned denials raises concerns that some Medicare Advantage beneficiaries and providers were initially denied services and payments that should have been provided.”
What is CMS audit?
In their audit, the OIG recommends that the Center for Medicare & Medicare Services (CMS) “enhance their oversight of Medicare Advantage contracts, including those with extremely high overturn rates and/or low appeal rates, and take corrective action as appropriate.”.
How long does Medicare Advantage last?
The benefits within a Medicare Advantage plan, as announced at the beginning of the year are fixed for the duration of the calendar year, but not beyond that one-year period . This means that a member of a specific Medicare Advantage plan who signed up for a set premium (or no premium), after finding out that their favorite doctor is in the network might find that the next year the premium, co-payments, and provider networks have changed. This is announced in their “Annual Notice of Change” received by the members in October which outline what changes will happen to their program on the next January 1.
What is Medicare Supplement?
These options include original Medicare and a Supplement, which offers the freedom of choice to visit any doctor and any hospital that accepts Medicare; or a Medicare Advantage program with its inherently unique set of network and procedure conditions. The Medicare Supplement route means that the senior can travel from coast to coast, without restriction, and there are no significant deductibles, pre-authorization procedures, or maximum out of pocket concerns when seeking the care their chosen physician feels is best for them, as long as the procedure is deemed medically necessary by Medicare.
How is the monthly premium subsidized?
The monthly premium is subsidized by the government’s payment to private insurance companies who then manage the care the senior receives. The incentive to closely scrutinize what is approved for care is what amounts the insurer’s profit – that is, the difference between the government’s monthly pay for the senior’s care, at a fixed rate, ...
Can Medicare Advantage network change?
While the Medicare Advantage network can be searched to see if the beneficiary’s doctor is within the network, that network can still change during the plan year, as doctor and hospital contracts are not always calendar-year contracts and providers can choose to leave the networks.
What is the OIG report?
Department of Health and Human Services (HHS) Office of the Inspector General (OIG) released a report highlighting concerns about how Medicare Advantage Organizations (MAOs) are using health risk assessments to improve care and health outcomes under the Medicare Advantage (MA) program, as intended , and about the sufficiency of oversight by the Centers for Medicare & Medicaid Services (CMS).
Why do MAOs use risk assessments?
However, some MAOs may be initiating and using the risk assessments, often by hiring companies to conduct them in beneficiaries’ homes, to collect diagnoses and maximize risk-adjustment payments without improving care.
How many MAOs are risk adjusted?
Ninety-five percent of these MAOs had a payment resulting solely from health risk assessments. For these 438 MAOs, risk-adjusted payments due solely to diagnoses reported on risk assessments varied significantly, ranging from a high of $243.9 million to a low of $1,558 across MAOs.
Can MAOs receive Medicare benefits?
CMS and the Medicare Payment Advisory Commission (MedPAC) have raised concerns in the past that MAOs may receive financial benefits without improving beneficiaries’ health if MAOs initiate health risk assessments and use them to collect diagnoses without ensuring that beneficiaries receive needed follow-up care.