U.S. Department of Health & Human Services  
Office of Inspector General
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EMIANNUAL
to
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EPORT 
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ONGRESS
October 1, 2016  to
March 31, 2017 l
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o A MESSAGE FROM THE INSPECTOR GENERAL 
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Daniel R. Levinson 
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Inspector General
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I am pleased to submit this Semiannual Report to Congress summarizing activities of the Office 
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of Inspector General (OIG), Department of Health and Human Services (HHS or the Department), for the 6-month 
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period that ended March 31, 2017.  OIGs mission is to protect the integrity of HHS programs and ensure the health and 
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welfare of the beneficiaries they serve.  Our dedicated employees work to fight fraud; enhance safety and quality of 
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  care; improve efficiency of program operations; reduce improper payments; foster prudent payment policies; and 
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improve data integrity and information security.  OIGs diverse workforce combines traditional disciplinesauditors, 
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evaluators, investigators, and attorneyswith additional expertise in medicine, technology, data analytics, and 
 
e economics to prevent fraud and abuse through recommendations to improve program operations; to use data 
c modeling and other techniques to detect problems quickly; and to take appropriate enforcement action when we 
i identify fraudulent and abusive practices.
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During this reporting period, we had significant accomplishments overseeing the Departments more than $1 trillion 
portfolio of health and human services.  For example, we continued to partner with HHS, the Department of Justice, 
U.S. Attorneys Offices, the Federal Bureau of Investigation, and State and local law enforcement in Health Care Fraud 
Strike Force teams.  During the reporting period, Strike Force efforts resulted in the filing of charges against 49 
individuals or entities, 152 criminal actions, and more than $266.8 million in investigative receivables.  Also during this 
reporting period, we issued noteworthy reviews of many critical Department services and expenditures.  One such 
review examined Federal payments for Medicare Part D catastrophic coverage; these payments exceeded $33 billion in 
2015, more than triple the amount paid in 2010.  OIG data analysis revealed 10 high priced drugs that accounted for 
nearly one-third of this spending, and we determined that CMS will likely need additional tools to secure the future of 
the Part D program.  In two reviews, we closely examined the challenges affecting the ability of Indian Health Service 
hospitals to provide safe, quality care to patients.  Through issuance of new Anti-Kickback Statute safe harbors, 
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  ii OFFICE OF   including one that aids beneficiaries in obtaining needed transportation for treatment, we enhanced flexibility for 
INSPECTOR   providers to improve efficiency and access to quality care while we continued to protect programs and patients from 
GENERAL fraud and abuse. 
Looking to the future, OIG is tracking its own performance in priority areas, such as the following:  (1) protecting 
beneficiaries from prescription drug abuse; (2) reducing improper payments for home health services in fraud hot 
spots; (3) improving program integrity for the Child Care and Development Fund grant programs; and (4) maximizing 
the effectiveness of State Medicaid Fraud Control Units.  We will build on our experience and expertise in pursuit of 
measurable improvements in these and other important areas.  We will remain an agile organization focused on the 
most pressing issues facing Department programs.  
OIG remains committed to working collaboratively with our partners to protect beneficiaries and oversee HHSs 
programs.  The success reflected in this Semiannual Report to Congress derives from the efforts of a dedicated, 
multidisciplinary workforce in OIG.  Once again, I would like to express my appreciation to Congress and to the 
Department for their sustained commitment to the important work of our office.
Daniel R. Levinson 
Inspector General 
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  iii  
n THE DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS), Office of Inspector General (OIG), provides 
o independent and objective oversight that promotes economy, efficiency, and effectiveness in HHS programs and operations.  OIGs 
program integrity and oversight activities are shaped by legislative and budgetary requirements and adhere to professional standards 
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t established by the Government Accountability Office (GAO), the Department of Justice (DOJ), and the Inspector General community.  
a OIG carries out its mission to protect the integrity of HHS programs and the health and welfare of the people served by those 
z programs through a nationwide network of audits, investigations, and evaluations.  Our work is conducted by the following operating 
components.  
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OAS
The Office of Audit Services (OAS).  OAS conducts audits of HHS programs and operations through its own resources or 
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by overseeing audit work done by others.  Audits examine the performance of HHS programs and/or its grantees and 
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contractors in carrying out their respective responsibilities and are intended to provide independent assessments of 
r HHS programs and operations.  These assessments help reduce waste, abuse, and mismanagement and promote the 
O economy, efficiency, and effectiveness of programs and operations throughout HHS.
OEI
  The Office of Evaluation and Inspections (OEI).  OEI conducts national evaluations to provide HHS, Congress, and the 
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public with timely, useful, and reliable information on significant issues.  These evaluations focus on preventing fraud, 
I waste, and abuse and promoting economy, efficiency, and effectiveness in HHS programs.  OEI reports also present 
O practical recommendations for improving program operations.
OI
The Office of Investigations (OI).  OI conducts criminal, civil, and administrative investigations of fraud and 
misconduct related to HHS programs, operations, and beneficiaries.  With investigators working in almost every State, 
the District of Columbia, and Puerto Rico, OI coordinates with DOJ and other Federal, State, and local law enforcement 
authorities.  OI also coordinates with OAS and OEI when audits and evaluations uncover potential fraud.  OIs 
investigative efforts often lead to criminal convictions, administrative sanctions, or civil monetary penalties (CMPs).
OCIG
The Office of Counsel to the Inspector General (OCIG). OCIG provides general legal services to OIG, rendering advice 
and opinions on HHS programs and operations and providing all legal support for OIGs internal operations.  OCIG 
represents OIG in all civil and administrative fraud and abuse cases involving HHS programs, including False Claims Act, 
program exclusion, self-disclosure, and CMP cases.  In connection with these cases, OCIG also negotiates and monitors 
corporate integrity agreements (CIAs).  OCIG renders advisory opinions, issues compliance program guidance, publishes 
fraud alerts, and provides other guidance to the health care industry about the anti-kickback statute and other OIG 
enforcement authorities.
EM
Executive Management (EM).  EM is composed of the Immediate Office of the Inspector General and the Office of 
Management and Policy.  EM is responsible for overseeing the activities of OIGs components; setting vision and 
direction, in collaboration with the components, for OIGs priorities and strategic planning; ensuring effective 
management of budget, finance, information technology (IT), human resources, and other operations; and serving as a 
liaison with HHS, Congress, and other stakeholders.  EM plans, conducts, and participates in a variety of cooperative 
projects within HHS and with other Government agencies.  EM provides critical data analytics, data management, and 
IT infrastructure that enables OIG components to conduct their work efficiently and effectively.
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  iv   
oe AS DELINEATED IN OIGS STRATEGIC PLAN, OIGs approach to protecting the integrity of HHS programs has 
tg four key goals: (1) fight fraud, waste, and abuse; (2) promote quality, safety, and value; (3) secure HHS programs future; 
h n and (4) advance excellence and innovation.  These goals drive OIGs work planning for audits and evaluations as well as 
a OIGs approach to enforcement.  OIG focuses on efficient oversight and on achieving outcomes that benefit the 
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h Departments programs and the people they serve.
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e Top Management Challenges Facing HHS
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i To focus the Departments attention on the most pressing issues, each year OIG identifies the Top Management and 
At Performance Challenges facing the Department.  These top challenges arise across HHS programs and Operating 
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 s Divisions, including Medicare, Medicaid, Administration for Children and Families (ACF), the Public Health Service, the 
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o Indian Health Service (IHS), and the Food and Drug Administration (FDA).  The top challenges cover critical HHS 

P responsibilities that include delivering quality services and benefits, exercising sound fiscal management, safeguarding 
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public health and safety, and enhancing cybersecurity.  
 
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i OIG Work Plan
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i OIGs Work Plan sets forth various projects that OIG plans to undertake during the fiscal year (FY) and beyond.  Projects 
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listed in the Work Plan span the Departments Operating Divisions, including the Centers for Medicare & Medicaid 
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Services (CMS), public health agencies such as the Centers for Disease Control and Prevention (CDC) and National 
Institutes of Health (NIH), and human resources agencies such as ACF and the Administration on Aging.  The Work Plan 
also includes oversight of State and local governments use of Federal funds as well as the administration of the 
Department.  Some of the projects described in the Work Plan are statutorily required.  
Compendium of Unimplemented Recommendations
OIG drives positive change not only by identifying problems, abuses, and deficiencies but also by recommending 
solutions to address them.  OIG maintains a list of recommendations to address vulnerabilities detected in its reviews and 
identifies the top unimplemented recommendations that, if implemented, are likely to garner significant savings and 
improvements in quality, efficiency, and effectiveness.  OIG systematically follows up on its recommendations with 
responsible Operating Divisions.  OIG compiles its top and most significant unimplemented recommendations in our 
Compendium of Unimplemented Recommendations.
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  v y OUR SEMIANNUAL REPORT TO CONGRESS (SEMIANNUAL REPORT) describes OIGs work in 
r identifying significant problems, abuses, deficiencies, remedies, and investigative outcomes relating to the administration 
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of HHS programs and operations.  This edition addresses work completed during the reporting period, October 1, 2016, 
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to March 31, 2017.  
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Enhancing Safety and Quality of Care
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Programs operated and administered by HHS touch the lives of nearly all Americans.  For example, FDAs oversight of our 
 
e food, drugs, and medical devices is critical to the well-being of the American population.  Furthermore, the Medicare and 
v Medicaid programs provide essential health care services to more than 120 million people.  HHS faces special challenges 
i serving vulnerable populations, including recipients of nursing home care, hospice care, and home- and community-
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based services (HCBS); IHS beneficiaries; and children.  
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During this semiannual period, OIG continued its work identifying whether States verify that nursing homes are 
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correcting previously identified deficiencies.  In our report, we found that Arizona did not verify nursing homes 
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correction of deficiencies in accordance with Federal requirements for more than half of the deficiencies identified during 
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previous State surveys.  We found that Arizonas practice for less serious deficiencies was to accept the nursing homes 
correction plans as confirmation of substantial compliance without obtaining the required evidence of correction.  
During this reporting period, OIG also issued two reports examining issues affecting IHS hospitals ability to provide 
quality care and comply with Medicare standards.  These reports described longstanding challenges in IHS hospitals, 
including ensuring access to needed care, maintaining clinical competence, recruiting and retaining essential staff, and 
keeping patients safe despite outdated buildings and equipment.  We also found limitations in IHSs monitoring of quality 
of care.  IHS has few sources of information on its hospitals performance and a limited capacity to provide clinical 
support; moreover, it lacks the quality assurance infrastructure and monitoring efforts that it urgently needs. 
Improving Efficiency of Program Operations  
To protect taxpayer dollars, HHS must run its programs efficiently.  OIG looks for opportunities for the Department to 
enhance efficiency in fiscal management, as well as in administrative infrastructure and program execution. 
During this semiannual period, OIG continued to engage in management reviews of new program implementation.  In 
December 2016, OIG issued an early implementation review of CMSs management of the Quality Payment Program 
(QPP).  OIG found that CMS made significant progress toward implementing the QPP, a set of clinician payment reforms 
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  vi EXECUTIVE  designed to put increased focus on the quality and value of care.  However, OIG identified two vulnerabilities that CMS 
SUMMARY  must address in 2017 because they are critical to the programs success:  providing sufficient guidance and technical 
assistance to ensure that clinicians are ready to participate in the QPP and developing IT systems to support data 
reporting, scoring, and payment adjustment.
OIGs work on sound financial management includes ensuring that Medicaid programs obtain prescription drug rebates 
to which they are entitled.  In a series of reports, OIG is determining whether each State billed and collected from 
pharmaceutical manufacturers the rebates they owed to States and the Federal Government for outpatient drugs 
dispensed in the Medicaid program.  In this semiannual reporting period, OIG issued reports focusing on claims from 
three States (Colorado, California, and Virginia) for Federal reimbursement for some Medicaid physician-administered 
drugs.  Consistent with previous findings, OIG found instances in which the audited States did not always invoice and 
collect all rebates due for drugs administered by physicians.
Efficiency of operations also extends to oversight of HHSs $100 billion discretionary grant portfolio.  During this 
semiannual period, OIG continued its oversight of grants by focusing on childcare program grant funds.  In one report in 
which we reviewed Head Start funds received by the Newark Preschool Council, we identified $10 million in unallowable 
funds for costs applicable to under-enrollment, general and administrative expenses, unauthorized purposes, and salary 
payments.  In another report, OIG found that Puerto Rico lacked sufficient policies and procedures to properly identify 
and assign childcare funds to voucher payments in accordance with Federal requirements. 
Reducing Improper Payments
Improper payments, as reported in the Departments financial statements, have demonstrated a steady increase over the 
last several years.  In FY 2016, the Department reported estimated improper payments of more than $96 billion. 
During this semiannual period, OIG issued several audits that identified improper payments as a result of issues related to 
eligibility determinations:
  Express Lane Eligibility.  Under the express lane eligibility option, which allows States to expedite and simplify 
enrollment in Medicaid and the Childrens Health Insurance Program (CHIP) by relying on findings from other 
agencies eligibility determinations, we estimated that improper Medicaid payments on behalf of potentially ineligible 
beneficiaries totaled $284.1 million. CHIP payments for potentially ineligible beneficiaries totaled $10.6 million.  
  Payments after death.  Medicare and Medicaid continue to make improper payments on behalf of beneficiaries 
who are deceased.  During this reporting period, we found that Florida did not always stop making capitation 
payments to Medicaid managed care organizations (MCOs) after a beneficiarys death, resulting in more than $26 
million in overpayments.
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  vii EXECUTIVE    Incarcerated beneficiaries.  We continued our work reviewing inappropriate payments for incarcerated 
SUMMARY  beneficiaries, recently reporting that CMS has not taken steps to recoup $34 million in potentially improper 
payments made on behalf of incarcerated beneficiaries.  
OIG also issued several audits identifying payments for medical devices and services that providers should not have billed:
  Improper Payments for Chiropractic Services.  Based on our sample results, we estimated that $358.8 million (82 
percent) of $438.1 million paid by Medicare for chiropractic services was unallowable.  
  Room and Board Costs Associated with HCBS Waiver Program Payments.  State Agencies claimed at least $176 
million in unallowable Medicaid reimbursements for services under the HCBS waiver program.
  Improper Payments for Cochlear Devices.  Medicare spent $2.7 million inappropriately for cochlear devices 
(hearing aid devices) that were replaced without cost to the hospital or beneficiary.  
In addition to work identifying situations in which providers should not have billed CMS for specific medical devices or 
services, OIG also has a body of work looking at situations where providers billed for goods and services at higher rates 
than allowed by program regulations.  In this reporting period, OIG looked at how a hospitals reporting of inaccurate 
wage data affected Medicare payments for hospital services.  
Fostering Prudent Payment Policies 
In an effort to secure HHS programs future, OIG assesses payment policies and identifies vulnerabilities and misaligned 
incentives.  
During this semiannual reporting period, OIG reported on several vulnerabilities in hospital billing under Medicares 
2-midnight policy for determining a patients status as inpatient or outpatient.  OIG identified a large number of 
potentially inappropriate short inpatient stays and an increased number of beneficiaries in outpatient stays facing higher 
coinsurance costs and more limited access to skilled nursing facility (SNF) services compared to beneficiaries receiving 
the same care as inpatients.  These findings raise concerns about costs to Medicare and beneficiaries.  
In another report on payment policies, OIG found that Federal payments for Part D catastrophic coverage exceeded $33 
billion in 2015, which is more than triple the amount paid in 2010.  Spending for high-price drugs contributed significantly 
to this growth.  Ten high-price drugs accounted for nearly one-third of all drug spending for catastrophic coverage in 
2015.  The issue of high-price drugs is not exclusive to catastrophic coverage; it affects Federal payments for the entire 
Part D benefit and can lead to higher premiums and drug costs for patients.
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  viii EXECUTIVE  Improving Data Integrity and Information Security
SUMMARY 
To fulfill its mission, the Department maintains and uses data related to Federal health insurance programs, public health 
and human services, and the beneficiaries whom the Department serves.  With the sheer amount of data and its 
complexity, however, the Department continues to face challenges in effectively using data to detect and prevent 
improper payments and to ensure safety and quality of care for program beneficiaries.  HHS also faces challenges to 
protect the privacy and security of the data it collects and maintains.  
During this reporting period, OIG continued to work on privacy and security of data, focusing on network and web 
application penetration testing.  The objective of the testing is to determine whether security controls are effective in 
preventing certain cyber-attacks, the likely level of sophistication an attacker needs to compromise systems or data, and 
the agencies ability to detect attacks and respond appropriately.  
Fighting Fraud in HHS Programs 
OIG remains at the forefront of the Nations efforts to fight fraud, waste, and abuse in HHS programs and hold 
wrongdoers accountable for their actions.  During the first half of FY 2017, OIG reported expected investigative recoveries 
of over $2.04 billion.  OIG also reported 468 criminal actions against individuals or entities that engaged in crimes against 
HHS programs, 461 civil actions, and 1,422 exclusions of individuals and entities from participation in Federal health care 
programs.
To fulfill our mission, OIG uses state-of-the-art investigative techniques and innovative data analytics.  These techniques 
support our investigations as part of the Medicare Fraud Strike Force  a partnership between OIG, DOJ, and other 
Federal, State, and local law enforcement agencies to combat health care fraud.  Strike Force teams use data analytics to 
detect and investigate health care fraud through a coordinated and data-driven approach.  During this semiannual period, 
Strike Force efforts led to multiple investigations, including a case in which four defendants involved in a home health 
care and hospice Medicare fraud scheme were sentenced to a combined 35 years and 2 months in prison and ordered to 
pay $33 million in restitution, joint and several.  
OIG has formed strong public and private partnerships to amplify our enforcement success.  During this reporting period, 
OIG special agents partnered with Medicaid Fraud Control Units (MFCUs) on 714 criminal investigations.  Results from 
those investigations included a 33-year prison sentence for a former staff physician for the City of Houston who was 
convicted on 14 counts of health care fraud.  OIG continues to participate in the Health Care Fraud Prevention 
Partnership, a national publicprivate partnership aimed at fighting and preventing health care fraud though information 
sharing.   We also work with industry groups focused on fraud prevention, such as the National Health Care Anti-Fraud 
Association and the Health Care Compliance Association.   
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  ix EXECUTIVE  During the semiannual period, OIG conducted a wide array of enforcement activities.  Key areas for enforcement 
SUMMARY  included:
  Prescription drugs: OIG is committed to combating drug diversion and pursues numerous cases against providers 
who knowingly engage in drug diversion.  In one recent example, an OIG investigation led to a physician being 
sentenced to 30 years for operating a pill mill with Pagans Motorcycle Club.
  Care in non-institutional settings: OIG continues to focus on fraud in non-institutional settings, including in 
Medicare home health services and HCBS, including personal care services (PCS).  For example, during this reporting 
period, an OIG investigation led to guilty pleas of nine defendants in a $33 million Detroit home health and hospice 
fraud scheme  Further, we issued an Investigative Advisory on Medicaid fraud and patient harm involving PCS.
  Grant fraud: A significant and growing portion of OIGs enforcement efforts target grant fraud.  In one grant fraud 
case during this reporting period, an executive of a health care center received an 18-year prison sentence and was 
ordered to pay $13.5 million in restitution for embezzling $17 million in HHS grant funds.
The body of this Semiannual Report provides further details about the examples used in this Executive Summary.  The 
remainder of this report is organized by HHS program area and includes audit and evaluation reports and the results of 
our investigations for this reporting period.  This report also includes appendices that fulfill our reporting requirements 
under the Inspector General Act of 1978 and Inspector General Empowerment Act of 2016.  
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  x     
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s Vicki L. Robinson, Senior  Ann T. Maxwell, Assistant  Daniel R.  Levinson, 
 s Counselor for Policy,  Inspector General, testified  Inspector General, testified 
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testified before the House  before the House  before the House 
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Committee on Oversight  Committee on Energy and  Committee on 
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and Government Reform:  Commerce: Subcommittee  Appropriations: 
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Subcommittee on Health  on Oversight and  Subcommittee on Labor, 
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Care, Benefits, and  Investigations: Existing  Health and Human 
C Administrative Rules:  Problems and Ways to  Services, Education, and 
Fraud, Waste, and Abuse  Strengthen the Program. Related Agencies: 
Under the Affordable Care  Management Challenges 
Act. at the Departments of 
Labor, Health and Human 
Services, and Education 
and the Social Security 
Administration.
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  xi   
ss ACA  Patient Protection and Affordable Care Act HCBS  home and community-based services
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ACF  Administration for Children and Families HHS  Department of Health and Human Services
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nti CDC  Centers for Disease Control and Prevention IHS  Indian Health Service
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CIA  corporate integrity agreement IT  information technology
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c CHIP   Childrens Health Insurance Program MAC  Medicare Administrative Contractors 
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CMP  civil monetary penalty MCO  managed care organization
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b CMS  Centers for Medicare & Medicaid Services MFCU  Medicaid Fraud Control Unit
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t CY  calendar year NIH  National Institutes of Health
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e DMEPOS  durable medical equipment,   OIG  Office of Inspector General
ln     prosthetics, orthotics, and supplies
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a OMB  Office of Management and Budget
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DOJ  Department of Justice
PCS  personal care services
FBI  Federal Bureau of Investigation
SAMHSA   Substance Abuse and Mental Health  
FDA  Food and Drug Administration     Services Administration
FY  fiscal year SNF  skilled nursing facility
GAO  Government Accountability Office
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  xii s Centers for Medicare & Medicaid Services .  .  .  .  .  .  .  .  .  .  .  .  .  .  .1
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Legal and Investigative Activities Related to Medicare  
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and Medicaid   .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .1 5
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o Public Health Agencies Reviews and Enforcement Activities .  .  .  . 29
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  Human Services Agencies Reviews and Enforcement Activities  .  . 31
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Other HHS-Related Reviews and Investigations   .  .  .  .  .  .  .  .  .  .  . 33
 
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Appendixes    .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  4. 0
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a Appendix A:  Questioned Costs and Funds Put to Better Use .  . 40
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Appendix B:  Peer-Review Results  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 48
Appendix C:  Summary of Sanction Authorities .  .  .  .  .  .  .  .  .  . 50
Appendix D:  Reporting Requirements in the Inspector General  
                        Act of 1978.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .5 3
Appendix E:  Reporting Requirements in the Inspector General  
                        Empowerment Act of 2016  .  .  .  .  .  .  .  .  .  .  .  .  . 55
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  xiii   
es The Medicare Program with Medicare requirements.
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ac CMS Oversight of Medicare Contractor   A-06-16-05003    March 2017
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v Performance
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ee CMS relies on contractors to administer the Medicare  Medicare Payments, Policies, and Practices
MS program and is responsible for overseeing contractors 
performance.  Medicare contractors are responsible for  Medicare Improperly Paid Providers Millions of Dollars for 
 
 d administering more than half a trillion dollars in benefits  Incarcerated Beneficiaries Who Received Services During 
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oai each year.  Medicare Administrative Contractors (MACs)  2013 and 2014
process Parts A and B claims; Medicare Advantage plans 
fc The Medicare Access and CHIP Reauthorization Act of 
  provide managed care services under Part C; Part D 
si 2015 (MACRA) requires CMS to establish policies and 
d plans provide prescription drug coverage under Part D; 
r implement claim edits to ensure that payments are not 
e and various benefit integrity contractors serve to 
e made for Medicare services rendered to incarcerated 
tM protect Medicare from fraud, waste, and abuse. beneficiaries.  Our audit found that CMSs policies and 
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procedures did not allow CMS to detect and recoup 
  Medicare Contractors Payments to Providers for Hospital 
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& improper payments to beneficiaries who were 
Outpatient Dental Services Generally Did Not Comply With 
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incarcerated.  CMS has not taken steps to determine 
Medicare Requirements
whether any of the $34.6 million in potentially improper 
In our previous audits of six Medicare contractors, we  payments (for claims for incarcerated beneficiaries) 
found that payments made to providers for hospital  made in 2013 and 2014 should have been denied.
outpatient dental services generally did not comply with 
We also found that CMSs planned corrective revisions 
Medicare requirements.  Of the 600 dental services in 
to its policies and procedures do not comply with 
our 6 stratified random samples, 542 did not comply 
Medicare requirements.  When CMS implements its 
with Medicare requirements.  We estimated that the six 
revised policies and procedures, it will, according to 
Medicare contractors in our audits improperly paid 
CMS officials, further adjudicate the $34.6 million in 
providers an estimated $9.8 million for hospital 
claims.  However, because the data that CMS plans to 
outpatient dental services that did not comply with 
use will be incomplete, these efforts will not identify all 
Medicare requirements.
improper payments.
CMS disagreed with our recommendation to implement 
CMS did not concur with our recommendation to 
national edits for hospital outpatient dental services but 
develop and implement a system that allows CMS to 
agreed to work with the Medicare contractors to 
collect the information necessary to fully comply with 
develop or strengthen their local edits to ensure that 
Medicare requirements and, if necessary, seek the 
payments made to providers for dental services comply 
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  1 CENTERS FOR   appropriate legislation and funding.  CMS concurred  CMS concurred with all of our recommendations to 
MEDICARE &   with our recommendations to review the $34.6 million  direct Medicare contractors to initiate recoupment for 
in claims to determine which portion, if any, was not  $415,000 in improper payments associated with the 
MEDICAID  
claimed in accordance with Medicare requirements;  332 claims whose dates of service were after the 
SERVICES
direct the Medicare contractors to recoup any ensuing  individuals dates of death; confirm that the $11,000 in 
improper payments; and identify improper payments  improper payments associated with the 95 claims that 
made on behalf of incarcerated beneficiaries after our  we identified have been recouped; and review the 
audit period to ensure that Medicare contractors recoup  accuracy of the beneficiary dates of death to determine 
those payments. whether any of the $1.5 million relating to the 1,047 
claims with conflicting date-of-death information were 
A-07-15-01158    October 2016
improper payments and, if so, direct Medicare 
contractors to initiate recoupment for the identified 
amounts.
The Medicare Program 
Medicares Policies and Procedures Identified Almost All 
The Medicaid Program A-07-16-05089  October 2017
Improper Claims Submitted for Deceased Individuals and 
Recouped Almost All Improper Payments Made for These 
Centers for Medicare  
Claims for January 2013 Through October 2015
& Medicaid Services   Hundreds of Millions in Medicare Payments for Chiropractic 
  OIG found that CMS had policies and procedures in  Services Did Not Comply With Medicare Requirements
Legal and   place to ensure that payments were not made for 
A previous OIG report found that, as chiropractic care 
Investigative Activities  Medicare services ostensibly rendered to deceased 
for a beneficiary extended beyond 12 treatments in a 
  individuals.  These policies and procedures generally 
year, it became increasingly likely that individual services 
Public Health Agencies  ensured that CMS did not make improper payments 
were medically unnecessary.  In addition, four OIG 
  when its data systems indicated at the time a claim was 
Human Services  reviews of individual chiropractors found that Medicare 
processed that the individual had died before the 
Agencies  made improper payments for chiropractic services that 
claimed date of service.  They also ensured that CMS 
 
were medically unnecessary, incorrectly coded, 
Other HHS-Related  correctly identified and recouped improper payments 
insufficiently documented, or not documented.  Our 
Reviews and   for almost all of the cases in which the Enrollment 
current report found that most Medicare payments for 
Investigations  Database (EDB) was updated with date-of-death 
  chiropractic services did not comply with Medicare 
information after the claims had been processed and 
Appendixes requirements.  Based on our sample results, we 
paid.
estimated that $358.8 million (82 percent) of the $438.1 
We also found that CMS did not identify and recoup all  million paid by Medicare for chiropractic services was 
improper payments.  Specifically, for our audit period  unallowable.  These overpayments occurred because 
we identified $426,000 in improper payments for 427  CMSs controls were not effective in preventing 
Medicare claims and $1.5 million in potentially improper  payments for medically unnecessary chiropractic 
payments for 1,047 Medicare claims with dates of  services.  
service that were after the individuals dates of death.  
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  2 CENTERS FOR   We made four recommendations to CMS that could  $6.1 million.  These improper claims included both 
MEDICARE &   have saved Medicare an estimated $358.8 million for  unallowable and unsupported patient days.
2013.  CMS concurred with our recommendations to 
MEDICAID  
determine a reasonable number of chiropractic services  WPS concurred with our recommendation to revise the 
SERVICES
necessary to actively treat spinal subluxation and  finalized Medicare cost report settlements to recover 
identify services for review in excess of that number and  and refund $6.1 million in Medicare DSH overpayments.  
to improve education of chiropractors on Medicare  WPS did not concur with our recommendations to 
coverage requirements for chiropractic services.  CMS  revise final cost report settlements that we did not 
did not concur with our recommendation to determine  review, recover and refund any additional Medicare DSH 
a reasonable limit for the number of chiropractic  overpayments, and identify and obtain any State-level 
services that Medicare will reimburse and implement a  guidance affecting recipient categories that figure into 
system edit to disallow services in excess of that limit.   Medicare DSH cost report payments.  
CMS did not comment on our recommendation to 
The Medicare Program  A-07-15-04219  November 2016
identify significant obstacles to developing a more 
The Medicaid Program reliable control for identifying maintenance therapy and 
work to establish such a control.
Hospitals Did Not Always Comply With Medicare 
Centers for Medicare  
A-09-14-02033  October 2016
& Medicaid Services   Requirements for Reporting Cochlear Devices Replaced 
  Without Cost 
Legal and  
Previous OIG reviews found that hospitals did not always 
Investigative Activities  Wisconsin Physicians Service Insurance Corporation Did Not 
comply with Medicare requirements for reporting 
  Properly Settle Indiana Medicare Disproportionate Share 
credits received from manufacturers for replaced 
Public Health Agencies 
Hospital Cost Report Payments   medical devices.  Our compliance reviews at specific 
 
Medicare, like Medicaid, includes provisions under  hospitals nationwide identified approximately $10 
Human Services 
Agencies  which Medicare-participating hospitals (providers) that  million in Medicare overpayments attributable to 
  serve a disproportionate share of low-income patients  hospitals that did not report to CMS device 
Other HHS-Related  may receive disproportionate share hospital (DSH)  manufacturer credits that they received or that were 
Reviews and  
payments.  Because these payments are the result of  available under the terms of manufacturer warranties 
Investigations 
calculations to which a number of sometimes complex  that they did not obtain.  During this review, we found 
 
Appendixes factors and variables (one of which is referred to as  that hospitals nationwide did not always comply with 
Medicaid patient days) contribute, they are at risk of  Medicare requirements for reporting cochlear devices 
overpayment.  We found that Wisconsin Physicians  (hearing aids) replaced without cost to the hospital or 
Service (WPS) did not properly settle Medicare cost  beneficiary.  For the 116 incorrectly billed claims we 
reports submitted by Indiana hospitals for Medicare  identified, hospitals received $2.7 million in Medicare 
DSH payments in accordance with Federal  overpayments. 
requirements, resulting in DSH overpayments totaling    
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  3 CENTERS FOR   CMS concurred with our recommendations that it  Because of the cost reporting errors, we estimated that 
MEDICARE &   instruct the Medicare contractors to (1) verify the $1.4  Medicare overpaid the Hospital $156,000 for FY 2015 
million in identified overpayments that hospitals stated  inpatient services and CY 2015 outpatient services.  We 
MEDICAID  
they refunded to Medicare during our review; (2) recover  also estimated that Medicare overpaid 55 other 
SERVICES
$686,000 in identified overpayments for calendar years  hospitals in Massachusetts a total of $133.6 million for 
(CY) 2013 and 2014 that had not been refunded to  FY 2015 inpatient services and CY 2015 outpatient 
Medicare; (3) assist hospitals in returning the agreed- services because the Hospitals wage data set the rural 
upon overpayments of $553,000 for CY 2012 claims that  floor wage index for Massachusetts.  
are outside the Medicare 4-year reopening period; and 
The Hospital did not concur with our recommendation 
(4) educate hospitals on how to appropriately bill for and 
to ensure that all personnel involved in Medicare cost 
report medical devices replaced without cost to the 
report preparation follow the requirements in the CMS 
hospital or beneficiary, including cochlear devices. 
  Provider Reimbursement Manual.  The Hospital 
The Medicare Program  A-01-15-00508  November 2016 concurred with our recommendation to strengthen 
The Medicaid Program review and reconciliation procedures to ensure that the 
Medicare wage data it reports to CMS in the future are 
Nantucket Cottage Hospital Did Not Accurately Report  accurate, allowable, supportable, and in compliance 
Centers for Medicare  
with Medicare requirements. 
& Medicaid Services   Certain Wage Data, Resulting in Overpayments to 
  Massachusetts Hospitals 
A-01-15-00502  March 2017
Legal and  
Medicare acute-care hospitals must report wage data 
Investigative Activities 
annually to CMS.  CMS uses the wage data to calculate 
 
acute-care hospital wage indexes, which measure  Vulnerabilities Remain Under Medicares 2-Midnight  
Public Health Agencies 
geographic area labor market costs relative to a national 
  Hospital Policy
Human Services  average.  Federal law requires CMS to annually adjust 
CMS implemented the 2-midnight rule to address 
Agencies  Medicare hospital payments to reflect local labor 
concerns about hospitals use of short inpatient and 
  markets; CMS uses area wage indexes to do this.  
Other HHS-Related  long outpatient stays.  The rule establishes that inpatient 
Previous OIG reviews found that hospitals often 
Reviews and   payment is generally appropriate if physicians expect 
reported inaccurate wage data, which resulted in 
Investigations 
beneficiaries care to last at least 2 midnights; 
increased Medicare payments in their designated 
 
otherwise, outpatient payment is generally appropriate.  
Appendixes geographic area.  Our current review found that 
During our review, we identified several vulnerabilities in 
Nantucket Cottage Hospital (the Hospital) did not always 
hospital billing under Medicares 2-midnight policy, 
comply with Medicare requirements for reporting wage 
including a large number of potentially inappropriate 
data in its FY 2011 Medicare cost report.  As a result, the 
short inpatient stays and an increased number of 
Hospital overstated wages and wage-related costs by 
beneficiaries in outpatient stays paying more and having 
$232,000 (net) and understated hours by 18,060 (net).  
limited access to skilled nursing facility (SNF) services 
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  4 CENTERS FOR   compared to inpatients.  These findings raise concerns  assistance, and to optimize back-end IT systems support.  
MEDICARE &   about the cost to Medicare and beneficiaries.  We 
OEI-12-16-00400  December 2016
recommended that CMS conduct analyses like those in 
MEDICAID  
this evaluation to target their oversight.  We also 
SERVICES
recommended that CMS explore ways to ensure that 
beneficiaries receiving hospital care in outpatient status  Drug Pricing and Reimbursement
have similar cost-sharing protections and access to SNF 
care as beneficiaries receiving similar hospital care in 
High-Price Drugs Are Increasing Federal Payments for 
inpatient status.  CMS concurred with all of our 
recommendations.  Medicare Part D Catastrophic Coverage 
Federal payments for Part D catastrophic coverage 
OEI-02-15-00020  December 2016
exceeded $33 billion in 2015, which is more than triple 
the amount paid in 2010.  Spending for high-price 
The Medicare Program 
Early Implementation Review: CMSs Management   drugs contributed significantly to this growth.  
The Medicaid Program
of the Quality Payment Program  Moreover, 10 high-price drugs accounted for nearly 
one-third of all drug spending for catastrophic 
CMS has made significant progress toward 
Centers for Medicare   coverage in 2015.  The issue of high-price drugs is not 
implementing the Quality Payment Program (QPP), a set 
& Medicaid Services   exclusive to catastrophic coverage; it affects the entire 
of clinician payment reforms designed to put increased 
 
Part D benefit and can lead to higher costs for patients.
focus on the quality and value of care.  As of December 
Legal and  
2016, CMS had finalized key policies to implement the  Securing the future of the Part D program while 
Investigative Activities 
  QPP, initiated engagement and outreach activities to  ensuring that patients have access to needed drugs is a 
Public Health Agencies  clinicians, launched a public-facing informational  complex issue that calls for a multifaceted approach.  
  website, and awarded various contracts for technical  Recently, CMS has taken steps in response to rising drug 
Human Services  assistance and training.  Although many milestones  prices.  Moving forward, CMS will likely need additional 
Agencies  remain before the QPP payment adjustments begin in  tools.  Potential tools have been discussed by experts 
  2019, OIG identified two vulnerabilities that are critical  and include restructuring the Part D benefit, creating 
Other HHS-Related 
for CMS to address in 2017 because of their potential  more transparency, promoting value-based options, and 
Reviews and  
Investigations  impact on the programs success: providing sufficient  revising the law to allow the Federal Government to 
  guidance and technical assistance to ensure that  negotiate prices for certain drugs.  CMS should carefully 
Appendixes clinicians are ready to participate in the QPP, and  assess these and other options and, working with 
developing IT systems to support data reporting,  Congress, make any needed changes to the Part D 
scoring, and payment adjustment. program. 
CMS officials stated they were committed to continuing  OEI-02-16-00270  January 2017 
to engage with clinicians and provide them with 
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  5 CENTERS FOR   Oversight of the Medicare Competitive   our data to help ensure that contracted suppliers bids 
MEDICARE &   Bidding Program adhere to the 50-percent rule.  
MEDICAID  
For the second review, we found that from July through 
SERVICES Medicare Market Shares of Mail Order Diabetes Test Strips From 
September 2016, sampled suppliers provided 18 types 
April to June 2016 and Medicare Market Shares of Mail Order 
of diabetes test strips via mail order.  The top strip type 
Diabetes Test Strips From July Through September 2016  accounted for 43 percent of the mail order market, and 
The Medicare Prescription Drug, Improvement, and  the top 10 strip types accounted for 98 percent.  The 
Modernization Act of 2003 requires CMS to phase in a  third report will be published in summer 2017. 
Competitive Bidding Program for durable medical 
OEI-04-16-00470  November 2016 
equipment, prosthetics, orthotics, and supplies 
(DMEPOS).  Under this program, suppliers compete to 
become Medicare contract suppliers for selected  OEI-04-16-00471  February 2017
The Medicare Program 
DMEPOS items, including diabetes test strips provided 
The Medicaid Program via mail order.  Additionally, the Medicare Improvements 
for Patients and Providers Act (MIPPA) requires mail 
Quality of Care and Beneficiary Access
Centers for Medicare   order suppliers to demonstrate in their bids that they 
& Medicaid Services   can provide at least 50 percent, by volume, of the types 
Case Review of Inpatient Rehabilitation Hospital Patients Not 
  of diabetes test strips provided to Medicare beneficiaries.
Suited for Intensive Therapy
Legal and  
Investigative Activities  OIG is conducting three studies to determine the  Inpatient rehabilitation (rehab) hospitals are 
  Medicare market shares of diabetes test strips for the  freestanding facilities that specialize in providing 
Public Health Agencies  periods April through June 2016, July through  intensive rehab therapy to patients recovering from 
  September 2016, and October through December 2016,  illness, injury, or surgery.  This intensive therapy requires 
Human Services  respectively.  For the first review, we found that from  endurance that some patients receiving post-acute care 
Agencies 
April to June 2016, sampled suppliers provided 30 types  do not have, potentially causing those patients to be 
 
Other HHS-Related  of diabetes test strips via mail order.  Of these strips,  better suited for an alternate setting, such as a SNF.  
Reviews and   two types accounted for about one-half of the mail  Medicare criteria for admission to post-acute care help 
Investigations  order market.  Therefore, a suppliers bid would meet  ensure that patients receive the most appropriate care 
  the MIPPA 50-percent rule if the bid declared that the  for their conditions and needs.  We found that Medicare 
Appendixes
supplier intended to provide either (1) both of these 2  patients who were not suited for intensive rehab 
types of strips or (2) at least 1 of these 2 types of strips  therapy had physical limitations, lacked endurance, had 
and a combination of certain subsets of the other 28  unresolved health problems, or had an altered mental 
types of strips sufficient to reach 50 percent.  Further,  status.  Most of these patients (32 of 39 stays) remained 
we found that 5 types of diabetes test strips accounted  in inpatient rehab hospitals for extended periods (which 
for 81 percent of the Medicare mail order market share,  we defined as stays lasting longer than 3 days) despite 
and 10 types accounted for 93 percent.  CMS will use  being unable to participate and benefit from intensive 
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  6 CENTERS FOR   therapy.  For 7 of the 39 stays, the medical records  North Carolina Claimed Millions in Unallowable School-Based 
MEDICARE &   indicated that the patients were in exceptionally poor  Medicaid Administrative Costs and Mississippi Claimed Millions 
condition and died within a few weeks after being 
MEDICAID   in Unallowable School-Based Medicaid Administrative Costs
admitted to an inpatient rehab hospital.  
SERVICES
States can be reimbursed for school-based 
We encouraged CMS to consider providing additional  administrative activities that directly support identifying 
technical assistance to ensure that Medicare patients  and enrolling potentially eligible children in Medicaid.  
are placed in the most appropriate setting for post-acute  School-based Medicaid administrative costs are one 
care, and that inpatient rehab hospitals do not admit  type of public assistance cost that can be reimbursed, if 
patients who are unable to participate in and benefit  costs claimed comply with Federal requirements. 
from intensive therapy.   Random moment sampling (RMS) is one acceptable 
method for allocating salaries and wages among 
OEI-06-16-00360  December 2016
Medicaid and other programs.
The Medicare Program 
In prior reviews of school-based and community-based 
The Medicaid Program
administrative costs that States allocated to Medicaid 
The Medicaid Program
using RMS, we identified significant overpayments.  As 
Centers for Medicare  
part of our Medicaid risk assessment, we noted that 
& Medicaid Services  
North Carolina and Mississippi used statistically invalid 
  Payments, Policies, and Practices 
RMS in allocating costs to Medicaid and did not 
Legal and  
promptly submit to HHS for review their cost allocation 
Investigative Activities  To fund their Medicaid programs, States receive Federal 
  grant awards that pay for the Federal share of their  plan (CAP) amendments describing their new random 
Public Health Agencies  Medicaid medical and administrative expenditures.  OIG  moment time study (RMTS) methodology.  As a result, 
  conducts audits on States withdrawals of Federal  North Carolina claimed almost $107.5 million (almost 
Human Services  $53.8 million Federal financial participation) and 
Medicaid funds to determine whether a State submitted 
Agencies  Mississippi claimed almost $42.4 million (almost $21.2 
an improper claim for Federal reimbursement and, 
 
million Federal financial participation) in unallowable 
Other HHS-Related  therefore, may owe money to the Federal Government.  
school-based Medicaid administrative costs for Federal 
Reviews and   If a State disagrees with our recommendation to refund 
Investigations  questioned costs identified in an audit, CMS still has the  FYs 2010 through 2012.
 
authority to recoup those costs.
Appendixes North Carolina and Mississippi did not specifically 
address our recommendations to refund unallowable 
costs to the Federal Government; address the statistical 
validity issues we identified; implement policies and 
procedures to ensure that their RMTS comply with 
Federal requirements for statistical validity; maintain 
adequate support for school-based administrative costs; 
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  7 CENTERS FOR   promptly submit to HHS for review and approval future  when determining payment rates, share (at CMSs 
MEDICARE &   CAP amendments; and review school-based Medicaid  discretion) the other findings of our HCBS waiver 
administrative costs claimed after our audit period and  program audits with all States, and encourage all States 
MEDICAID  
refund unallowable amounts.  to review their procedures for calculating and claiming 
SERVICES
costs under their HCBS waiver programs. 
A-04-15-00101  October 2016
A-07-16-03212  October 2016
A-04-15-00103  March 2017
 
North Carolina Improperly Claimed Federal Reimbursement for 
State Agencies Claimed Unallowable and Unsupported  Some Medicaid Nonemergency Transportation Services and 
Medicaid Reimbursements for Services Under the Home- and  Louisiana Did Not Always Comply With Federal and State 
The Medicare Program  Community-Based Services Waiver Program  Requirements for Claims Submitted for the Nonemergency 
The Medicaid Program In this review, we described instances from eight  Medical Transportation Program 
previous audits in which States did not always comply 
The objective of these reviews was to determine 
with Federal requirements in administering their HCBS 
Centers for Medicare   whether the State agencies claimed Federal Medicaid 
waiver programs.  Specifically, States did not always 
& Medicaid Services   reimbursement for nonemergency medical 
exclude unallowable room-and-board costs when 
  transportation (NEMT) services claims submitted by 
Legal and   determining payment rates under the HCBS waiver  transportation providers in accordance with certain 
Investigative Activities  program, resulting in unallowable Medicaid 
Federal and State requirements.  We found that North 
  reimbursement.  States did not have adequate controls 
Carolina and Louisiana claimed Federal Medicaid 
Public Health Agencies  to ensure that their HCBS waiver programs complied 
reimbursement for some NEMT services that did not 
  with applicable Federal requirements regarding the 
comply with Federal or State requirements.  Based on 
Human Services  need to exclude unallowable room-and-board costs 
our sample results, we estimated that North Carolina 
Agencies 
when determining payment rates and to ensure that 
  improperly claimed at least $18.7 million ($12 million 
certain other costs complied with the requirements 
Other HHS-Related  Federal share) for unallowable NEMT services for the 
associated with their HCBS waiver programs.  As a 
Reviews and   audit period, and Louisiana claimed approximately $1.1 
Investigations  result, the States claimed at least $176.5 million (Federal 
million.  North Carolina also improperly claimed $20 
  share) in unallowable and unsupported Federal 
million in NEMT administrative expenditures, which 
Appendixes Medicaid reimbursement for services under their HCBS 
resulted in excess Federal reimbursement of $3.1 
waiver programs. 
million.  Additionally, none of the 16 counties in our 
sample fully complied with the States NEMT policy.  
CMS concurred with our recommendations to share the 
Louisiana did not have adequate support for about 
findings of our HCBS waiver program audits with all 
$183,000 (Federal share) of costs claimed. 
States to reinforce Medicaid requirements that prohibit 
 
the inclusion of unallowable room-and-board costs 
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  8 CENTERS FOR   North Carolina generally disagreed with our  We found that California did not correctly identify all 
MEDICARE &   recommendations to refund $12 million for unallowable  non-reimbursable claims for nonemergency services 
MEDICAID   NEMT services identified in our sample, refund $3.1  provided to qualified aliens for select quarters in State 
million for the additional Federal reimbursement  FYs 2010 through 2014.  Specifically, the State agencys 
SERVICES
received for NEMT expenditures improperly claimed at  Medicaid Management Information System (MMIS) did 
the incorrect rate, improve the design of the NEMT  not identify all claims for its adjustment reports for the 
program, monitor the results of the counties reviews of  audit period for which Federal reimbursement was 
transportation services and vendors, update its  unallowable.  As a result, the State agency claimed $9.9 
procedures for claiming Federal reimbursement for  million in unallowable Federal Medicaid reimbursement. 
NEMT administrative costs, and implement regulations 
requiring safety and risk management measures as  California partially agreed with our recommendation to 
conditions of payment.   refund $9.9 million to the Federal Government.  
California agreed with our recommendations to identify 
The Medicare Program 
Louisiana partly agreed with our recommendations to  and refund the Federal share of overpayments for any 
The Medicaid Program refund $1.1 million for improper claims, refund  quarters in State FYs 2015 and 2016 in which claims 
$183,000 for costs claimed without adequate support,  were approved for payment in one quarter and paid in a 
Centers for Medicare   strengthen its policies and procedures to ensure that  subsequent quarter, and to ensure that the MMIS 
& Medicaid Services   providers comply with all State and Federal  correctly identifies all nonreimbursable claims for 
  requirements, and strengthen controls over its process  nonemergency services provided to qualified aliens. 
Legal and   for reporting expenditures claimed for NEMT services.  
A-09-15-02020  January 2017 
Investigative Activities 
  A-04-15-04037  November 2016
Public Health Agencies 
  Review of Massachusetts Medicaid Managed Care Program 
A-06-15-00019  January 2017
Human Services  Potential Savings With Minimum Medical Loss Ratio; Review of 
Agencies 
South Carolina Medicaid Managed Care Program Potential 
 
Other HHS-Related  California Improperly Claimed Federal Medicaid  Savings With Minimum Medical Loss Ratio; and Review of 
Reviews and  
Reimbursement for Certain Nonemergency Services   California Medicaid Managed-Care Program Potential Savings 
Investigations 
  Federal health care benefits are generally allowable  With Minimum Medical Loss Ratio
Appendixes when provided to a beneficiary who is a U.S. citizen, 
We conducted a series of reviews to determine whether 
U.S. national, or qualified alien.  In general, a qualified 
Medicaid could achieve savings if States required 
alien is not permitted to receive Federal benefits until 
Medicaid MCOs to meet a minimum medical loss ratio 
5 years from the date he or she enters the United 
(MLR) standard and pay remittances if the MLR standard 
States with qualified alien status.  States must have a 
was not met.  An MLR is the percentage of premium 
system that verifies whether qualified aliens have met 
dollars an insurer spends to provide medical services 
the required waiting period. 
and health care quality improvement activities for its 
 
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  9 CENTERS FOR   members compared to the premium dollars it uses to  Floridas Medicaid beneficiaries were moved into 
MEDICARE &   pay for administrative expenses. managed care.  Our audit found that Florida did not 
always stop making capitation payments after a 
MEDICAID  
The Massachusetts Medicaid program could have saved 
beneficiarys death, despite its efforts to identify and 
SERVICES
$4.7 million (approximately $3.5 million Federal share) 
recover any overpayments.  We estimated that Florida 
in 2014 if the State agency required its Medicaid 
made overpayments to MCOs totaling $26.2 million 
managed care plans to meet the minimum MLR  ($15.4 million Federal share) during our audit period.  
standard and required remittances when Medicaid 
managed care plans did not meet the MLR standard.   Florida did not indicate whether it agreed or disagreed 
South Carolinas Medicaid managed care program and  with our recommendations to identify and recover 
nine California Medicaid MCOs would not have saved  overpayments totaling $26.2 million from MCOs and 
any Medicaid funds in 2014 if they had required their  refund $15.4 million (Federal share) to the Federal 
Medicaid managed care plans to meet the minimum  Government; perform monthly reviews of Florida 
The Medicare Program  MLR standard and required remittances when Medicaid  Medicaid Management Information System (FMMIS) 
The Medicaid Program managed care plans did not meet the MLR standard.   records to ensure that beneficiaries with dates of death 
Accordingly, we made no recommendations to South  (DODs) are removed from the Florida Statewide 
Carolina or California. Medicaid Managed Care Program; implement policies 
Centers for Medicare  
and procedures for identifying and correcting inaccurate 
& Medicaid Services  
Massachusetts agreed with our recommendations to  death information received through its sources of death 
 
incorporate into its contracts with Medicaid MCOs the  data, specifically ensuring that differences in the DODs 
Legal and  
Investigative Activities  MLR standards adopted in the CMS final rule and  between the FMMIS and incoming death records are 
  consider implementing into its Medicaid MCO contracts  quickly resolved; and improve its collaborative efforts 
Public Health Agencies  a remittance requirement, if appropriate.   with the Social Security Administration, the Department 
  of Children and Families, and Floridas Bureau of Vital 
Human Services  A-01-15-00505  November 2016 Statistics to identify and resolve inconsistencies in 
Agencies  recipient information.  Florida described steps it had 
 
A-04-16-06191  December 2016 taken or planned to take to implement our 
Other HHS-Related 
recommendations.   
Reviews and  
Investigations 
A-09-15-02025  January 2017 A-04-15-06182  November 2016
 
Appendixes
Florida Managed Care Organizations Received Medicaid 
New Jersey Claimed Medicaid Adult Mental Health Partial 
Capitation Payments After Beneficiarys Death 
Care Services That Were Not in Compliance With Federal and 
The Florida Statewide Medicaid Managed Care Program 
pays MCOs to provide covered health care services in  State Requirements 
return for a monthly fixed payment for each eligible  During a prior review of New Jerseys claims for 
beneficiary (capitated payment).  In 2014, nearly all of 
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  10 CENTERS FOR   Medicaid services to adults with mental illness who  on findings from other agencies eligibility 
MEDICARE &   reside in community residences, we identified a  determinations.  Congress will determine whether to 
significant number of services improperly submitted for  reauthorize the ELE option in 2017.  OIG conducted 
MEDICAID  
Federal Medicaid reimbursement.  Based on these  three studies that fulfill a congressional mandate to 
SERVICES
results, we decided to review clinic services provided to  assess whether State agencies met Federal 
these Medicaid beneficiaries on an outpatient basis.  For  requirements in making eligibility determinations using 
this review, we estimated that New Jersey improperly  ELE and developing eligibility error rates.  See results of 
claimed at least $94.8 million in Federal Medicaid  those reports below.
reimbursement for partial care services that did not 
meet Federal and State requirements.  The partial care 
State Use of Express Lane Eligibility for Medicaid and CHIP 
services program provides individualized outpatient 
Enrollment
clinic services (e.g., group and individual therapy, 
prevocational services, and medication management) to  This study examined the benefits and barriers to State 
The Medicare Program 
beneficiaries with mental illness to reduce unnecessary  use and expansion of ELE.  We found that States that 
The Medicaid Program hospitalization.  The deficiencies occurred because New  used ELE to expedite and simplify enrollment in 
Jersey did not adequately monitor the partial care  Medicaid and CHIP adopted variations of three models, 
Centers for Medicare   services program to ensure that providers complied with  with more than half adopting an automated model that 
& Medicaid Services   these requirements.   requires minimal action from staff and beneficiaries.  All 
  14 States that used ELE reported benefits, including 
Legal and   New Jersey disagreed with our recommendation to  reduced administrative burden and cost savings, and 
Investigative Activities  refund $94.8 million to the Federal Government and  some States reported that they rely heavily on ELE.  
  generally agreed with our recommendations to issue  Eleven States reported that they encountered barriers 
Public Health Agencies  guidance to the partial care provider community on  when they implemented ELE, such as problems sharing 
  Federal and State requirements for claiming these  information across agencies, but reported that they 
Human Services 
services and improve its monitoring of partial care  overcame these barriers through strong partnerships 
Agencies 
  providers to ensure compliance with Federal and State  and integrated eligibility systems.  Despite largely 
Other HHS-Related  requirements.  positive experiences using ELE, 5 of the 14 States that 
Reviews and  
adopted ELE discontinued its use, mainly because of 
Investigations  A-02-13-01029  December 2016
competing priorities, system changes, and short-term 
 
agreements with partner agencies.  None of the nine 
Appendixes
States still using ELE plan to expand its use.
Express Lane Eligibility
We concluded that although State use of ELE is not 
Congress authorized States to adopt the Express Lane  widespread, ELE appears to meet the intended objective 
Eligibility (ELE) option, which allows States to expedite  of easing the eligibility and enrollment process.  Based 
and simplify enrollment in Medicaid and CHIP by relying  on this review of State experiences with ELE, OIG did not 
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  11 CENTERS FOR   identify any significant impediments to continuing to  appropriately redetermine, if necessary, the current 
MEDICARE &   allow voluntary use of ELE once States and CMS have  eligibility status of the sample applicants who were 
corrected process problems and gaps in oversight  enrolled on the basis of eligibility determinations that 
MEDICAID  
identified by OIG audits of ELE enrollments.   were not made in compliance with Federal 
SERVICES
Reauthorization of the ELE option would allow States  requirements.   
that rely on ELE to continue its use and give other States 
A-04-15-08043  October 2016
the opportunity to adopt ELE and likely experience 
similar benefits.   
OEI-06-15-00410  October 2016 Childrens Health Insurance Program Enrollment Using the 
Express Lane Eligibility Option Did Not Always Meet Federal 
Requirements
Medicaid Enrollment Using the Express Lane Eligibility 
The Medicare Program  We found that States generally determined CHIP 
Option Did Not Always Meet Federal Requirements 
eligibility using the ELE option in accordance with 
The Medicaid Program
Under the ELE option, a State Medicaid agency can use  Federal requirements.  However, on the basis of our 
findings (e.g., income) from eligibility determinations  sample, we estimated that Federal and State CHIP 
Centers for Medicare  
made by a different agency within the State to facilitate  payments on behalf of potentially ineligible beneficiaries 
& Medicaid Services  
enrollment into Medicaid.  Based on our sample, we  totaled $10.6 million.  We attribute the enrollment of 
 
estimated that Federal and State Medicaid payments on  potentially ineligible beneficiaries to State-specific 
Legal and  
Investigative Activities  behalf of potentially ineligible beneficiaries totaled  eligibility determination errors.  In addition, States did 
  $284.1 million.  We attribute the enrollment of  not develop mandated error rates specific to the ELE 
Public Health Agencies  potentially ineligible beneficiaries to State-specific  population because CMS did not provide States with an 
  eligibility determination errors.  In addition, States did  error rate methodology. 
Human Services  not develop the mandated error rates specific to the ELE 
Agencies  population because CMS did not provide States with an  CMS concurred with our recommendations to monitor 
  error rate methodology.   States that use the ELE option for CHIP eligibility 
Other HHS-Related 
determinations for compliance with Federal 
Reviews and  
CMS concurred with our recommendations to monitor  requirements; provide technical assistance to States to 
Investigations 
  States that use the ELE option for Medicaid eligibility  accurately identify beneficiaries who enroll through the 
Appendixes determinations for compliance with Federal  ELE option; issue guidance to States to calculate 
requirements; provide technical assistance to States to  statutorily required eligibility error rates for those 
accurately identify beneficiaries who enroll through the  enrolled through the ELE option; and ensure States 
ELE option; issue guidance to States to calculate  appropriately redetermine, if necessary, the current 
statutorily required eligibility error rates for those  eligibility status of the sample applicants who were 
enrolled through the ELE option; and ensure that States  enrolled on the basis of eligibility determinations that 
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  12 CENTERS FOR   were not made in compliance with Federal  reimbursement for physician-administered drugs, and 
MEDICARE &   requirements.    that it work with CMS to determine the unallowable 
portion of $1.2 million and refund that amount.  
MEDICAID  
A-04-15-08045  October 2016
Colorado did not concur with our recommendations 
SERVICES
that it refund to the Federal Government $6.5 million 
for claims for physician-administered drugs that were 
Rebates for Physician-Administered Drugs   ineligible for Federal reimbursement.   
Dispensed to Medicaid Enrollees 
A-07-14-06050  January 2017
Colorado Claimed Unallowable Federal Reimbursement for 
Some Medicaid Physician-Administered Drugs California Did Not Bill Manufacturers for Rebates for Physician-
We conducted a review to determine whether States  Administered Drugs Dispensed to Enrollees of Some Medicaid 
The Medicare Program 
are complying with Federal Medicaid requirements for 
Managed-Care Organizations and Virginia Did Not Bill 
The Medicaid Program billing manufacturers for rebates for physician-
Manufacturers for Some Rebates for Physician-Administered 
administered drugs.  For a covered outpatient drug to 
Drugs Dispensed to Enrollees of Medicaid Managed-Care 
Centers for Medicare   be eligible for Federal reimbursement under Medicaids 
& Medicaid Services   drug rebate requirements, manufacturers must pay  Organizations
  rebates to the States for the drugs.  States generally  We conducted reviews in California and Virginia to 
Legal and   offset their Federal share of these rebates against their  determine whether States are complying with Federal 
Investigative Activities 
Medicaid expenditures and bill the manufacturers for  Medicaid requirements for billing manufacturers for 
 
rebates to reduce the cost of drugs to the program.   rebates for physician-administered drugs dispensed to 
Public Health Agencies 
However, a prior OIG review found that States did not  enrollees of MCOs.  For a covered outpatient drug to be 
 
always invoice and collect all rebates due for drugs  eligible for Federal reimbursement under Medicaids 
Human Services 
Agencies  administered by physicians.  We found that Colorado did  drug rebate requirements, manufacturers must pay 
  not invoice manufacturers for rebates associated with  rebates to the States for the drugs.  States generally 
Other HHS-Related  $6.5 million in physician-administered drugs and $1.6  offset their Federal share of these rebates against their 
Reviews and   million that did not have National Drug Codes (NDC) in  Medicaid expenditures and bill the manufacturers for 
Investigations 
the utilization data or may have been otherwise  rebates to reduce the cost of drugs to the program.  
 
Appendixes ineligible for Federal reimbursement. However, a prior OIG review found that States did not 
always invoice and collect all rebates due for drugs 
Colorado concurred with our recommendations that it 
administered by physicians.  We found that California 
strengthen its internal controls to ensure that all 
claimed an estimated $7.3 million in Federal 
physician-administered drugs eligible for rebates are 
reimbursement that was unallowable and $35.2 million 
involved, that it work with CMS to determine and 
that may have been unallowable because it did not 
refund the unallowable portion of Federal 
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  13 CENTERS FOR   comply with Federal Medicaid requirements.  Virginia  deficiencies identified during surveys, such as nursing 
MEDICARE &   did not bill manufacturers for an estimated $2.9 million  homes failure to provide necessary care and services.  
in rebates. State survey agencies must verify the correction of 
MEDICAID  
identified deficiencies by obtaining evidence of 
SERVICES
California concurred with our recommendations to work 
correction or through onsite reviews.  This review of the 
with its MCOs to ensure submission of drug utilization 
State survey agency in Arizona is part of an ongoing 
data and to implement a rebate and NDC reporting  series of reviews of States verification of correction of 
requirement.  California partially concurred with  deficiencies.
collecting an estimated $7.3 million in Federal 
reimbursement that was unallowable and $35.2 million  We found that Arizona did not always verify nursing 
that may have been unallowable because California did  homes correction of deficiencies identified during 
not comply with Federal Medicaid requirements. surveys in 2014 in accordance with Federal 
requirements.  We estimated that Arizona did not verify 
The Medicare Program  Virginia concurred with recommendations that it work  nursing homes correction of deficiencies in accordance 
The Medicaid Program with CMS to resolve the drug utilization data without  with Federal requirements for 361 (56 percent) of the 
valid NDCs by determining the correct NDCs, to bill for  650 deficiencies identified during surveys in 2014.  
the estimated rebates and refund the Federal share,  Arizonas practice for less serious deficiencies was to 
Centers for Medicare  
that it implement Medicaid Management Information  accept the nursing homes correction plans as 
& Medicaid Services  
System edits to verify that NDCs are valid, and that it  confirmation of substantial compliance without 
 
ensure that MCOs submit drug utilization data  obtaining the required evidence of correction.
Legal and  
containing NDCs for all physician-administered drugs. 
Investigative Activities 
Arizona concurred with our recommendation to 
 
A-09-15-02035  December 2016 improve its practices for verifying nursing homes 
Public Health Agencies 
correction of identified deficiencies by obtaining nursing 
 
homes evidence of correction for less serious 
Human Services  A-03-15-00201  December 2016
Agencies  deficiencies. 
 
Other HHS-Related  A-09-16-02013  October 2016
Reviews and  
Quality of Care and Beneficiary Access
Investigations 
 
Arizona Did Not Always Verify Correction of Deficiencies 
Appendixes
Identified During Surveys of Nursing Homes Participating in 
Medicare and Medicaid
Federal regulations require nursing and skilled nursing 
facilities (nursing homes) to submit correction plans to 
CMS or their respective State survey agency for certain 
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  14   
sd OIG INVESTIGATES ALLEGATIONS OF FRAUD, waste,  NIH, Substance Abuse and Mental Health Services 
ei and abuse in all HHS programs.  Our largest body of  Administration (SAMHSA), and other HHS agencies.  
a
i work involves investigating matters related to the  Under certain circumstances, OIG investigates 
tc
i Medicare and Medicaid programs, such as patient harm;  noncustodial parents who fail to pay court-ordered child 
vdi billing for services not rendered, medically unnecessary  support.  OIG also investigates allegations of employee 
i services, or upcoded services; illegal billing, sale,  misconduct, whistle blower reprisals, and wrongdoing 
te
c diversion, and off-label marketing of prescription drugs;  by HHS agency officials. 
M
A and solicitation and receipt of kickbacks, including illegal 
One of the most common types of fraud perpetrated 
  payments to patients for involvement in fraud schemes 
 d against Medicare, Medicaid, and other Federal health 
e and illegal referral arrangements between physicians 
n care programs involves filing false claims for 
v and medical companies.
ia reimbursement.  False claims may be pursued under 
t  Specific case types include fraud schemes related to:  Federal and State criminal statutes and, when 
ae
appropriate, under the False Claims Act (FCA).  
gr   controlled and noncontrolled prescription drugs, 
Depending on the types of fraud or other violations 
ia   home health agencies and personal care services, 
t involved, OIG investigations may culminate in criminal or 
sc   ambulance transportation,  civil court judgments and decisions, administrative 
edi   DME, and  sanctions and decisions, and/or negotiated settlement 
v
e   diagnostic radiology and laboratory testing.  agreements.  Investigative outcomes take many forms, 
n
including incarceration, restitution, fines, penalties, 
M
I OIG also conducts investigations involving organized  forfeitures, assessments, and exclusion of individuals or 
 
d  criminal activity, including medical identity theft and  entities from participation in all Federal health care 
o
fraudulent medical schemes established for the sole 
n programs.  Frequently used exclusion and penalty 
t purpose of stealing Medicare dollars.  Investigators are 
authorities are described on our website at:  
a 
d opening an increasing number of cases against health  http://oig.hhs.gov/fraud/enforcement/cmp/. 
 
le care providers and patients who engage in these health 
at care fraud schemes.  Those who participate in the  During the first half of FY 2017, we reported 415 
ga schemes may face heavy fines, jail time, and exclusion  criminal and 458 civil actions against individuals or 
el from participation in Federal health care programs.  entities that engaged in health-care-related offenses.  
e
L We also reported over $1.52 billion in investigative 
R In addition to investigating Medicare and Medicaid 
receivables due to HHS and more than $482.7 million in 
fraud, OIG investigates fraud, waste, and abuse in other 
non-HHS investigative receivables, including civil and 
HHS programs, including ACF, IHS, Health Resources and 
administrative settlements or civil judgments related to 
Services Administration (HRSA), and Administration for 
Medicare, Medicaid, and other Federal, State, and 
Community Living (ACL).  OIG investigates potential 
private health care programs. 
misuse of grants and contract funds awarded by CDC, 
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  15 LEGAL AND   The following are recently completed actions and  Fernandez acknowledged that she directed her co-
INVESTIGATIVE   settlements organized by allegation or subject type: conspirators to make kickback payments and write and 
cash checks for the purpose of facilitating kickback 
ACTIVITIES  
Prescription Drugs payments and concealing fraud proceeds.  Alvarez 
RELATED TO  
admitted that he participated in the conspiracy by 
MEDICARE AND  
Pennsylvania  William J. OBrien III was a doctor of  writing checks to money launderers to obtain cash to 
MEDICAID osteopathic medicine.  According to evidence presented 
pay the kickbacks to Medicare beneficiaries.  Fernandez 
at trial, OBrien worked with Pagans Motorcycle Club, 
and Alvarez each pleaded guilty to conspiracy to 
an outlaw gang known for violence and drug dealing, to 
commit health care fraud and were sentenced to a 
operate a pill mill out of OBriens medical offices.  
combined 12 years and 6 months in prison and ordered 
Health Care Fraud  
OBrien wrote fraudulent prescriptions for oxycodone 
Prevention  to pay $11 million in restitution.  Two other defendants 
and Enforcement  and other drugs, while the Pagans recruited pseudo- involved in the scheme were previously sentenced to a 
  patients to buy the fraudulent prescriptions.  After  combined 3 years in prison and ordered to pay $10.9 
Other Criminal and Civil  filling the prescriptions, the Pagans resold the pills on 
million in restitution.
Enforcement Activities 
the street.  From March 2012 to January 2015, OBrien 
distributed more than 700,000 pills containing 
Pharmaceutical Companies
oxycodone and other Schedule II controlled substances 
Centers for Medicare  
& Medicaid Services   in furtherance of the conspiracy.  OBrien was found  Florida  Shire Holdings US AG, Shire Pharmaceuticals, 
  guilty of distribution of controlled substances resulting  LLC, and Shire Regenerative Medicine LLC (collectively, 
Legal and   in death and sentenced to 30 years in prison and 
Shire) entered into a settlement agreement to resolve 
Investigative Activities  ordered to pay $5.3 million in restitution, joint and 
allegations in connection with the sale of a human skin 
 
several.  Eight additional defendants involved in the 
substitute product called Dermagraft from 2007 to 
Public Health Agencies 
scheme were sentenced to a combined 49 years and 10 
2014.  Specifically, Shire allegedly paid kickbacks to 
 
months in prison.  Five defendants have pleaded guilty 
Human Services  physicians who purchased Dermagraft and, in turn, 
Agencies  and are awaiting sentencing.   billed Medicare, Medicaid, and other federally funded 
  health care programs for the product and related 
Other HHS-Related 
services, and paid kickbacks to physicians employed by 
Reviews and   Pharmacy
the Veterans Administration (VA) who caused the VA to 
Investigations 
  purchase Dermagraft under a contract with Shire.  
Florida  From July 2012 through March 2016, Niurka 
Appendixes Shire also marketed Dermagraft for uses not approved 
Fernandez co-owned and operated several pharmacies 
by the FDA to physicians who billed Federal programs.  
in the Miami area, and her son, Roberto Alvarez, was 
The company made false statements intended to inflate 
the registered agent of one of the pharmacies.  
the price of Dermagraft and to conceal, avoid, or 
Fernandez admitted to leading a fraud scheme that paid 
decrease an obligation to pay money to the United 
Medicare beneficiaries and patient recruiters for 
States.  The company also caused physicians to upcode 
prescriptions that were medically unnecessary.  
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  16 LEGAL AND   claims to Federal programs for Dermagraft and related  Fraud Strike Force case worked jointly with the Federal 
INVESTIGATIVE   services.  Shire agreed to pay $350 million to resolve  Bureau of Investigation (FBI).
their liability under the False Claims Act.
ACTIVITIES  
Louisiana  Elaine Davis was the owner of Christian 
RELATED TO  
Wisconsin  Forest Laboratories, LLC and Forest  Home Health Agency (Christian), and Dr. Pramela Ganji 
MEDICARE AND  
Pharmaceuticals, Inc. (collectively Forest) entered into  was the medical director of the agency.  According to 
MEDICAID a settlement agreement to resolve kickback allegations  evidence presented at trial, Davis and Ganji caused 
relating to three Forest products.  Specifically, between  Christian to bill for home health services that were not 
January 2008 and December 2011, Forest allegedly paid  medically necessary or were not provided, based upon 
kickbacks to physicians to induce them to prescribe the  false certifications of medical necessity signed by Ganji.  
Health Care Fraud  
drugs Bystolic, Savella, and Namenda.  The alleged  The vast majority of these patients did not require home 
Prevention 
kickbacks took the form of payments and meals  health care services, and Ganji falsely claimed that 
and Enforcement 
  provided in connection with speaker programs about  beneficiaries she had never examined were qualified to 
Other Criminal and Civil  the three drugs.  Forest agreed to pay $38 million to  receive these services.  The defendants were sentenced 
Enforcement Activities 
resolve its liability under the False Claims Act. for conspiracy to commit health care fraud and health 
care fraud.  Davis was sentenced to 8 years in prison 
while Ganji was sentenced to 6 years in prison.  They 
Centers for Medicare  
Home Health Care were ordered to pay a combined $9 million in 
& Medicaid Services  
  restitution, joint and several.  This case was investigated 
Michigan  Zafar Mehmood and Badar Ahmadani were 
Legal and   as part of the Southern Louisiana Strike Force.
owners of 16 home health care agencies in the Detroit 
Investigative Activities 
  area.  According to evidence presented at trial,  the 
Public Health Agencies  defendants, from October 2004 through 2011, obtained  Transportation Services
  patients by paying cash kickbacks to recruiters, who in 
Human Services 
turn paid cash to patients to induce them to sign up for  Massachusetts  Medstar Ambulance, Inc., Medstar 
Agencies 
home health care with their agencies.  Mehmood and  EMS, Inc., MetroWest Emergency Medical Services, Inc., 
 
Ahmadani also paid kickbacks to physicians to refer  Fitchburg Emergency Medical Services, Inc., Pioneer 
Other HHS-Related 
Reviews and   patients to the companies for home health care services  Valley EMS, Inc., Critical Systems, Inc., Nicolas Melehov, 
Investigations  that were medically unnecessary and were not provided.   and Gregory Melehov (collectively, Medstar) agreed 
 
The defendants were found guilty and sentenced for  to pay $12.7 million and enter into a CIA to resolve its 
Appendixes
health-care-related charges and other charges stemming  liability under the False Claims Act.  From January 2011 
from this scheme.  Mehmood was sentenced to 30 years  through October 2014, Medstar allegedly submitted 
in prison and ordered to pay $40.4 million in restitution,  false claims to Medicare for ambulance transportation 
joint and several, and Ahmadani was sentenced to 8  services in which the services did not qualify for 
years in prison and ordered to pay $38.1 million in  reimbursement because the transports were not 
restitution, joint and several.  This was a Health Care  medically reasonable and necessary; the transport was 
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  17 LEGAL AND   not to or from a covered destination; claims were  Laboratories
INVESTIGATIVE   submitted without the necessary beneficiary and/or 
provider signatures and/or complete documentation;  Wisconsin  Gottfried Kellermann, NeuroScience, Inc., 
ACTIVITIES  
and bills were submitted for higher levels of services  and Pharmasan Labs, Inc.  (collectively, Defendants), 
RELATED TO  
than were required by patients conditions.  entered into a settlement agreement to resolve 
MEDICARE AND  
allegations that they submitted false claims to Medicare 
MEDICAID
and TRICARE for urinary transmitter testing.  From 
Durable Medical Equipment  January 2008 through January 2014, Pharmasan and 
Kellermann allegedly violated Clinical Laboratory 
Pennsylvania  Biocompatibles, Inc., entered into a  Improvement Amendments (CLIA) regulations by 
Health Care Fraud  
settlement agreement to resolve allegations that the  intentionally subjecting certain Pharmasan as-measured 
Prevention 
and Enforcement  defendant knowingly caused false claims to be  urinary neurotransmitter test results to a shift factor 
  submitted to Medicare and Medicaid.  Specifically,  that they had not validated pursuant to CLIA regulations.  
Other Criminal and Civil  Biocompatibles allegedly marketed a device known as  In addition, the United States contended that, during 
Enforcement Activities 
LC Bead, which was cleared by the FDA as an  this same period, the Defendants applied unvalidated 
embolization device that can be placed in blood vessels  reference ranges to urinary neurotransmitter test 
Centers for Medicare   to block or reduce blood flow to certain types of tumors  results.  The Defendants agreed to pay $6.1 million to 
& Medicaid Services   and arteriovenous malformations.  However, LC Bead  resolve their liability under the False Claims Act.
  was never cleared by FDA as a drug-device combination 
Legal and   product or for use as a drug-delivery device.   New Jersey  MedNet, Inc., entered into a settlement 
Investigative Activities  Biocompatibles allegedly loaded the LC Bead with  agreement to resolve allegations that, from March 2006 
  chemotherapy drugs and used it as a drug-delivery  through January 2014, it entered into fee-for-service 
Public Health Agencies  device.  When LC Bead was combined with prescription  or direct-bill agreements with certain hospital and 
 
drugs for use as a drug-eluting bead, it constituted a  physician clinic customers.  Under these agreements, 
Human Services 
new combination drug device product that was not  MedNet allegedly charged a fee to customers for certain 
Agencies 
  approved by the FDA and not covered by Medicare and  services that they performed in connection with two 
Other HHS-Related  Medicaid.  The defendant agreed to pay $25 million to  types of cardiac monitoring.  MedNet allowed the 
Reviews and   resolve its False Claims Act liability.  In addition, as part  customers to bill Medicare directly for these same 
Investigations 
of the criminal resolution, Biocompatibles was ordered  services and permitted the customers to retain the 
 
to pay an $8.75 million criminal fine for the misbranding  reimbursements they received from Medicare.  
Appendixes
of LC Bead and a criminal forfeiture of $2.25 million.   However, the Medicare reimbursement exceeded the 
fee that MedNet charged the customers.  The United 
States contended that these arrangements resulted in a 
  net profit to MedNets customers who were part of 
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  18 LEGAL AND   these agreements and provided remuneration to these  optimizations, and other procedures.  SMH is an acute 
INVESTIGATIVE   customers to induce referrals from the customers for  care hospital owned and operated by Baptist Health 
ACTIVITIES   MedNets services.  The defendant agreed to pay $1.3  System of South Florida (Baptist).  SMH agreed to pay 
million to resolve their liability under the False Claims Act.   $12.5 million and enter into a 5-year CIA with OIG to 
RELATED TO  
resolve its liability under the False Claims Act.  
MEDICARE AND  
MEDICAID
Radiology
Nursing Homes
New York  Zwanger & Pesiri Radiology Group, LLP, 
Zwanger Radiology, P.C., and Dr. Steven Mendelsohn  Tennessee  Life Care Centers of America (LCCA) and 
Health Care Fraud  
(collectively, Defendants) entered into a settlement  LCCAs owner and sole shareholder, Forrest Preston, 
Prevention 
agreement to resolve allegations that between July  entered into a settlement agreement to resolve 
and Enforcement 
  2009 and February 2014 they billed Medicare and  allegations that, from January 2006 to February 2013, 
Other Criminal and Civil  Medicaid for radiology testing that was not ordered by a  LCCA caused the submission of false claims to Medicare 
Enforcement Activities 
treating physician, and procedures were performed or  and TRICARE for medically unnecessary rehabilitation 
supervised by physicians or at a practice location that  therapy services provided to patients at LCCAs SNFs.  
was/were not enrolled in Medicare and/or Medicaid.   LCCA is the Nations fourth largest chain of SNFs.  The 
Centers for Medicare  
The Defendants agreed to pay $8.1 million and enter  defendants agreed to pay $145 million plus interest to 
& Medicaid Services  
  into a 5-year CIA with OIG to resolve their liability under  resolve their liability under the False Claims Act, along 
Legal and   the False Claims Act.  Contemporaneously with the civil  with a 5-year comprehensive CIA requiring management 
Investigative Activities  settlement, Zwanger-Pesiri pleaded guilty to two counts  certifications from numerous employees at the 
 
of health care fraud for illegally performing and billing  corporate, divisional, regional, and facility level.  
Public Health Agencies 
for procedures that had not been ordered by treating 
 
physicians and agreed to forfeit an additional $2.4 
Human Services 
million.   Physicians
Agencies 
 
Other HHS-Related  Georgia  Dr. Robert E. Windsor owned and operated 
Reviews and   Hospitals Georgia Surgical Monitoring, LLC. According to the 
Investigations  investigation, from January 2010 through July 2013, 
 
Florida  South Miami Hospital, Inc. (SMH), entered into  Windsor billed for services that he did not perform.  
Appendixes
a settlement agreement to resolve its liability for  Specifically, Windsor billed for intra-operative 
submitting claims to Medicare, Medicaid, TRICARE, and  monitoring, a procedure for reducing the risk of 
Federal Employee Health Benefit Programs for medically  neurological deficits during operations that involve the 
unnecessary electro physiology studies, echo  nervous system.  During surgery, a patient is connected 
cardiograms, tilt-table tests, implantable cardiovascular- electronically to a system that allows a physician to 
defibrillators, biventricular pacemakers, atrioventricular  remotely monitor the neurologic system and provide 
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  19 LEGAL AND   guidance to the operating surgeon to prevent  HEAT Provider Compliance Training 
INVESTIGATIVE   neurological damage.  This complex monitoring requires 
specialized skills and experience and is usually provided  OIG provides free training on our website for health care 
ACTIVITIES  
by a neurologist.  Windsor directed a medical assistant  providers, compliance professionals, and attorneys.  
RELATED TO  
to conduct this monitoring on his behalf with no  OIGs Provider Compliance Training was an initiative 
MEDICARE AND  
supervision.  Windsor was sentenced to 3 years and 2  developed as part of HEAT in 2011 that continues to 
MEDICAID
months in prison and ordered to pay $1.1 million in  reach the health care community with OIGs message of 
restitution after his guilty plea to health care fraud. compliance and prevention via free, downloadable, 
comprehensive training materials and podcasts.  OIGs 
New York  Hudson Valley Hematology-Oncology  provider compliance training resources can be accessed 
Health Care Fraud  
Associates, R.L.L.P.  (Hudson), entered into a settlement  at:  https://oig.hhs.gov/compliance/compliance-
Prevention 
and Enforcement  agreement to resolve Hudsons liability for improperly  guidance/index.asp.  
  submitting claims to Medicare and Medicaid.  From June 
Other Criminal and Civil  2010 through June 2015, Hudson allegedly routinely 
Enforcement Activities  waived co-payments without an individualized  Health Care Fraud Strike Force Activities 
determination of financial hardship or exhaustion of 
reasonable collection efforts and billed Medicare and  In 2007, Health Care Fraud Strike Force teams began an 
Centers for Medicare  
Medicaid for evaluation and management services, even  effort to combine resources of Federal, State, and local 
& Medicaid Services  
  though Hudson did not provide any significant,  law enforcement entities to prevent and combat health 
Legal and   separately identifiable services to the beneficiaries.  The  care fraud, waste, and abuse.  These partnerships 
Investigative Activities  defendant agreed to pay $5.5 million and enter into a  between OIG and HHS, DOJ, U.S.  Attorneys Offices, 
  5-year CIA with OIG to resolve its liability.  FBI, and State and local law enforcement have a 
Public Health Agencies  common goal: successfully analyze health care fraud 
 
data and investigative intelligence to quickly identify 
Human Services 
Health Care Fraud Prevention   fraud and bring prosecutions.  Strike Force teams 
Agencies 
operate in nine areas: Miami, Florida; Los Angeles, 
  and Enforcement
Other HHS-Related  California; Detroit, Michigan; Houston, Texas; Brooklyn, 
Reviews and   New York; southern Louisiana; Tampa, Florida; Chicago, 
On May 20, 2009, the Secretary of HHS and the Attorney 
Investigations 
Illinois; and Dallas, Texas.
  General announced the creation of the Health Care 
Appendixes Fraud Prevention and Enforcement Action Team (HEAT),  During the first half of FY 2017, Strike Force efforts 
an interagency effort focused specifically on combating  resulted in the filing of charges against 49 individuals or 
health care fraud.  HEAT includes senior officials from  entities, 152 criminal actions, and more than $266.8 
DOJ and HHS who are strengthening programs and  million in investigative receivables.
investing in new resources and technologies to prevent 
and combat fraud, waste, and abuse.
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  20 LEGAL AND   Below are examples of Strike Force cases: Other Criminal and Civil  
INVESTIGATIVE   Michigan  Four defendants in a home health care and 
Enforcement Activities 
ACTIVITIES   hospice Medicare fraud scheme pleaded guilty to 
RELATED TO   conspiracy to commit health care fraud and wire fraud.  
Special Assistant U.S. Attorney Program 
MEDICARE AND   They were sentenced to a combined 35 years and 2 
MEDICAID months in prison and ordered to pay $33 million in  During this reporting period, DOJ and OIG continued 
restitution, joint and several.  Three of the defendants, 
their participation in a program in which OIG attorneys, 
Shahid Tahir, Manawar Javed, and Muhammad Tariq, 
some of whom are Special Agents, serve as Special 
owned home health care and hospice companies, while 
Assistant U.S. Attorneys.  These OIG attorneys are 
Health Care Fraud   the fourth, Hatem Ataya, was a physician who conspired 
detailed full time to DOJs Criminal Division, Fraud 
Prevention  with the other defendants.  From January 2006 through 
Section, for temporary assignments, including 
and Enforcement 
June 2015, Tahir, Javed, and Tariq paid kickbacks, bribes, 
  assignments to the Health Care Fraud Strike Force.  
and other inducements to Ataya and other physicians, 
Other Criminal and Civil  Other attorneys prosecute matters on a case-by-case 
as well as to marketers and patient recruiters, for 
Enforcement Activities  basis.  Both arrangements offer excellent litigation 
beneficiary referrals to companies they owned.  The 
training for OIG attorneys and enhance collaboration 
co-defendants admitted that they then billed Medicare 
between the departments in their efforts to fight fraud.  
Centers for Medicare   for home health care and hospice services that were 
Under this program, OIG attorneys have successfully 
& Medicaid Services   often medically unnecessary and/or not provided.
  litigated important criminal cases relating to the 
Legal and   New York  Olga Novogordosky co-owned Cropsey  fraudulent billing of medical equipment and supplies, 
Investigative Activities  Medical Care.  According to the investigation,   infusion therapy, and physical therapy, as well as other 
  Novogordosky and her co-conspirators, from November  types of Medicare and Medicaid fraud.
Public Health Agencies 
2009 through October 2012, executed a scheme to 
 
defraud Medicare and Medicaid by billing for services 
Human Services  Below is a related case example:
Agencies  not rendered, billing for services that were not medically 
Texas  Oakey Chikere was the owner and operator of 
  necessary, and providing cash kickbacks to beneficiaries.  
Other HHS-Related  Novogordosky also helped to create a fake shell  Direct Care medical clinic in the Houston area.  
Reviews and   According to the investigation, the defendant led a 
company name for the purpose of money laundering to 
Investigations  scheme from about March 2011 through February 2013 
pay kickbacks to patients.  Novogordosky was sentenced 
 
to bill Medicare for services that were not medically 
to 1 year and 1 day in prison and ordered to pay $6.5 
Appendixes
necessary and were not provided.  Specifically, Chikere 
million in restitution, joint and several, after her guilty 
recruited doctors to work for him, representing that 
plea to conspiracy to commit money laundering and 
conspiracy to commit health care fraud.  Ten defendants  they would be paid for certifying and recertifying 
involved in the scheme were previously sentenced to a  patients for home health care, regardless of whether 
combined 17 years and 1 day in prison and ordered to  the home health services were medically necessary.  
pay $13.5 million in restitution, joint and several.  Chikere marketed to home health agencies that, for a 
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  21 LEGAL AND   fee, his doctors would fraudulently certify Medicare  order to submit false claims to Medicare.  Investigators 
INVESTIGATIVE   beneficiaries for home health services.  Chikere would  believe that Martinez, through Magnifique, was paid 
ACTIVITIES   then refer the patient to a home health agency he had  over $4.7 million for services Magnifique did not render.  
an arrangement with, and he would be paid a kickback.   Martinez was detained while trying to enter the United 
RELATED TO  
A jury convicted Chikere of conspiracy to commit health  States from an inbound flight originating in Cuba.  He is 
MEDICARE AND  
care fraud and health care fraud, and he was sentenced  currently in custody and will face charges stemming 
MEDICAID
to 5 years and 10 months in prison and ordered to pay  from his indictment.
$258,738 in restitution.
Because of the success of OIGs Most Wanted Fugitives 
website, OIG launched its Most Wanted Deadbeat 
Health Care Fraud  
Most Wanted Fugitives Listed on OIGs Website  Parents website at https://oig.hhs.gov/fraud/child-
Prevention 
and Enforcement  support-enforcement/index.asp.  The site identifies 
  The OIG Most Wanted Fugitives website continues to  parents who fail to pay court-ordered child support for 
Other Criminal and Civil  garner national and international attention and has  their children; as a result, an unnecessary strain is 
Enforcement Activities 
greatly assisted in helping to capture fugitives charged  placed on the custodial parents and the children as well 
with defrauding Federal health care programs and  as on agencies that enforce these matters.  The Human 
stealing millions of taxpayer dollars.  The Most Wanted  Services Reviews section of this Semiannual Report 
Centers for Medicare  
Fugitives website is continually updated and features a  provides examples.
& Medicaid Services  
  profile for each fugitive as well as an online tip form and 
Legal and   a hotline number for individuals to report fugitive-
Investigative Activities  related information to OIG, in English or Spanish, 24  HHS OIG Hotline
 
hours a day, 365 days a year.  The Most Wanted 
Public Health Agencies  The mission of the HHS OIG Hotline is to support OIGs 
Fugitives list can be accessed at https://oig.hhs.gov/
  oversight responsibilities in safeguarding the integrity of 
fraud/fugitives/. 
Human Services 
all programs and personnel under purview of HHS and 
Agencies 
One of OIGs Most Wanted Fugitives, Ariel Martinez  protect them from fraud, waste, and abuse.  We achieve 
 
Other HHS-Related  Ruiz, was captured during this reporting period.   our mission through our dedication to timely intake and 
Reviews and   Martinez was indicted on charges of health care fraud in  analysis of information received from various sources, 
Investigations  June 2016 and fled the United States.  Martinez was the  such as the Report Fraud link on the HHS OIG Internet 
 
owner operator of Magnifique Home Health in Miami,  website.  Strategically located within the Office of 
Appendixes
Florida.  According to the indictment, from July 2014  Investigations, the Hotline is the public-facing division 
through February 2015, Martinez conspired to defraud  for OIGs intake and evaluation of fraud tips.  During this 
Medicare by submitting false claims.  Specifically,  semiannual reporting period, the OIG Hotline reported 
Martinez and others obtained the names and Medicare  expected recoveries of $9.6 million as a direct result of 
identification numbers of Medicare beneficiaries, along  cases originating from Hotline complaints.  
with the names and provider numbers of physicians, in 
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  22 LEGAL AND   OIG Hotline Activity (10/1/163/31/17): MFCUs employed 1,965 individuals.  Collectively, in FY 
INVESTIGATIVE   2016, MFCUs reported 18,730 investigations, of which 
  Contacts to 1-800-HHS-TIPS phone line, including  15,509 were related to Medicaid fraud and 3,221 were 
ACTIVITIES  
callers seeking information:  66,891 related to patient abuse and neglect, including 
RELATED TO  
  Total Tips Evaluated :  14,562 misappropriation of patients private funds.  The cases 
MEDICARE AND  
resulted in criminal charges or indictments involving 
MEDICAID   Tips Referred for Action:  9,970
1,721 individuals, including 1,249 for fraud and 472 for 
  Closed, no basis provided for further action:  4,222 patient abuse and neglect.  In total, 1,564 convictions 
  Closed, no HHS violation:  370 were reported in FY 2016, of which 1,160 were related 
to Medicaid fraud and 404 were related to patient 
Health Care Fraud  
Prevention  Source Types of TIPS referred for action: abuse and neglect.  Civil judgments and settlements for 
and Enforcement  FY 2016 totaled 998, and monetary recoveries in civil 
    Phone:  5,127 cases totaled over $1.5 billion.  (See Medicaid Fraud 
Other Criminal and Civil 
Control Units 2016 Expenditures and Statistics 
Enforcement Activities    Internet:  3,768
contained in an Interactive Map and Chart).
  Letters/Faxes:  1,075
Centers for Medicare  
OIG Onsite Reviews of MFCUs  
& Medicaid Services   State Medicaid Fraud Control Units 
  In addition to an annual recertification review of each 
Legal and   MFCU, OIG conducts periodic in-depth reviews of a 
OIG Oversight of State Medicaid Fraud Control Units
Investigative Activities  sample of MFCUs.  OIG evaluates MFCU operations in 
  MFCUs are key partners with OIG in the fight against 
accordance with 12 performance standards and 
Public Health Agencies  fraud, waste, and abuse in State Medicaid programs.  
assesses compliance with laws, regulations, and OIG 
  OIG has oversight responsibility for MFCUs and 
policy guidance.  OIG issued a report of an onsite review 
Human Services 
administers grants that provide Federal funding for Unit 
of the following MFCU during the reporting period: 
Agencies 
operations.  The Federal Government reimburses 75 
 
Other HHS-Related  percent of the costs of operating a Unit; the States    Oregon State Medicaid Fraud Control Unit: 2016 
Reviews and   contribute the remaining 25 percent.  MFCUs  Onsite Review (OEI-09-16-00200, December 2016).
Investigations  investigate and prosecute Medicaid provider fraud and 
 
patient abuse and neglect in health care facilities or  The following is a case example of joint efforts 
Appendixes
board and care facilities.   with MFCUs:
Texas  Jocelyn Pyles Elo was a physician working for 
MFCU Funding and Accomplishments in FY 2016 Elite P. Medical Clinic in Houston, Texas.  According to 
the investigation, from May 2009 to September 2011, 
In FY 2016, combined Federal and State expenditures 
Pyles conspired with others to bill for services she did 
for the operation of the 50 MFCUs (in 49 States and the 
not provide.  In actuality, an unlicensed foreign medical 
District of Columbia) totaled almost $259 million.  The 
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  23 LEGAL AND   graduate saw all the patients at the clinic alone and was  the exclusion of individuals and entities from Federal 
INVESTIGATIVE   instructed not to sign patient progress notes at those  health care programs and the imposition of CMPs for 
visits.  Pyles would arrive at the clinic after hours and  submitting false and fraudulent claims to a Federal 
ACTIVITIES  
sign the treatment notes to make it appear as if she saw  health care program or for violating the anti-kickback 
RELATED TO  
the patients when in actuality she did not.  A jury found  statute, the Stark law, or the Emergency Medical 
MEDICARE AND  
Pyles guilty of 14 counts of health care fraud, and she  Treatment and Labor Act (EMTALA), also known as the 
MEDICAID
was sentenced to 1 year and 1 day in prison and  patient dumping statute.  
ordered to pay $560,718 in restitution.
During this semiannual reporting period, OIG imposed 
1,504 administrative sanctions in the form of program 
Health Care Fraud  
Advisory Opinions and Other Industry Guidance  exclusions or administrative actions for alleged fraud or 
Prevention 
abuse or other activities that posed a risk to Federal 
and Enforcement 
As part of OIGs continuing efforts to promote the  health care programs and their beneficiaries.  Exclusion 
 
Other Criminal and Civil  highest level of ethical and lawful conduct by the  and penalty authorities are described in Appendix D and 
Enforcement Activities  health care industry, we issue advisory opinions and  on our website at http://oig.hhs.gov/fraud/
other guidance to educate industry and other  enforcement/cmp/index.asp.
stakeholders on how to avoid fraud, waste, and abuse.  
Centers for Medicare  
Advisory opinions, which are developed in consultation 
& Medicaid Services  
with DOJ, are issued to requesting parties regarding  Program Exclusions 
 
the interpretation and applicability of certain statutes 
Legal and  
During this semiannual reporting period, OIG excluded 
Investigative Activities  relating to Federal health care programs.  HIPAA,  
1,422 individuals and entities from Medicare, Medicaid, 
  205, allows OIG to provide case-specific formal 
and other Federal health care programs.  Most of the 
Public Health Agencies  guidance on the application of the anti-kickback 
  statute and safe harbor provisions and other OIG  exclusions resulted from convictions for crimes relating 
Human Services  to Medicare or Medicaid, for patient abuse or neglect, 
health care fraud and abuse sanctions.  During the first 
Agencies  or as a result of license revocation.  OIG is also 
half of FY 2017, OIG received 22 requests for advisory 
 
responsible for reinstating providers who apply and have 
opinions and issued 5 advisory opinions and 1 
Other HHS-Related 
met the requirements of their exclusions.  For a list of 
Reviews and   modification of an advisory opinion. 
excluded individuals and entities, see https://exclusions.
Investigations 
  oig.hhs.gov/.  
Appendixes Sanction Authorities and Other  
Administrative Actions The following are examples of program 
exclusions:
Various Federal laws provide authorities the ability to 
District of Columbia  Florence Bikundi was an owner of 
impose administrative sanctions for fraud and abuse as 
Global Healthcare, Inc.  According to court documents, 
well as other activities that pose a risk to Federal health 
Bikundi fraudulently gained approval as a provider in the 
care programs and their beneficiaries.  Sanctions include 
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  24 LEGAL AND   Medicaid program.  From August 2009 through February  OIG refers individuals and entities that have potentially 
INVESTIGATIVE   2014, Bikundi led a scheme to bill Medicaid for services  engaged in grant or contract fraud or misconduct to the 
that were not provided, creating phony time sheets,  HHS Suspension and Debarment Official, who is 
ACTIVITIES  
patient files, and employment files.  Bikundi was  responsible for determining whether to impose a 
RELATED TO  
convicted of health care fraud, money laundering, and  suspension or debarment.  OIG continues to develop a 
MEDICARE AND  
other charges stemming from this scheme, and was  robust Suspension and Debarment program and uses 
MEDICAID
sentenced to 10 years in prison and ordered to pay $80.6  this tool to protect Government programs against fraud, 
million in restitution, joint and several.  In April of 2000,  waste, poor performance, and noncompliance with 
Bikundi was excluded based on the loss of her license to  contract provisions or applicable law.
practice as a licensed practical nurse in the State of 
Health Care Fraud  
Prevention  Virginia, and this exclusion remains in place.  OIG 
The following are debarment examples: 
and Enforcement  excluded Bikundi for a minimum period of 55 years.
  Florida  Ana Luz Marcano, through her employment at 
Other Criminal and Civil  Virginia  Martin Matthews Martin was licensed as a  the Childrens Home Society, engaged in a scheme to 
Enforcement Activities 
nurse aide.  According to court documents, while working  falsify and expedite applications to the Florida School 
as a nurse aide in a nursing home, Martin sexually  Readiness Program.  According to the investigation, 
assaulted an 84-year old patient.  The patient was not  Marcano charged an illegal fee to low-income parents 
Centers for Medicare  
& Medicaid Services   alert, nonverbal, and suffered from dementia.  Martin  for subsidized daycare benefits that parents were not 
  was sentenced to 22 years in prison based on his  entitled to receive.  The referral forms Marcano 
Legal and   conviction for rape.  In addition, the Virginia State Board  completed designated the children as at-risk and 
Investigative Activities  of Nursing revoked his license to practice as a nurse aide.   eligible to receive immediate placement ahead of 
 
OIG excluded Martin for a minimum period of 30 years.   families already on a waiting list for these services.  The 
Public Health Agencies 
defendant was convicted of an organized scheme to 
 
defraud and was debarred based on an OIG referral to 
Human Services 
Suspensions and Debarments 
Agencies  the Department for a 3-year period. 
 
Other HHS-Related  Suspensions and debarments are administrative tools  Nevada  Belinda Thompson was the executive director 
Reviews and   used by HHS and other Federal agencies to protect the  of Goshen Community Development.  Goshen was 
Investigations  Government from individuals and entities that have  funded in excess of $6 million, primarily with SAMHSA 
 
engaged in contract fraud, misused grant funds, or are  grant funds.  The funds were intended to fund sub-
Appendixes
otherwise not presently responsible.  Because these are  grantees to perform community services such as drug 
Government-wide sanctions, an individual or entity that  abuse prevention services and HIV and TB services, law 
has been suspended or debarred by HHS or any other  enforcement checkpoints, and community services 
agency is ineligible from participating in any future  training.  According to the investigation, Thompson 
funding opportunities across the Federal Government  knowingly embezzled Goshens Federal grant funds.  The 
for a specified period of time. defendant was convicted of theft of Government 
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  25 LEGAL AND   property, ordered to repay $399,000, and subsequently  company and its predecessors failed to implement 
INVESTIGATIVE   debarred based on an OIG referral to the Department  policies and procedures required by the CIA, and that 
for a 3-year period. poor claims submission practices led to significant error 
ACTIVITIES  
rates and overpayments by Medicare. 
RELATED TO  
MEDICARE AND  
Corporate Integrity Agreements 
MEDICAID
Civil Monetary Penalties Law 
Many health care providers elect to settle their cases 
before litigation.  As part of the settlements, providers  The Civil Monetary Penalties Law (CMPL) authorizes OIG 
often agree to enter into CIAs with OIG to avoid  to impose administrative penalties on and assessments 
Health Care Fraud  
exclusions from Medicare, Medicaid, and other Federal  against a person who, among other things, submits, or 
Prevention 
health care programs.  Under a CIA, a provider commits  causes to be submitted, claims to a Federal health care 
and Enforcement 
  to establishing a program and taking other specified  program that the person knows, or should know, are 
Other Criminal and Civil  steps to ensure future compliance with Medicare and  false or fraudulent.  In addition to administrative 
Enforcement Activities  Medicaid rules.  The compliance programs are designed,  penalties and assessments, OIG can also exclude 
in part, to prevent future fraud.  OIG monitors providers  individuals for engaging in conduct prohibited by the 
compliance with these agreements and may impose  CMPL.  During this semiannual reporting period, OIG 
Centers for Medicare  
penalties on entities that fail to comply with the  concluded cases involving more than $26.3 million in 
& Medicaid Services  
  requirements of their CIAs.  CMPs and assessments. 
Legal and  
Investigative Activities 
The following is a CIA enforcement example: The following is a CMP example:
 
Public Health Agencies  Kentucky  Kindred Healthcare, Inc., the Nations largest  New Jersey  Roben Brookhim agreed to pay $1.1 
  provider of post-acute care, including hospice and home  million in assessments and penalties and be excluded 
Human Services 
health services, paid a penalty of more than $3 million  from participation in all Federal health care programs 
Agencies 
for failing to comply with a CIA.  The CIA was the result  for a period of 50 years pursuant to 42 U.S.C.  
 
Other HHS-Related  of allegations involving claims for hospice services that  1320a-7(b)(7) (fraud, kickbacks, and other prohibited 
Reviews and   were medically unnecessary and claims for continuous  activities).  Brookhim is a New Jersey dentist who was 
Investigations  or crisis care services when the patients were not  previously excluded due to the suspension of his license 
 
experiencing a crisis.  The penalty for violating the CIA  to practice dentistry in 1999.  OIG alleged that Brookhim 
Appendixes
resulted from Kindreds failure to correct improper  knowingly presented or caused to be presented to 
billing practices in the fourth year of the 5-year  Medicaid claims for items or services he knew or should 
agreement.  OIG made several unannounced site visits  have known were false or fraudulent or otherwise not 
to Kindred facilities and found ongoing violations.   provided as claimed; knowingly presented or caused to 
Specifically, CIA-required audits performed by Kindreds  be presented to Medicaid claims for items or services 
internal auditors in 2013, 2014, and 2015 found that the  furnished by an excluded person; and was the owner 
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  26 LEGAL AND   and managing employee of an entity that was  Tennessee  Metro Knoxville HMA, LLC agreed to pay 
INVESTIGATIVE   participating while he was excluded from participating in  $45,000 to resolve its potential liability under EMTALA.  
Federal health care programs. OIG alleged that Metro Knoxville violated EMTALA when 
ACTIVITIES  
it discharged a patient without having provided an 
RELATED TO  
adequate medical screening examination or treatment 
MEDICARE AND  
Patient Dumping  sufficient to stabilize the patient.  OIGs investigation 
MEDICAID
revealed that blood test results indicated the presence 
Some of the CMPL cases that OIG resolved during this 
of an emergency medical condition; however, Metro 
semiannual reporting period were pursued under the 
Knoxville discharged the patient without confirming that 
Emergency Medical Treatment and Labor Act (EMTALA), a 
such blood levels had stabilized. 
Health Care Fraud  
statute designed to prevent hospitals from denying 
Prevention 
emergency care to patients and to ensure patient access to 
and Enforcement 
  appropriate emergency medical services.   Self-Disclosure Programs 
Other Criminal and Civil 
Enforcement Activities 
Health care providers, suppliers, or other individuals or 
The following are EMTALA case examples:
entities subject to CMPs can apply for acceptance into 
Missouri  Research Medical Center (RMC) agreed to  the Provider Self-Disclosure Protocol, a program created 
Centers for Medicare  
pay $360,000 to resolve its potential liability under 
in 1998, to voluntarily disclose self-discovered evidence 
& Medicaid Services  
EMTALA.  OIG alleged that RMC failed to provide an 
  of potential fraud.  The self-disclosure program may give 
adequate medical screening examination and 
Legal and   providers the opportunity to potentially avoid costs or 
Investigative Activities  improperly transferred a patient.  The patient arrived at  possible disruptions associated with Government-
  RMCs emergency room (ER) with a psychiatric  directed investigations and civil or administrative 
Public Health Agencies  emergency medical condition.  Without providing 
litigation.  Application processes for two additional 
  stabilizing treatment, RMC transferred the patient to a 
self-disclosure programs were recently added to the OIG 
Human Services 
nearby facility by private vehicle.  During the transfer, 
website for HHS contractors and grantees.  The OIG 
Agencies 
the patient exited the vehicle and was struck by another 
  contractor self-disclosure program enables contractors 
Other HHS-Related  vehicle.  During its investigation, OIG found 17 occasions  the opportunity to self-disclose when they have 
Reviews and   where RMC failed to provide adequate medical 
potentially violated the False Claims Act or other Federal 
Investigations  screening examinations and improperly transferred or 
criminal laws prohibiting fraud, conflict of interest, 
 
discharged patients, without providing stabilizing 
bribery, or gratuity.  This self-disclosure process is 
Appendixes
treatment, who arrived at its ER with psychiatric 
available only to those with a Federal Acquisition 
emergency medical conditions.  At the time each patient 
Regulation-based contract with HHS.  The OIG Grant 
arrived, RMC had the capacity to treat, stabilize, or 
Self-Disclosure program is available for application by 
admit each patient.  
HHS grantees or HHS grant sub-recipients and provides 
the opportunity for voluntarily disclosure to OIG of 
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  27 LEGAL AND   potential fraud.  OIG evaluates the reported results of 
INVESTIGATIVE   each internal investigation under the provider self-
disclosure protocol to determine the appropriate course 
ACTIVITIES  
of action.  The self-disclosure guidelines are available on 
RELATED TO  
the OIG website at https://oig.hhs.gov/compliance/
MEDICARE AND  
self-disclosure-info/index.asp.  During this semiannual 
MEDICAID
reporting period, self-disclosure cases resulted in more 
than $23 million in HHS receivables.  
Health Care Fraud   The following are examples of provider  
Prevention 
self-disclosure settlements:
and Enforcement 
  Texas  Memorial Hermann Health System agreed to 
Other Criminal and Civil  pay $5.6 million to resolve its liability under the CMPL 
Enforcement Activities 
for conduct it disclosed to OIG.  Specifically, OIG alleged 
that, between September 1, 2009, and October 20, 
2015, it improperly submitted claims to Medicare, 
Centers for Medicare  
& Medicaid Services   Medicaid, and TRICARE for certain outpatient services 
  by automatically appending modifiers 59 or 91 to 
Legal and   Current Procedural Terminology (CPT) codes without 
Investigative Activities  regard for clinical appropriateness. 
 
Public Health Agencies  Oklahoma  Muscogee Creek Nation Department of 
 
Health, acting on behalf of its subsidiary Creek Nation 
Human Services 
Hospital and Clinics d/b/a Creek Nation EMS, agreed to 
Agencies 
pay $171,767 to resolve its liability under the CMPL for 
 
Other HHS-Related  conduct it disclosed to OIG.  Specifically, OIG alleged 
Reviews and   that, from July 4, 2011, through January 24, 2015, Creek 
Investigations 
Nation EMS improperly billed for ambulance transport 
 
services provided by an unlicensed emergency medical 
Appendixes
technician.
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  28     
ss Indian Health Service assistance and training. 
we
i Indian Health Service Hospitals: More Monitoring Needed to  OEI-06-14-00010    October 2016
et
ii Ensure Quality Care  
vv
We found that IHS may be missing opportunities to 
ei Indian Health Service Hospitals: Longstanding Challenges 
t identify and remediate quality problems in its hospi-
Rc Warrant Focused Attention to Support Quality Care 
tals because it performed limited oversight activities 
A
  regarding quality care and compliance with the Con- IHS hospital administrators reported a range of 
s
  ditions of  Participation.  IHS relies on its Area Offices  interrelated challenges affecting their ability to provide 
et
to monitor hospitals.  However, Area Office staff have  quality care and maintain compliance.  IHS hospitals face 
in
c few sources of information about hospital quality, and  continual increases in the number of American Indian/
e
n most limit reviews of that information to infrequent  Alaskan Natives using their services, yet they provide a 
m
e meetings of each hospitals Governing Board.  Further,  small scope of medical services and limited options for 
ge Condition-of-Participation compliance surveys are not  specialists and community support (e.g., nursing homes 
Ac conducted by CMS with the frequency needed to make  and home health).  IHS hospitals particularly struggle to 
r them a useful tool.  Staffing shortages in Area Offices  maintain the skills necessary to treat complex inpatient 
 
ho also limit the clinical support and guidance that they are  cases.  Another significant concern among IHS hospital 
tf able to provide, and the most promising efforts to im- administrators is the inability to recruit and retain 
n
l prove hospital quality lack dedicated funding.  Addition- needed staff.  The dependence on acting personnel 
aE ally, hospitals struggle to implement data-driven quality  and contracted providers to fill vacancies sometimes 
e
  improvement methods as a result of limited information  creates instability in IHS hospitals and weakens the 
Hd
technology knowledge, a lack of resources, and difficul- continuity of care provided to patients.  Further, hospital 
n
  ties with the electronic health record systems.   administrators reported that limited resources for 
ca
maintaining old hospital structures and outdated 
i
l We recommended that IHS: (1) implement a quality- equipment sometimes result in service interruptions 
b focused compliance program; (2) establish standards  and raise concerns about patient safety.
u and expectations for Area Office/Governing Board 
P oversight activities; (3) work to identify new  and more  We recommended that the Office of the Secretary of 
meaningful  hospital performance metrics; and (4)  HHS lead an examination of the quality of care delivered 
continue to invest in training for hospital administration  in IHS hospitals as part of its newly formed executive 
and staff.  Additionally, we recommended that CMS  council and use the findings to identify and implement 
assist IHS in its oversight efforts by conducting more  innovative strategies to mitigate IHSs longstanding 
frequent surveys of non-accredited hospitals, informing  challenges.  We also recommended that IHS conduct a 
IHS leadership when hospitals are cited with  needs assessment and develop an agency-wide strategic 
deficiencies, and continuing to provide technical  plan with actionable initiatives and target dates to build 
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  29 PUBLIC HEALTH  a unified vision of IHS priorities and how to achieve  reimbursement for services ordered or prescribed by 
them.  The Office of the Secretary, IHS, and CMS  the excluded individual.  OIG is responsible for excluding 
AGENCIES  
provided a joint response to this report and its  individuals who have defaulted on HEAL loans from 
REVIEWS AND  
companion report.  Collectively, these HHS agencies  participation in Federal health care programs.
ENFORCEMENT  
concurred with all recommendations in both reports. 
ACTIVITIES
HEAL Exclusions
OEI-06-14-00011    October 2016
During this semiannual reporting period, nine 
individuals and related entities were excluded as a result 
of PSC referral of their cases to OIG.  Individuals who 
Public-Health-Related Legal  
have been excluded because of default may enter into 
Actions and Investigations settlement agreements, whereby the exclusions are 
stayed while they pay specified amounts each month to 
Public-Health-Related 
Legal Actions and   Health Education Assistance Loan Program satisfy their debts.  If they default on these settlement 
Investigations agreements, they may be excluded until the entire debt 
OIG excludes individuals who have defaulted on Health  is repaid and they may not appeal the exclusions.
Education Assistance Loan (HEAL) loans from 
Centers for Medicare   After being excluded for nonpayment of their HEAL 
participation in Federal health care programs.  Under 
& Medicaid Services  
debts, 2,649 individuals chose to enter into settlement 
the HEAL program, which stopped making loans in 1998, 
 
agreements or completely repay their debts.  That figure 
Legal and   HRSA guaranteed commercial loans to students seeking 
includes 12 individuals who entered into such 
Investigative Activities  education in health-related fields.1   The students are 
settlement agreements or completely repaid their debts 
  allowed to defer repayment of the loans until after they 
during this semiannual reporting period.  More than 
Public Health Agencies  graduate and begin to earn income.  Although HHSs 
$210 million is being repaid through settlement 
  Program Support Center (PSC) takes steps to ensure 
Human Services  repayment, some loan recipients do not resolve their  agreements or through complete repayment.  Of that 
Agencies  amount, more than $984,000 is attributable to this 
indebtedness.  After PSC has exhausted efforts to secure 
  semiannual reporting period.
repayment of a debt, it declares an individual in default.  
Other HHS-Related 
Reviews and   The Social Security Act permits exclusion thereafter of  The following are settlement agreement examples.  
Investigations  such individuals from Medicare, Medicaid, and all other 
These practitioners entered into settlement agreements 
  Federal health care programs for nonpayment of the 
to repay the amounts indicated:
Appendixes
loans.
  Florida Chiropractor - $132,333
Exclusion means that the individual may not receive 
  Iowa  Optometrist - $72,9835
reimbursement under these programs for professional 
services rendered, nor may any other provider receive 
1 The HEAL Program, noted in previous Semiannual Reports, was permanently transferred from HHS to the U.S.  Department of Education as required by the 
Consolidated Appropriations Act, 2014 (Pub. L. 113-76).  The transfer was completed on July 1, 2014.
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  30     
ss Administration for Children   Puerto Rico concurred with our recommendation to 
we improve its controls for provider and client eligibility 
and Families 
i determinations and for processing claims to ensure that 
et
ii payments for the CCDF program are made only for 
vv Childcare and Head Start Programs eligible clients and to eligible providers.  Puerto Rico also 
ei concurred with our recommendations to return $83,000 
t
ACF provides Federal grants through several programs, 
Rc to the Federal Government for unallowable obligations 
including Head Start and the Child Care and 
A and establish policies and procedures to ensure that 
 
s Development Fund (CCDF).  CCDF (authorized by the  child care funds are identified and assigned to voucher 
 
et Child Care and Development Block Grant Act and the  payments in compliance with obligation requirements. 
in Social Security Act  418) assists low-income families 
c
e receiving temporary public assistance, and families  A-02-13-02005    January 2017
n
m transitioning from public assistance to obtain child care 
e so that they may work or obtain training or education.
ge
Newark Preschool Council, Inc., Did Not Always Comply With 
Ac
Puerto Ricos Controls for Its Child Care and Development  Head Start Requirements 
r
 
so Program Claims Were Not Effective  Our review of Newark Preschool Council, Inc. (Newark), 
ef We conducted this review to determine whether Puerto  which operated throughout Newark, New Jersey, found 
n
c Ricos Department of the Familys controls for provider  that Newark did not always comply with Head Start 
iE and client eligibility determinations and for processing  program requirements.  As a result, Newark received 
v
  approximately $10 million in excess Head Start funds 
CCDF program claims were effective.  We found that all 
rd
during a 17-month period.  In addition, it did not 
of the provider eligibility controls we tested for provider 
en
monitor its partner agencies operations to ensure that 
background checks, required provider forms, and 
Sa
children at these facilities received Head Start services.
provider rate agreements were not effective.  Of the 
 
n client eligibility controls we tested, Puerto Ricos 
ACF generally concurred with our recommendations 
a controls for family income and need-for-service  that it ask Newark to refund $10 million to the Federal 
m eligibility were not effective.  Although Puerto Ricos  Government for unallowable costs applicable to under-
controls for verifying clients citizenship were effective, 
enrollment, general and administrative expenses, 
u Puerto Rico was not implementing Federal law 
unauthorized purposes, and salary payments; complete 
H regarding client eligibility.  Puerto Rico lacked sufficient 
the closeout process for Newarks Head Start grant; if 
written policies and procedures and sufficient staff to 
Newark is awarded a Head Start grant in the future, 
effectively oversee licensed providers, and it lacked 
ensure that Newark maintains its funded enrollment 
adequate procedures to monitor non-licensed providers 
level, properly monitor partner agencies, and follow its 
in relation to its CCDF Program.  
policies and procedures relating to salary payments and 
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  31 HUMAN   cash management for any future grant awards; and  years of probation and ordered to pay restitution of 
SERVICES   retain information related to Federal funds used to  $101,804 after pleading guilty to felony failure to pay 
acquire, construct, or renovate its grantees properties  legal child support. 
AGENCIES  
in accordance with departmental requirements.  
REVIEWS AND  
Newark, which did not provide comments to the report,  Engaging the Public in Capturing  
ENFORCEMENT 
has filed for bankruptcy.   Deadbeat Parents  
ACTIVITIES
A-02-14-02024    February 2017 Because of the success of OIGs Most Wanted Fugitives 
website, OIG launched its Most Wanted Deadbeat 
Parents website.  The site identifies parents who fail to 
Child Support Enforcement   pay court-ordered child support for their children and 
Administration for  
thereby put an unnecessary strain on the custodial 
Children and Families 
Activities
  parents and the children as well as on agencies that 
Child Support   enforce these matters.  The site, which is updated 
Enforcement Activities OIG Investigations   frequently, includes information on OIGs role in 
pursuing parents who fail to pay court-ordered child 
OIG investigates noncustodial parents who violate 18 
Centers for Medicare   support.  OIGs Most Wanted Deadbeat Parents website 
U.S.C.  228 by failing to pay court-ordered child 
& Medicaid Services   can be found at https://oig.hhs.gov/fraud/child-
  support.  OIG works with ACFs Office of Child Support  support-enforcement/index.asp.
Legal and   Enforcement; DOJ; U.S.  Attorneys Offices; the U.S.  
Investigative Activities  Marshals Service; and Federal, State, and local partners 
  to address egregious child support enforcement cases 
Public Health Agencies  with appropriate law enforcement and prosecutorial 
  action.  During this semiannual reporting period, OIG 
Human Services 
investigations of child support enforcement cases 
Agencies 
nationwide resulted in 13 criminal actions and court-
 
ordered restitution and settlements of $2 million.
Other HHS-Related 
Reviews and  
Investigations 
The following is an example of a child support 
 
Appendixes enforcement case:
South Dakota  In January 2001, Cory T.  Carter was 
ordered to pay $375 per month for the support of his 
two children.  Carter rarely made payments to the 
custodial parent of his children and had not made a 
payment in many months.  Carter was sentenced to 5 
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  32  
ds Grants and Contracts previously sentenced to a combined 17 years and 11 
en months in prison and ordered to pay $272,830 in 
to HHS is the largest grant-making organization and one of  restitution, joint and several.  
a the largest contracting agencies in the Federal 
i
lt Government.  In FY 2016, HHS awarded more than  Kentucky  Jerome Hahn was the owner, chief executive 
ea
$463.5 billion in grants and over $21.1 billion in  officer, and president of Telehealth Holdings, LLC.  Hahn, 
Rg
contracts across all program areas.  OIGs direct annual  on behalf of Telehealth, allegedly made false statements 
i
-t discretionary appropriation funding is used to conduct  and false certifications in applications submitted to NIH 
Ss program integrity and enforcement activities with  to obtain Small Business Innovation Research grants to 
He regard to the more than 100 public health and human  fund the development of various medical devices, 
Hv services programs carried out by more than 70,000  including a sleep apnea monitoring system and an 
n employees around the world.  The size and scope of  electronic pillbox.  The Government alleged that Hahn 
 
rI departmental awards make their operating effectiveness  created phony invoices that grossly overstated expenses 
 
ed crucial to the success of programs designed to improve  and manufactured products in China when all products 
hn the health and well-being of the public.  were supposed to be produced domestically.  As a result 
t of these false claims, NIH paid Federal grant funds to 
a
O Telehealth Holdings, LLC, for which the company was 
 
s Grant Fraud Investigations not entitled.  Hahn and Telehealth agreed to pay $1.9 
w million, joint and several, to resolve their liability under 
the False Claims Act.  
e The following are case examples related to misuse 
i of grant funds: 
v
e Alabama  Jonathan Dunning was the CEO of  Small Business Innovative Research Program 
R Birmingham Health Center, a federally funded health 
The National Defense Authorization Act for Fiscal Year 
care center.  The investigation disclosed that Dunning 
2012,  5143, requires OIG to annually report on the 
engaged in a fraudulent scheme in which approximately 
number of cases that were referred with relation to 
$17 million in Federal grant funds was embezzled from 
fraud, waste, or abuse in the Small Business Innovative 
HRSA.  The funds were meant to provide quality health 
Research/Small Business Technology Transfer (SBIR/
care for the homeless and low-income individuals in the 
STTR) program.  OIG must also report on the actions 
Birmingham, Alabama, area.  Instead, funds were 
taken in each case; justification for not taking action on 
diverted by fraud to the defendants multiple 
a case; and an accounting of funds used to address 
corporations for personal use.  Dunning was found guilty 
waste, fraud, and abuse in this program.  In our 
on 98 counts of conspiracy, wire fraud, bank fraud, and 
December 2016 report delivered to the three 
money laundering and was sentenced to 18 years in 
congressional oversight committees, we reported that 
prison and ordered to pay $13.5 million in restitution.  
OIG spent approximately $151,182 in salaries on 
Three defendants involved in the scheme were 
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  33 OTHER   oversight related to the SBIR/STTR program.  HHS  OIG Reviews of Non-Federal Audits 
HHS-RELATED  referred two new SBIR/STTR cases to OIG in FY 2016. 
OIG reviews audits conducted by non-Federal auditors 
REVIEWS AND  
of entities receiving Federal awards.  During this 
INVESTIGATIONS 
Recovery Act Retaliation Complaint Investigations semiannual period, OIGs National External Audit Review 
Center reviewed 740 reports covering $578 billion in 
The American Recovery and Reinvestment Act (Recovery  audited costs.  Federal dollars covered by these audits 
Other Reporting  Act),  1553, prohibits non-Federal employers that have  totaled $139.3 billion, of which about $84.8 billion were 
Requirements and  received Recovery Act funding from retaliating against  HHS funds.
Reviews  
employees who disclose evidence of mismanagement of 
 
Recovery Act funds or any violation of law related to  Office of Management and Budget (OMB) Circular A-133 
Implementation of 
Recovery Act funds.  OIGs are required to include in  and the more recent uniform guidance at 2 CFR  200, 
Health Insurance  
Marketplaces  their Semiannual Report to Congress the retaliation  Subpart F establishes audit requirements for State and 
  complaint investigations that they decided not to  local governments, colleges and universities, and 
Public Summary Reports conduct or continue during the reporting period.   nonprofit organizations receiving Federal awards.  Under 
During this reporting period, OIG did not close any  this circular and uniform guidance, covered entities 
investigations. must conduct annual organization-wide single audits 
Centers for Medicare  
of all Federal money they receive.  These audits are 
& Medicaid Services  
conducted by non-Federal auditors, such as public 
 
Contract Audits accounting firms and State auditors.  OIG reviews the 
Legal and  
Investigative Activities  quality of these audits and assesses the adequacy of the 
  Pursuant to the National Defense Authorization Act for  entities management of Federal funds.  
Public Health Agencies  FY 2008,  845, OIGs appointed under the Inspector 
  General Act of 1978 are required to submit, as part of  OIGs oversight of non-Federal audit activity informs 
Human Services  their Semiannual Report to Congress pursuant to  Federal managers about the soundness of management 
Agencies  section 5 of such Act, information on final completed  of Federal programs and identifies any significant areas 
  contract audit reports issued during the period to the  of internal control weakness, noncompliance, and 
Other HHS-Related 
contracting activity containing significant audit findings.   questioned costs for resolution or follow-up.  We 
Reviews and  
Investigations  OIG issued no final reports meeting  845 criteria during  identify entities for high-risk monitoring, alert program 
  this semiannual period.  officials to any trends that could indicate problems in 
Appendixes HHS programs, and profile non-Federal audit findings of 
a particular program or activity over time to identify 
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  34 OTHER   systemic problems.  We also provide training and  economy and efficiency or the prevention and detection 
HHS-RELATED  technical assistance to grantees and members of the  of fraud and abuse.  Most audits and other reviews that 
REVIEWS AND   auditing profession.  OIG maintains a process to assess  we conduct are designed to test compliance with and/or 
the quality of the non-Federal reports received and the  assess the administration and oversight of existing laws 
INVESTIGATIONS 
audit work that supports the selected reports.  and regulations.  Our reports of such reviews describe 
findings, which include questioned costs, inefficiencies, 
OIGs reports on non-Federal audits reviewed during this 
vulnerabilities to fraud, inconsistencies, errors in 
Other Reporting  reporting period are categorized in the following table.
application, or weaknesses in oversight or supporting 
Requirements and 
systems.  Our corresponding recommendations tell HHS 
Reviews  
  Non-Federal Audits, October 1, 2016,   and its operating or staff divisions what administrative, 
Implementation of  through March 31, 2017 regulatory, or legislative actions we believe are needed 
Health Insurance   to effectively respond to the findings.  Our regularly 
Marketplaces        Number of Non-Federal Audits  published core publications reflect the relationship 
  Not requiring changes or having minor changes  696 between our work and laws and regulations.
Public Summary Reports
  Requiring major changes  39
  Our Semiannual Report to Congress describes 
  Having significant technical inadequacies  5 findings and recommendations from recently 
Centers for Medicare  
& Medicaid Services     Total  740 completed reviews, many of which focus on 
  existing laws and regulations.  
Legal and   The 740 reports included 1,414 recommendations for 
  Our Compendium of Priority Recommendations 
Investigative Activities  improving management operations.  In addition, these 
describes priority findings and recommendations 
  audit reports provided information for 23 OIG special 
from past periods that remain to be implemented.  
Public Health Agencies  memorandums that identified concerns for increased 
  monitoring by management.   Our Work Plan provides citations to laws and 
Human Services  regulations that are the subject of ongoing or 
Agencies  future reviews.
 
Other Reporting  
Other HHS-Related  We also review proposed legislation and regulations 
Reviews and   related to HHS programs and operations.  HHS routinely 
Requirements and Reviews
Investigations  involves OIG and its operating and other staff divisions 
 
in the review and development of HHS regulations 
Appendixes Legislative and Regulatory Reviews
through a well-established HHS process.  Our audits, 
evaluations, and investigations are sometimes cited in 
Pursuant to the Inspector General Act,  4(a)(2), OIG is 
regulatory preambles as influencing HHS regulations.  In 
required to review existing and proposed legislation and 
addition, we provide independent, objective technical 
regulations relating to HHSs programs and operations 
assistance on a bipartisan, bicameral basis to 
and make recommendations concerning their impact on 
congressional committees and members who request it. 
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  35 OTHER   Implementation of Health   grant funds, Colorado did not expend $9.7 million of 
HHS-RELATED  Federal establishment grant funds in accordance with 
Insurance Marketplaces
REVIEWS AND   Federal requirements, and Kentucky misallocated $49.1 
million in establishment costs.
INVESTIGATIONS 
OIG continues to review programs implemented 
pursuant to the Patient Protection and Affordable Care  We found that New York did not have adequate internal 
Act (ACA).  OIGs ACA oversight strategy focuses on the  controls to ensure that it properly allocated costs, 
Other Reporting  health insurance marketplaces, reforms in the Medicare  Minnesota did not have adequate policies and 
Requirements and  and Medicaid programs, and public health programs.   procedures to follow Federal requirements, Colorado 
Reviews  
Key focus areas for our marketplace oversight include  lacked adequate stewardship of Federal funds, and 
 
payment accuracy, eligibility, management and  Kentucky used an incorrect cost-allocation methodology.
Implementation of 
administration, and security.  In developing our work 
Health Insurance  
New York disagreed with our recommendations to 
Marketplaces  plan, we coordinate with GAO and other Federal and 
refund $148.7 million to the Federal Government for 
  State oversight agencies. 
the misallocated funds and improve its allocation 
Public Summary Reports
procedures.  Minnesota generally disagreed with our 
State-Based Marketplaces recommendations to refund $1.3 million and improve 
Centers for Medicare  
its procedures.  Colorado disagreed with our 
& Medicaid Services  
New York Misallocated Costs to Establishment Grants for a  recommendation to refund $9.7 million but agreed with 
 
Legal and   Health Insurance Marketplace; The Minnesota Marketplace  our recommendation to improve its policies and 
procedures.  Kentucky disagreed with our 
Investigative Activities  Misallocated Federal Funds and Claimed Unallowable Costs; 
  recommendations to refund $49.1 million and agreed to 
Colorado Did Not Correctly Expend Establishment Grant Funds 
Public Health Agencies  improve its allocation procedures and develop a written 
for Establishing a Health Insurance Marketplace; and Kentucky 
  policy. 
Human Services  Misallocated Millions to Establishment Grants for a Health 
Agencies 
Insurance Marketplace 
  A-02-14-02017    November 2016
Other HHS-Related  We conducted these audits to determine whether the 
Reviews and   State agencies allocated costs to their establishment 
Investigations  A-05-14-00045    November 2016
grants for establishing a health insurance marketplace in 
 
accordance with Federal requirements.  We found that 
Appendixes
New York, Colorado, Kentucky, and Minnesota did not  A-07-14-02801    December 2016
always follow Federal requirements in implementing a 
health insurance marketplace.  New York misallocated 
A-04-14-07050    February 2017
$148.7 million in establishment costs, Minnesota 
misallocated or misspent $1.3 million in establishment 
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  36 OTHER   Federal Marketplace Information Security
HHS-RELATED 
Data Inadequacies Undermine CMSs Oversight of the  The University of California at Riversides Pilot Payroll 
REVIEWS AND  
INVESTIGATIONS  Inconsistency Resolution Process for the Federal Marketplace  Certification System Did Not Provide Accountability Over 
Ensuring that only eligible applicants can enroll in  Payroll Charges to Federal Awards
qualified health plans (QHPs) and insurance affordability 
We estimated that the University of California at 
programs depends on the integrity of the enrollment 
Other Reporting  Riverside (the University) put at risk $11.7 million in 
process.  A key part of that process involves resolving 
Requirements and  salaries and $5.9 million in associated facilities and 
Reviews   inconsistencies between self-attested information 
administrative costs claimed against NIH awards.  The 
  submitted by applicants and data received through 
Universitys prior effort-reporting system did not always 
Implementation of  Federal and other data sources.  We found that the 
provide the information needed to confirm that payroll 
Health Insurance  
Federal marketplace was unable to calculate the total 
costs had been appropriately allocated to Federal 
Marketplaces 
number of applicants with inconsistencies between 
awards, and its current payroll certification system pilot 
 
self-attested information submitted by applicants and 
Public Summary Reports (pilot PCS) provided less accountability over payroll 
data received through Federal or other data sources 
charges to Federal awards than its prior effort-reporting 
during the first open enrollment period.  Our findings 
system.  Effort reporting is a person-based methodology 
Centers for Medicare   demonstrate that CMS could not readily answer basic 
that allocates each employees reasonable estimate of 
& Medicaid Services  
questions about inconsistencies, and these data 
time worked on all awards and other activities.  
 
limitations preclude CMS from accurately counting and 
Legal and  
tracking inconsistencies by applicants seeking to enroll  Furthermore, the Universitys IT controls for systems 
Investigative Activities 
in a qualified health plan.   used to support the pilot PCS did not always ensure the 
 
  security of data used to support labor charges.  General 
Public Health Agencies 
CMS concurred with our recommendation to improve  IT control weaknesses included unrestricted remote 
 
Human Services  its management of the inconsistency resolution process  access, inadequate password settings, poor patch 
Agencies  to ensure that it can readily identify all applicants with  management, and expired vendor support.  
  inconsistencies.  CMS should refine its data 
Other HHS-Related  The University generally disagreed with our procedural 
management system so that it can track individuals and 
Reviews and   recommendations that it increase its accountability over 
readily count the number of each type of inconsistency 
Investigations 
payroll charges to Federal awards and that it strengthen 
  and whether those inconsistencies are unresolved, 
its general IT controls for systems it used to support the 
Appendixes resolved, or expired.
pilot PCS.
OEI-01-14-00620    March 2017
A-04-13-01026    February 2017
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  37 OTHER   Public Summary Reports findings that we identified related to security 
HHS-RELATED  management, configuration management, system 
REVIEWS AND   State agencies are required to establish appropriate  software controls, and website and database 
computer system security requirements and conduct  vulnerability scans.  However, it described corrective 
INVESTIGATIONS 
biennial reviews of computer system security used in  actions that it had taken or planned to take to remediate 
the administration of State plans for Medicaid and other  all the vulnerabilities.
 
Federal entitlement benefits (45 CFR  95.621).  OIG 
Other Reporting  A-06-15-00057    March 2017
conducts reviews of States computer systems used to 
Requirements and 
administer HHS-funded programs. 
Reviews  
   
Public Summary Report: Information Technology Control 
Implementation of 
Public Summary Report: New York Implemented Security 
Health Insurance   Weaknesses Found at the Commonwealth of Massachusetts 
Controls Over Its Health Insurance Exchange Website and 
Marketplaces 
Medicaid Management Information System 
  Database but Could Improve Security Controls 
The Massachusetts Medicaid program (MassHealth) did 
Public Summary Reports
The New York marketplace had implemented security 
not safeguard Medicaid Management Information 
controls, including policies and procedures, to protect 
System (MMIS) data and supporting systems in 
Centers for Medicare   personally identifiable information (PII) on its website 
accordance with Federal requirements.  Specifically, 
& Medicaid Services   and database.  However, it did not always comply with 
MassHealth had vulnerabilities related to security 
  Federal requirements.  As a result, the website had 
management, configuration management, system 
Legal and  
vulnerabilities that, if exploited, could have resulted in 
software controls, and website and database 
Investigative Activities 
the disclosure of participant PII.   
  vulnerability scans. 
Public Health Agencies    Although we did not identify evidence that the 
  Although we did not identify evidence that the  vulnerabilities that we identified in the New York 
Human Services  vulnerabilities had been exploited, exploitation could 
marketplaces website had been exploited, exploitation 
Agencies  result in unauthorized access to, and disclosure of, 
could have resulted in unauthorized access to and 
 
sensitive information, as well as disruption of operations 
Other HHS-Related  disclosure of PII, as well as disruption of critical 
critical to MassHealth.  As a result, the vulnerabilities 
Reviews and   marketplace operations.  As a result, the vulnerabilities 
Investigations  were collectively and, in some cases, individually  were collectively and, in some cases, individually 
  significant and could have compromised the 
significant and could have compromised the 
Appendixes confidentiality, integrity, and availability of MassHealths 
confidentiality, integrity, and availability of the 
MMIS.  These vulnerabilities existed because 
marketplace.  In addition, without proper safeguards, 
MassHealth did not implement sufficient controls over 
systems were not protected from those with malicious 
its Medicaid data and information systems.  
intent to obtain access to commit fraud, waste, or abuse 
 
or launch attacks against other computer systems and 
MassHealth did not indicate concurrence or non-
networks.
concurrence with our recommendations to address the 
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  38 OTHER   The New York marketplace did not indicate concurrence  Colorado concurred with our detailed recommendations 
HHS-RELATED  or non-concurrence with our recommendation that it  to address the vulnerabilities that we identified related 
REVIEWS AND   improve the protection of PII on its website. to its risk assessment policies and procedures, database 
  administration and security, website security, and USB 
INVESTIGATIONS 
A-02-15-03001    November 2016 port and device security for its Medicaid eligibility 
determination and claim processing information 
  systems. 
Other Reporting   
Requirements and  Public Summary Report: The State of Colorado Did Not Meet 
A-07-15-00463    October 2016
Reviews   Federal Information System Security Requirements for 
 
Safeguarding Its Medicaid Systems and Data 
Implementation of 
Health Insurance   Colorado had not implemented adequate information 
Marketplaces  system general controls over the Colorado Medicaid   
  eligibility determination and claims processing systems 
Public Summary Reports
to fully comply with Federal requirements.  The 
vulnerabilities that we identified increased the risk to 
Centers for Medicare   the confidentiality, integrity, and availability of 
& Medicaid Services   Colorados Medicaid data.  In evaluating Colorados risk 
  assessment, database security, website security, and 
Legal and  
universal serial bus (USB) device security for its 
Investigative Activities 
Medicaid eligibility determination and claim processing 
 
information systems, we identified vulnerabilities 
Public Health Agencies 
related to inadequate risk assessment policies and 
 
procedures, improper administration of the Medicaid 
Human Services 
Agencies  claims database, inadequate security of Medicaid 
  databases, inadequate website security, and improper 
Other HHS-Related  management of USB ports and devices. 
Reviews and  
 
Investigations 
 
Appendixes
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  39 s Appendix A
e
x
Questioned Costs and Funds Put to Better Use 
i
d
The following tables summarize OIGs monetary recommendations and HHS responses to them.  This information is 
n
provided in accordance with the Inspector General Act,  5(a)(8) and (a)(9) (5 U.S.C. App.  5(a)(8) and (a)(9)), and the 
e
Supplemental Appropriations and Rescissions Act of 1980.  
p
p Audit Reports With Questioned Costs
A Questioned costs are those questioned by OIG audits because of an alleged violation of a provision of a law, regulation, 
contract, grant, or other agreement governing the expenditure of funds.  Costs are questioned because the expenditure 
was not supported by adequate documentation or because the expenditure was unnecessary or unreasonable.  OIG 
includes those questioned costs that HHS program officials, in management decisions, have agreed should not be 
Appendix A 
charged to the Federal Government, commonly referred to as disallowed costs, as part of the expected recoveries in the 
Questioned Costs and 
Executive Summary section at the beginning of the Semiannual Report.  Superscripts indicate end notes that follow the 
Funds Put to Better Use 
tables below.
 
Appendix B 
Peer-Review Results  Table 1  Audit Reports with Questioned Costs
 
Reports Dollar Value Questioned Dollar Value Unsupported
Appendix C 
Summary of Sanction  Section 1
Authorities   Reports for which no management decisions had been  175 $438,171,000 $18,200,000
  made by the beginning of the reporting period1
Appendix D  Reports issued during the reporting period 54 $471,830,000 $50,000
Reporting  
Total Section 1 229 $910,001,000 $18,250,000
Requirements in the  
Inspector General Act  
of 1978   Section 2
  Reports for which management decisions were made during the reporting period2, 3
Appendix E  Disallowed costs 134 *$357,870,000 $0
Reporting   Costs not disallowed 3 $4,146,000  $55,000
Requirements in the  
Total Section 2 137 $362,016,000 $55,000
Inspector General  
*Audit receivables (expected recoveries).
Empowerment Act  
of 2016
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  40 APPENDIXES
Reports Dollar Value Questioned Dollar Value Unsupported
Section 3
Reports for which no management decisions had   92 $547,985,000 $18,195,000
been made by the end of the reporting period  
(Sec. 1 minus Sec. 2)
Section 4
Appendix A 
Reports for which no management decisions were   47 $174,772,000 $18,145,000
Appendix B  made within 6 months of issuance4
Appendix C 
Appendix D 
Audit Reports With Funds Recommended To Be Put to Better Use 
Appendix E
The phrase recommendations that funds be put to better use means that funds could be used more efficiently if 
management took action to implement an OIG recommendation through reductions in outlays, deobligation of funds, 
Centers for Medicare  
and/or avoidance of unnecessary expenditures.  Table 2 reports HHS program officials decisions to take action on these 
& Medicaid Services  
audit recommendations.
 
Legal and  
Investigative Activities  Table 2  Audit Reports with Funds To Be Put to Better Use
 
Public Health Agencies  Reports Dollar Values
 
Section 1
Human Services 
Agencies  Reports for which no management decisions had been   6 $15,051,289,000
  made by the beginning of the reporting period1
Other HHS-Related 
Reports issued during the reporting period 4 $366,487,000
Reviews and  
Investigations  Total Section 1 10 $15,417,776,000
 
Appendixes
Section 2
Reports for which management decisions were made during the reporting period
Value of recommendations agreed to by management
Based on proposed management action 1 $12,776,000
Based on proposed legislative action $0
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  41 APPENDIXES
Reports Dollar Values
Value of recommendations not agreed to by management 0 $0
Total Section 2 1 $12,776,000
Section 3
Reports for which no management decisions had been made  9
Appendix A  $15,405,000,000
by the end of the reporting period2 (Sec. 1 minus Sec. 2)
Appendix B 
Appendix C 
End Notes 
Appendix D 
Table 1 End Notes
Appendix E
1 T  he opening balance was adjusted upward by $75.4 million because of a reevaluation of previously issued 
recommendations.
Centers for Medicare  
& Medicaid Services  
2 R evisions to previously reported management decisions:
 
Legal and  
  A-01-11-02500 Review of Massachusetts Title IV-E Adoption Assistance Costs for Federal Fiscal Years 2006 thru 
Investigative Activities 
2008.  Subsequent review by ACF determined that additional costs totaling $1,695,066 was unallowable and issued 
 
a disallowance letter to recover cost.
Public Health Agencies 
    A-06-15-00014 Medicare Contractor Payments to Providers for Hospital Outpatient Dental Services in Jurisdiction H 
Human Services  Generally Did Not Comply With Medicare Requirements Subsequent review of claims by CMS determined that the 
Agencies  final amount of over payment for the questioned period was $10,582,929, resulting in additional overpayment 
 
totaling $8,815,823.
Other HHS-Related 
Reviews and     A--10-14-22271 State of Washington  
Investigations  In consideration of additional supporting documentation provided by the State of Washington, ACF reduced the 
 
disallowance in this finding by $17,950,349.
Appendixes
  A-06-12-00053 Texas Did Not Always Comply With Federal and State Requirements for Claims Submitted for the 
Nonemergency Medical Transportation Program. Based on revised appraisal of the statistical sample, it was 
determined that some claims were allowable.  Disallowed cost for $30,385,925 was reduced by $5,877,059.
  Not detailed are net reductions to previously disallowed management decisions totaling $3,609,297.
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  42 APPENDIXES 3 I ncluded are management decisions to disallow $85 million in questioned costs that were identified by non-Federal 
auditors in audits of State and local governments, colleges and universities, and nonprofit organizations receiving 
Federal awards conducted in accordance with OMB Circular A-133.  OIG is currently ensuring that work performed by 
these non-Federal auditors complies with Federal audit standards; accordingly, OIG tracks, resolves, and reports on 
recommendations in these audits.
4 B  ecause of administrative delays, some of which were beyond management control, resolution of the following 47 
audits were not completed within 6 months of issuance of the reports; however, agency management has informed us 
Appendix A  that the agency is working to resolve the outstanding recommendations before the end of the next semiannual 
reporting period: 
Appendix B 
CIN: A-01-02-00006  REVIEW OF RATE SETTING METHODOLOGY MEDICAID SCHOOL-BASED CHILD HEALTH    
Appendix C 
      PROGRAM COSTS CLAIMED BY THE CONNECTICUT DEPARTMENT OF SOCIAL SERVICES JULY  
Appendix D        1997 THROUGH JUNE 2001, MAY 2003, $32,780,146
Appendix E
CIN: A-01-14-02503  MARYLAND MISALLOCATED MILLIONS TO ESTABLISHMENT GRANTS FOR A HEALTH INSURANCE  
      MARKETPLACE, MAR 2015, $28,400,000
Centers for Medicare  
& Medicaid Services   CIN: A-07-13-01125  MEDICARE IMPROPERLY PAID MEDICARE ADVANTAGE ORGANIZATIONS MILLIONS OF DOLLARS  
        FOR UNLAWFULLY PRESENT BENEFICIARIES FOR 2010 THROUGH 2012, APR 2014, $26,150,043
Legal and  
CIN: A-02-12-02016  PUERTO RICO IMPROPERLY CLAIMED SOME CHILD CARE AND DEVELOPMENT TARGETED  
Investigative Activities 
        FUNDS, JAN 2016, $12,471,385
Public Health Agencies 
CIN: A-01-15-02500  VERMONT DID NOT PROPERLY ALLOCATE MILLIONS TO ESTABLISHMENT GRANTS FOR A  
 
      HEALTH INSURANCE MARKETPLACE, SEP 2016, $11,243,006
Human Services 
Agencies 
CIN: A-07-15-01159  MEDICARE IMPROPERLY PAID MILLIONS OF DOLLARS FOR UNLAWFULLY PRESENT  
 
Other HHS-Related        BENEFICIARIES FOR 2013 AND 2014, SEP 2016, $9,267,392
Reviews and  
Investigations  CIN: A-01-13-00518  MEDICARE COMPLIANCE REVIEW OF HOME HEALTH VNA FOR 2011 AND 2012, AUG 2016,  
        $6,348,971
Appendixes
CIN: A-03-12-00004  REVIEW OF HORIZONS 2009 AND 2010 BONA FIDE SERVICE FEES, MAR 2013, $4,344,417
CIN: A-02-12-02012  NEW YORK IMPROPERLY CLAIMED SOME CHILD CARE AND DEVELOPMENT TARGETED FUNDS,  
      JUL 2015, $3,827,836
 
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  43 APPENDIXES CIN: A-05-13-00014  OHIO EXCEEDED THE 5-PERCENT LIMIT FOR CLAIMING CHILD CARE DEVELOPMENT FUND  
      ADMINISTRATIVE EXPENDITURES, NOV 2013, $3,164,630
CIN: A-03-13-00024  REVIEW OF NEW ORLEANS REGIONAL PHYSICIAN HOSPITAL ORGANIZATION, INC.S 2009, 2010,  
      AND 2011 BONA FIDE SERVICE FEES, APR 2014, $2,880,698
CIN: A-03-13-00025  REVIEW OF UAB HEALTH SYSTEMS 2009, 2010, AND 2011 BONA FIDE SERVICE FEES, JAN 2014,  
      $2,812,109
Appendix A 
CIN: A-03-13-00026  REVIEW OF USABLE MUTUALS   (ARKANSAS BLUE CROSS BLUE SHIELD) 2009, 2010, AND 2011  
Appendix B        BONA FIDA SERVICE FEES, JAN 2014, $2,763,821
Appendix C  CIN: A-03-11-00002  REVIEW OF NEW ENGLAND JOINT ENTERPRISE 2009 DIR REPORTS, APR 2012, $2,710,732
Appendix D  CIN: A-03-12-00006  REVIEW OF TAHMOS 2009 AND 2010 BONA FIDE SERVICE FEES, MAR 2013, $2,355,532
Appendix E
CIN: A-03-13-00020  REVIEW OF CAPITAL DISTRICT PHYSICIANS HEALTH PLAN, INC.S 2009, 2010, AND 2011 BONA  
      FIDE SERVICE FEES, JAN 2014, $2,070,605
Centers for Medicare  
CIN: A-03-12-00007  REVIEW OF ARCADIANS 2009 AND 2010 BONA FIDE SERVICE FEES, FEB 2013, $2,048,967
& Medicaid Services  
 
CIN: A-03-12-00005  REVIEW OF WINDSORS 2009 AND 2010 BONA FIDE SERVICE FEES, JAN 2013, $1,948,737
Legal and  
Investigative Activities 
CIN: A-03-13-00018  REVIEW OF AMERIGROUP CORPORATIONS 2009, 2010, AND 2011 BONA FIDE SERVICE FEES,  
 
      JAN 2014, $1,943,251
Public Health Agencies 
  CIN: A-03-13-00019  REVIEW OF BLUECROSS BLUESHIELD OF SOUTH CAROLINAS 2009, 2010, AND 2011 BONA FIDE  
Human Services 
      SERVICE FEES, DEC 2013, $1,799,096
Agencies 
 
CIN: A-09-14-02041  MEDICARE IMPROPERLY PAID HOSPITALS FOR BENEFICIARIES WHO HAD NOT RECEIVED 96 OR  
Other HHS-Related 
      MORE CONSECUTIVE HOURS OF MECHANICAL VENTILATION, JUN 2016, $1,488,165
Reviews and  
Investigations 
CIN: A-07-11-06013  THE UNIVERSITY OF COLORADO DENVER DID NOT ALWAYS CLAIM SELECTED COSTS CHARGED  
 
      DIRECTLY TO DEPARTMENT OF HEALTH AND HUMAN SERVICES AWARDS IN ACCORDANCE WITH  
Appendixes
      FEDERAL REGULATIONS, JUN 2013, $1,419,524
CIN: A-03-12-00008  REVIEW OF XL HEALTH DIR, JAN 2013, $1,410,342
CIN: A-03-13-00021  REVIEW OF FALLON COMMUNITY HEALTH PLANS 2009, 2010, AND 2011 BONA FIDE SERVICE  
      FEES, JAN 2014, $1,079,578
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  44 APPENDIXES CIN: A-05-12-00089  THE COUNCIL ON RURAL SERVICE PROGRAMS, INC., CLAIMED UNALLOWABLE HEAD START  
      COSTS, NOV 2013, $1,074,352
CIN: A-03-13-00022  REVIEW OF MD CARE, INC.S 2009, 2010, AND 2011 BONA FIDE SERVICE FEES, JAN 2014,  
      $1,040,501
CIN: A-03-13-00023  REVIEW OF NATIONAL RURAL ELECTRIC COOPERATIVE ASSOCIATIONS 2009, 2010, AND 2011  
      BONA FIDE SERVICE FEES, JAN 2014, $957,921
Appendix A 
CIN: A-09-14-01007  NEVADA MISALLOCATED COSTS FOR ESTABLISHING A HEALTH INSURANCE MARKETPLACE TO ITS  
Appendix B        ESTABLISHMENT GRANTS, FEB 2016, $893,464
Appendix C  CIN: A-04-15-04040  MEDICAL ACCESS UGANDA LIMITED GENERALLY MANAGED THE PRESIDENTS EMERGENCY  
      PLAN FOR AIDS RELIEF FUNDS IN ACCORDANCE WITH AWARD REQUIREMENTS, JUN 2016,  
Appendix D 
      $751,399
Appendix E
CIN: A-09-11-01007  HAWAII CLAIMED UNALLOWABLE COMMUNITY SERVICES BLOCK GRANT COSTS FOR HONOLULU  
      COMMUNITY ACTION PROGRAM, INC.S EXPENDITURES UNDER THE RECOVERY ACT, FEB 2013,  
Centers for Medicare         $513,649
& Medicaid Services  
  CIN: A-04-13-01024  THE UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL DID NOT ALWAYS CLAIM SELECTED  
Legal and         COSTS CHARGED DIRECTLY TO DEPARTMENT OF HEALTH AND HUMAN SERVICES AWARDS IN  
Investigative Activities        ACCORDANCE WITH FEDERAL REQUIREMENTS, JUN 2014, $352,843
 
Public Health Agencies  CIN: A-01-10-02505  RESULTS OF LIMITED SCOPE REVIEW OF CTE, INC., MAY 2011, $293,870
 
CIN: A-02-11-02015  PUERTO RICO CLAIMED UNALLOWABLE COMMUNITY SERVICES BLOCK GRANT RECOVERY ACT  
Human Services 
Agencies        COSTS FOR INSTITUTO SOCIO-ECONOMICO, INC., APR 2013, $285,412
 
Other HHS-Related  CIN: A-02-11-02017  NEW JERSEY CLAIMED UNALLOWABLE COMMUNITY SERVICES BLOCK GRANT COSTS INCURRED  
Reviews and         BY CHECK-MATE INC., UNDER THE RECOVERY ACT, AUG 2014, $246,359
Investigations 
  CIN: A-09-09-00045  RISK ADJUSTMENT DATA VALIDATION OF PAYMENTS MADE TO PACIFICARE OF CALIFORNIA FOR  
Appendixes       CALENDAR YEAR 2007 (CONTRACT H0543), NOV 2012, $224,388
CIN: A-05-12-00012  ROCKFORD HUMAN SERVICES DID NOT ALWAYS CHARGE ALLOWABLE COSTS TO THE  
      COMMUNITY SERVICES BLOCK GRANT - RECOVERY ACT PROGRAM, JUL 2013, $205,296 
 
CIN: A-06-09-00012  RISK ADJUSTMENT DATA VALIDATION OF PAYMENTS MADE TO PACIFICARE OF TEXAS FOR  
      CALENDAR YEAR 2007 (CONTRACT NUMBER H4590), MAY 2012, $183,247
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  45 APPENDIXES CIN: A-04-11-01004  NORTHEAST FLORIDA COMMUNITY ACTION AGENCY, INC., DID NOT ALWAYS CHARGE  
      ALLOWABLE COSTS TO THE COMMUNITY SERVICES BLOCK GRANT - RECOVERY ACT PROGRAM,  
      SEP 2012, $165,795
CIN: A-04-11-01008  CENTRAL FLORIDA COMMUNITY ACTION AGENCY, INC., DID NOT ALWAYS CHARGE ALLOWABLE  
      COSTS TO THE COMMUNITY SERVICES BLOCK GRANT - RECOVERY ACT PROGRAM, APR 2013,  
      $160,404
CIN: A-05-14-00017  OHIO DID NOT ALWAYS MAKE CORRECT MEDICAID CLAIM ADJUSTMENTS, SEP 2016, $151,313
Appendix A 
Appendix B  CIN: A-07-11-02766  NOT ALL COMMUNITY SERVICES BLOCK GRANT COSTS CLAIMED ON BEHALF OF THE CARBON  
      COUNTY COMMUNITY ACTION COMMITTEE FOR THE PERIOD OCTOBER 1, 2008, THROUGH  
Appendix C 
      SEPTEMBER 30, 2010, WERE ALLOWABLE, AUG 2013, $143,588
Appendix D 
CIN: A-09-11-01013  OREGON CLAIMED SOME POTENTIALLY UNALLOWABLE COMMUNITY SERVICES BLOCK GRANT  
Appendix E       COSTS FOR MULTNOMAH COUNTYS EXPENDITURES UNDER THE RECOVERY ACT, APR 2013,  
      $115,911
Centers for Medicare  
CIN: A-06-11-00058  CROWLEYS RIDGE DEVELOPMENT COUNCIL, INC., CLAIMED UNALLOWABLE COSTS UNDER A  
& Medicaid Services  
      RECOVERY ACT GRANT, AUG 2012, $115,420
 
Legal and   CIN: A-07-12-02779  NOT ALL COMMUNITY SERVICES BLOCK GRANT RECOVERY ACT COSTS CLAIMED ON BEHALF OF  
Investigative Activities 
      THE COMMUNITY ACTION PARTNERSHIP OF NATRONA COUNTY FOR THE PERIOD JULY 1, 2009,  
 
      THROUGH SEPTEMBER 30, 2010, WERE ALLOWABLE, JUN 2013, $104,971
Public Health Agencies 
  CIN: A-02-11-02000  REVIEW OF SELECT EXPENDITURES CLAIMED BY THE RESEARCH FOUNDATION OF THE STATE  
Human Services        UNIVERSITY OF NEW YORK, STATE UNIVERSITY OF NEW YORK AT ALBANY, OCT 2011, $27,384
Agencies 
  CIN: A-09-11-01014  HAWAII CLAIMED UNALLOWABLE COMMUNITY SERVICES BLOCK GRANT COSTS FOR HAWAII  
Other HHS-Related 
      COUNTY ECONOMIC OPPORTUNITY COUNCILS EXPENDITURES UNDER THE RECOVERY ACT, JUL  
Reviews and  
      2012, $22,602
Investigations 
 
CIN: A-05-11-00053  THE COLUMBUS URBAN LEAGUE CLAIMED SOME UNALLOWABLE COSTS TO HEAD START,  
Appendixes
      SEP 2012, $13,102
  TOTAL CINS:    47
       TOTAL AMOUNT:   $174,772,000
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  46 Table 2 End Notes
APPENDIXES
1 The opening balance had no prior period adjustments of previously issued recommendations. 
2 B  ecause of administrative delays, some of which were beyond management control, 6 of the 9 audits open at end of the 
period were not resolved within 6 months of issuance of reports.  OIG is working with management to reach resolution 
on these recommendations before the end of the next semiannual reporting period:
CIN: A-05-12-00020  MEDICARE AND BENEFICIARIES COULD SAVE BILLIONS IF CMS REDUCES HOSPITAL OUTPATIENT  
Appendix A        DEPARTMENT PAYMENT RATES FOR AMBULATORY SURGICAL CENTER-APPROVED PROCEDURES  
      TO AMBULATORY SURGICAL CENTER PAYMENT RATES, APR 2014, $15,000,000,000
Appendix B 
CIN: A-09-14-02041  MEDICARE IMPROPERLY PAID HOSPITALS FOR BENEFICIARIES WHO HAD NOT RECEIVED 96 OR  
Appendix C 
      MORE CONSECUTIVE HOURS OF MECHANICAL VENTILATION, JUN 2016, $19,562,498
Appendix D 
CIN: A-07-13-02795  PALMETTO GOVERNMENT BENEFITS ADMINISTRATOR DID NOT ALWAYS REFER MEDICARE COST  
Appendix E       REPORTS AND RECONCILE OUTLIER PAYMENTS IN JURISDICTION 1, JUL 2015, $15,792,301
CIN: A-09-14-02037  MEDICARE DID NOT PAY SELECTED INPATIENT CLAIMS FOR BONE MARROW AND STEM CELL  
Centers for Medicare  
      TRANSPLANT PROCEDURES IN ACCORDANCE WITH MEDICARE REQUIREMENTS, FEB 2016,  
& Medicaid Services  
      $2,054,306
 
Legal and  
CIN: A-04-14-04028  NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES DID NOT ALWAYS CLAIM  
Investigative Activities 
      COSTS UNDER CDC PREVENTION AND PUBLIC HEALTH FUND AWARDS IN ACCORDANCE WITH  
 
      FEDERAL REQUIREMENTS, JAN 2016, $493,401
Public Health Agencies 
 
CIN: A-03-14-00406  WEST VIRGINIA MADE INCORRECT MEDICAID ELECTRONIC HEALTH RECORD INCENTIVE  
Human Services 
      PAYMENTS TO HOSPITALS, AUG 2016, $208,117
Agencies 
 
Other HHS-Related 
Reviews and  
  TOTAL CINs:  6
Investigations 
 
      TOTAL AMOUNT:  $15,038,111,000
Appendixes
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  47 APPENDIXES Appendix B 
Peer-Review Results
The Inspector General Act of 1978, as amended, requires OIGs to report the results of peer reviews of their operations 
conducted by other OIGs, the date of the last peer review, outstanding recommendations from peer reviews, and peer 
reviews conducted by the OIG of other OIGs in the semiannual period.  Peer reviews are conducted by member 
Appendix A 
organizations of the Council of the Inspectors General on Integrity and Efficiency (CIGIE).  Recently CIGIE approved a new 
Appendix B  peer-review process for Inspection and Evaluation units within OIGs across the Federal Government, including at HHS OIG, 
the implementation of which will begin in 2018.
Appendix C 
Appendix D 
Office of Audit Services
Appendix E During this semiannual reporting period, no peer reviews involving the Office of Audit Services (OAS) were completed.  
Listed below is information concerning OASs peer-review activities during prior reporting periods.
Centers for Medicare  
& Medicaid Services   Date Reviewing Office Office Reviewed
  OAS
May 2015 Department of Transportation HHS OIG, OAS
Legal and  
Investigative Activities 
The system of quality control for the audit organization of HHS OIG in effect for the year ending September 30, 2014, has 
 
been suitably designed and complied with to provide HHS OIG with reasonable assurance of performing and reporting in 
Public Health Agencies 
conformity with applicable professional standards in all material respects.  Federal audit organizations can receive a rating 
 
Human Services  of pass, pass with deficiencies, or fail.  HHS OIG received a peer-review rating of pass.
Agencies 
 
Other HHS-Related  Date Reviewing Office Office Reviewed
Reviews and   OAS
December 2015 HHS OIG, OAS U.S. Department of Agriculture 
Investigations 
(USDA)
 
Appendixes
The system of quality control for the audit organization of USDA OIG in effect for the year ending March 31, 2015, has 
been suitably designed and complied with to provide USDA OIG with reasonable assurance of performing and reporting 
in conformity with applicable professional standards in all material respects.  Federal audit organizations can receive a 
rating of pass, pass with deficiencies, or fail.  USDA OIG received a peer-review rating of pass.
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  48 APPENDIXES Office of Investigations
During this semiannual reporting period, no peer reviews involving Office of Investigations (OI) were completed.  Listed 
below is information concerning OIs peer-review activities during prior reporting periods.
Date Reviewing Office Office Reviewed
OI
August 2015 DOL-OIG HHS OIG, OI
Appendix A  The system of internal safeguards and management procedures for the investigative function of HHS OIG in effect for the 
year ending September 30, 2015, were in full compliance with the quality standards established by CIGIE and the 
Appendix B 
Attorney Generals guidelines.
Appendix C 
Appendix D  Date Reviewing Office Office Reviewed
OI
Appendix E June 2014 HHS OIG, OI TIGTA
Centers for Medicare   The system of internal safeguards and management procedures for the investigative function of TIGTA, in effect through 
& Medicaid Services   June 2014, were in full compliance with the quality standards established by CIGIE and the Attorney Generals guidelines.
 
Legal and  
Investigative Activities 
 
Public Health Agencies 
 
Human Services 
Agencies 
 
Other HHS-Related 
Reviews and  
Investigations 
 
Appendixes
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  49 APPENDIXES Appendix C
Summary of Sanction Authorities
The Inspector General Act of 1978, as amended, specifies requirements for semiannual reports to be made to the 
Secretary for transmittal to Congress.  A list of authorities provided under other statutes appears below.
Appendix A 
Program Exclusions
Appendix B 
The Social Security Act,  1128 (42 U.S.C.  1320a-7), provides several grounds for excluding individuals and entities from 
Appendix C  participation in Medicare, Medicaid, and other Federal health care programs.  Exclusions are required for individuals and 
entities convicted of the following types of criminal offenses:  (1) Medicare or Medicaid fraud; (2) patient abuse or 
Appendix D 
neglect; (3) felonies for other health care fraud; and (4) felonies for illegal manufacture, distribution, prescription, or 
Appendix E dispensing of controlled substances.  
OIG is authorized to exclude individuals and entities on several other grounds, including misdemeanors for other health 
Centers for Medicare  
care fraud (other than Medicare or Medicaid) or for illegal manufacture, distribution, prescription, or dispensing of 
& Medicaid Services  
controlled substances; suspension or revocation of a license to provide health care for reasons bearing on professional 
 
competence, professional performance, or financial integrity; provision of unnecessary or substandard services; 
Legal and  
Investigative Activities  submission of false or fraudulent claims to a Federal health care program; or engaging in unlawful kickback arrangements.
 
The ACA added another basis for imposing a permissive exclusion, that is, knowingly making, or causing to be made, any 
Public Health Agencies 
false statements or omissions in any application, bid, or contract to participate as a provider in a Federal health care 
 
Human Services  program, including managed care programs under Medicare and Medicaid, as well as Medicares prescription drug 
Agencies  program.
 
Other HHS-Related  Providers subject to exclusion are granted due process rights.  These include a hearing before an administrative law judge 
Reviews and   and appeals to the HHS Departmental Appeals Board and Federal district and appellate courts regarding the basis for and 
Investigations 
the length of the exclusion.
 
Appendixes
Civil Monetary Penalties Law
The CMPL of the Social Security Act, 1128A (42 U.S.C.  1320a 7a), imposes penalties, assessments, and exclusion from 
participation in Federal health care programs for engaging in certain activities.  For example, a person who submits, or 
causes to be submitted, to a Federal health care program a claim for items and services that the person knows, or should 
know, is false or fraudulent is subject to a penalty of up to $15,270 for each item or service falsely or fraudulently 
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  50 APPENDIXES claimed, an assessment of up to three times the amount falsely or fraudulently claimed, and exclusion.
For the purposes of the CMPL, should know is defined to mean that the person acted in reckless disregard or 
deliberate ignorance of the truth or falsity of the claim.  The law and its implementing regulations also authorize actions 
for a variety of other violations, including submission of claims for items or services furnished by an excluded person; 
requests for payment in violation of an assignment agreement; violations of rules regarding the possession, use, and 
transfer of biological agents and toxins; and payment or receipt of remuneration in violation of the anti-kickback statute 
(42 U.S.C.  1320a 7b(b)).  
Appendix A 
The ACA added more grounds for imposing CMPs.  These include, among other types of conduct, knowingly making, or 
Appendix B 
causing to be made, any false statements or omissions in any application, bid, or contract to participate as a provider in a 
Federal health care program (including Medicare and Medicaid managed care programs and Medicare Part D); the ACA 
Appendix C 
authorizes a penalty of up to $55,262 for each false statement, as well as activities relating to fraudulent marketing by 
Appendix D 
MCOs, their employees, or their agents.  
Appendix E
The 21st Century Cures Act (enacted on December 13, 2016) added more grounds for imposing CMPs, assessments, and 
exclusion from Federal health care programs for fraudulent conduct in an HHS grant, contract, or other agreement.  OIG 
Centers for Medicare   may assess CMPs of up to $10,000 per claim and assessments of up to 3 times the amount claimed for knowingly 
& Medicaid Services   presenting a false or fraudulent claim.  In addition, OIG may impose a penalty of up to $50,000 and assessments of up to 
 
3 times the amount of funds at issue (1) for each instance of knowingly making a false statement in a document required 
Legal and  
to be submitted in order to receive funds under an HHS contract, grant, or other agreement; (2) for knowingly making or 
Investigative Activities 
using a false record or statement that is material to a false or fraudulent claim; and (3) for knowingly making or using a 
 
false record or statement material to an obligation to pay or transmit funds or property owed to HHS.  OIG may impose a 
Public Health Agencies 
penalty of up to $10,000 per day and assessments of up to 3 times the amount at issue for knowingly concealing, or 
 
knowingly and improperly avoiding or decreasing, an obligation owed to HHS with respect to an HHS grant, contract, or 
Human Services 
Agencies  other agreement.  Finally, HS OIG may impose a penalty of up to $15,000 per day for failing to grant timely access to OIG 
  upon reasonable request for audits or to carry out other statutory functions in matters involving an HHS grant, contract, 
Other HHS-Related 
or other agreement. 
Reviews and  
Investigations 
  Patient Dumping
Appendixes
The Social Security Act, 1867 (42 U.S.C.  1395dd), provides that when an individual goes to the emergency room of a 
Medicare-participating hospital, the hospital must provide an appropriate medical screening examination to determine 
whether that individual has an emergency medical condition.  If an individual has such a condition, the hospital must 
provide either treatment to stabilize the condition or an appropriate transfer to another medical facility. 
If a transfer is ordered, the transferring hospital must provide stabilizing treatment to minimize the risks of transfer and 
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  51 APPENDIXES must ensure that the receiving hospital agrees to the transfer and has available space and qualified personnel to treat the 
individual.  In addition, the transferring hospital must effect the transfer through qualified personnel and transportation 
equipment.  Further, a participating hospital with specialized capabilities or facilities may not refuse to accept an 
appropriate transfer of an individual who needs services if the hospital has the capacity to treat the individual.  
OIG is authorized to collect CMPs of up to $52,414 against small hospitals (fewer than 100 beds) and up to $104,826 
against larger hospitals (100 beds or more) for each instance in which the hospital negligently violated any of the 
section 1867 requirements.  In addition, OIG may collect a penalty of up to $104,826 from a responsible physician for 
Appendix A  each negligent violation of any of the section 1867 requirements and, in some circumstances, may exclude a 
responsible physician.
Appendix B 
Appendix C 
Anti-Kickback Statute and Civil False Claims Act Enforcement Authorities
Appendix D 
The Anti-Kickback Statute  The anti-kickback statute authorizes penalties against anyone who knowingly and willfully 
solicits, receives, offers, or pays remuneration, in cash or in kind, to induce or in return for (1) referring an individual to a 
Appendix E
person or an entity for the furnishing, or arranging for the furnishing, of any item or service payable under the Federal 
health care programs or (2) purchasing, leasing, or ordering, or arranging for or recommending the purchasing, leasing, 
Centers for Medicare  
or ordering, of any good, facility, service, or item payable under the Federal health care programs.  Social Security Act,  
& Medicaid Services  
1128B(b) (42 U.S.C.  1320a-7b(b)).
 
Legal and  
Individuals and entities that engage in unlawful referral or kickback schemes may be subject to criminal penalties under 
Investigative Activities 
the general criminal anti-kickback statute; a CMP under OIGs authority pursuant to the Social Security Act,  1127(a)(7) 
 
(42 U.S.C.  1320a-7a); and/or program exclusion under OIGs permissive exclusion authority under the Social Security 
Public Health Agencies 
Act,  1128(b)(7) (42 U.S.C.  1320a-7(b)(7)).
 
Human Services 
The False Claims Act  Under the False Claims Act (FCA), as amended by the False Claims Amendments Act of 1986 (FCA) 
Agencies 
  (31 U.S.C.  37293733), a person or an entity is liable for up to treble damages and a penalty between $10,957 and 
Other HHS-Related  $21,916 for each false claim it knowingly submits, or causes to be submitted, to a Federal program.  Similarly, a person or 
Reviews and   an entity is liable under the FCA if it knowingly makes or uses, or causes to be made or used, a false record or statement 
Investigations 
to have a false claim paid.  The FCA defines knowing to include not only the traditional definition but also instances in 
 
which the person acted in deliberate ignorance or reckless disregard of the truth or falsity of the information.  Under the 
Appendixes
FCA, no specific intent to defraud is required.  Further, the FCA contains a qui tam, or whistle blower, provision that allows 
a private individual to file a lawsuit on behalf of the United States and entitles that whistle blower to a percentage of any 
fraud recoveries.  The FCA was again amended in 2009 in response to recent Federal court decisions that narrowed the 
laws applicability.  Among other things, these amendments clarify the reach of the FCA to false claims submitted to 
contractors or grantees of the Federal Government.
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  52 APPENDIXES Appendix D 
Reporting Requirements in the Inspector General Act of 1978  
The reporting requirements of the Inspector General Act of 1978, as amended, are listed in the following table along with 
the location of the required information.
Appendix A 
Section Requirement Location
Appendix B 
Section 4
Appendix C 
(a)(2) Review of legislation and regulations Other HHS-Related Reviews and Investigations 
section  
Appendix D 
Appendix E
Section 5
(a)(1) Significant problems, abuses, and deficiencies Throughout this report
Centers for Medicare  
(a)(2) Recommendations with respect to significant problems, abuses, and  Throughout this report
& Medicaid Services  
deficiencies
 
(a)(3) Prior significant recommendations on which corrective action has not  OIG Compendium of Unimplemented 
Legal and  
been completed Recommendations
Investigative Activities 
  (a)(4) Matters referred to prosecutive authorities Legal and Investigative Activities section
Public Health Agencies  (a)(5) Summary of instances in which information requested by OIG was  None for this reporting period
  refused
Human Services  (a)(6) List of audit reports Submitted to the Secretary under separate cover
Agencies 
(a)(7) Summary of significant reports Throughout this report
 
Other HHS-Related  (a)(8) Statistical Table 1  Reports With Questioned Costs Appendix A
Reviews and  
(a)(9) Statistical Table 2  Funds Recommended To Be Put to Better Use Appendix A
Investigations 
(a)(10) Summary of previous audit reports without management decisions, in  Appendix A
 
which no establishment comment was returned within 60 days, and in 
Appendixes
which there are any outstanding unimplemented recommendations
(a)(11) Description and explanation of revised management decisions Appendix A
(a)(12) Management decisions with which the Inspector General disagrees None for this reporting period
(a)(13) Information required by the FISMA Reported annually in the spring Semiannual Report 
to Congress, Other HHS-Related Reviews and 
Investigations section
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  53 APPENDIXES
Section Requirement Location
(a) Results of peer reviews of HHS OIG conducted by other OIGs or the  Appendix B
(14)-(16) date of the last peer review, outstanding recommendations from peer 
reviews, and peer reviews conducted by HHS OIG of other OIGs
(a)(17) Investigative statistical tables Appendix E
(a)(18) Metrics description for statistical tables Appendix E
(a)(19) Investigations on Senior Government Employees Appendix E
Appendix A 
(a)(20) Description of whistle blower retaliation instances Appendix E
Appendix B 
(a)(21) Description of attempts to interfere with OIG independence Appendix E
Appendix C  (a)(22) Description of closed and non-disclosed reports and investigations  Appendix E
regarding Senior Government Employees
Appendix D 
Other reporting requirements
Appendix E 845 Significant contract audits required to be reported pursuant to the  "Other HHS-Related Reviews and Investigations 
National Defense Authorization Act for FY 2008 (P.L.  No.  110-181),   section
845.
Centers for Medicare  
205 Pursuant to HIPAA (P.L.  No.  104-191),  205, the Inspector General is  Reported annually in the fall Semiannual Report,  
& Medicaid Services  
required to solicit proposals annually via a Federal Register notice for  Appendix F 
 
developing new and modifying existing safe harbors to the anti-
Legal and  
kickback statute of the Social Security Act,  1128(b) and for 
Investigative Activities  developing special fraud alerts.  The Inspector General is also required 
  to report annually to Congress on the status of the proposals received 
Public Health Agencies  related to new or modified safe harbors.
  1553 Pursuant to the American Recovery and Reinvestment Act of 2009,   "Other HHS-Related Issues" section
Human Services  1553, OIG reports to Congress the retaliation complaint investigations 
Agencies  it decided not to conduct or continue during the period.
 
Other HHS-Related 
Reviews and  
Investigations 
 
Appendixes
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  54 APPENDIXES Appendix E 
Reporting Requirements in the Inspector General Empowerment Act of 2016
The Inspector General Empowerment Act of 2016 (IGEA) establishes new reporting requirements for the Semiannual 
Reports to Congress.  These requirements amend portions of  5 of the IG Act.  The requirements are below in italics, 
followed by OIGs responses. 
Appendix A 
Each Inspector General shall, not later than April 30 and October 31 of each year, prepare semiannual reports 
Appendix B 
summarizing the activities of the Office during the immediately preceding six-month periods ending March 31 and 
Appendix C  September 30.  Such reports shall include, but need not be limited to-
Appendix D 
  (10) a summary of each audit report, inspection reports, and evaluation reports issued before the  
Appendix E   commencement of the reporting period- 
    (a) for which no management decision has been made by the end of the reporting period (including the  
    date and title of each such report), an explanation of the reasons such management decision has not  
Centers for Medicare  
    been made, and a statement concerning the desired timetable for achieving a management decision on  
& Medicaid Services  
    each such report;
 
Legal and  
For audit, inspection, and evaluation reports issued before the commencement of the reporting period, OIG had 204 
Investigative Activities 
reports for which no management decision has been made.*
 
Public Health Agencies 
*This includes information compiled from OIGs Office of Audit Services (OAS) and Office of Evaluation and Inspections 
 
(OEI) databases.  The OAS database began tracking management decisions in FY 1990.  The OEI database began tracking 
Human Services 
management decisions in FY 2011.  These 204 reports reflect situations in which the agency failed to provide a 
Agencies 
  management decision for at least one of the recommendations we made in a given report.  Due to the volume of reports 
Other HHS-Related  with recommendations for which no management decision has been made, OIG is working to reconfigure its databases 
Reviews and   to provide information in this section in a table format, similar to 10c, in future Semiannual Reports.
Investigations 
      (b) for which no establishment comment was returned within 60 days of providing the report to the  
Appendixes
    establishment; and
Currently, OIG tracks this measure on a 30-day time frame.  In connection with draft reports that include 
recommendations, OIG typically requests establishment comments within 30 days.  In some instances, OIG grants 
extensions when requested and appropriate.  When OIG does not receive establishment comments or a request for 
extension within the 30-day time frame, OIG issues the report and typically notes the lack of establishment comments. 
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  55 APPENDIXES For the period October 1, 2016, through March 31, 2017, we received establishment comments during our 30-day time 
frame for all OIG reports.  We are exploring ways to modify our reporting inputs to capture this new 60-day requirement.  
    (c) for which there are any outstanding unimplemented recommendations, including the aggregate  
    potential cost savings of those recommendations.
OIG is actively tracking 1,223 unimplemented or open recommendations made in reports issued since FY 2011.  Given 
the volume of recommendations OIG makes on an annual basis, the table below reflects only the data that are 
Appendix A  immediately accessible within OIGs automated tracking system:
Appendix B  Number of Reports 
Number of Unimplemented  Dollar Value of Aggregate 
Fiscal Year (2011-2017) with Unimplemented 
Appendix C  Recommendations Potential Cost Savings
Recommendations
Appendix D 
2011 28 66 $475,140,370
Appendix E 2012 46 78 $416,404,187
2013 59 139 $1,004,149,575
Centers for Medicare   2014 67 140 $15,288,185,803
& Medicaid Services  
2015 64 155 $640,366,375
 
Legal and   2016 134 383 $516,922,675
Investigative Activities  2017 (partial year) 73 262 $831,782,190
 
Totals 471 1,223 $19,172,951,175
Public Health Agencies 
   
Human Services  OIG annually produces a Compendium of Unimplemented Recommendations (Compendium), which constitutes OIGs 
Agencies 
response to a specific requirement of the IG Act, as amended ( 5(a)(3)).  It identifies significant recommendations with 
 
respect to problems, abuses, or deficiencies for which corrective actions have not been completed.  The Compendiums 
Other HHS-Related 
Reviews and   Appendix includes a list of OIGs significant unimplemented recommendations.  These recommendations represent 
Investigations  opportunities to achieve expected impact through cost savings, improvements in program effectiveness and efficiency, 
  and increasing quality of care and safety of beneficiaries.  In OIGs view, these recommendations would most positively 
Appendixes
impact HHS programs in terms of cost savings and/or quality improvements and should therefore be prioritized for 
implementation.
  (17) statistical tables showing-
    (A) the total number of investigative reports issued during the reporting period;
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  56 APPENDIXES     (B) the total number of persons referred to the Department of Justice for criminal prosecution during  
    the reporting period;
    (C) the total number of persons referred to State and local prosecuting authorities for criminal  
    prosecution during the reporting period; and
    (D) the total number of indictments and criminal informations during the reporting period that resulted  
    from any prior referral to prosecuting authorities;
Appendix A 
Total number of investigative reports issued during the reporting period 1
Appendix B 
Total number of persons referred to DOJ/State and local prosecuting authorities for criminal prosecution during the  1,086
Appendix C  reporting period2
Total number of indictments and criminal informations during the reporting period that resulted from any prior  327
Appendix D 
referral to prosecuting authorities
Appendix E
  (18) a description of the metrics used for developing the data for the statistical tables under paragraph (17);
Centers for Medicare  
& Medicaid Services   Regarding (17)(A), OIG considers Investigative Reports as Management Implication Reports (MIR) and Investigative 
  Advisories.  A MIR is a document that identifies systemic weaknesses or vulnerabilities within HHS programs, which are 
Legal and   generally identified during the course of an OIG investigation and could lead to fraud, waste, or abuse.  It provides 
Investigative Activities 
recommendations to correct or minimize the problem.  Corrective actions may require administrative, procedural, policy, 
 
regulatory, or legislative change.  When a MIR is issued to an HHS Operating or Staff division, it is generally signed by the 
Public Health Agencies 
Inspector General.  Investigative Advisories are similar documents, emphasizing an identified HHS issue, which are 
 
generally signed by the Deputy Inspector General for Investigations. 
Human Services 
 
Agencies 
  Regarding (17)(B) and (C), OIG is reporting on referrals to both Federal and State/local prosecuting jurisdictions.  When 
Other HHS-Related  OIG opens an investigation, it evaluates the complaint and makes a decision whether to refer the matter for prosecution.  
Reviews and  
Generally, if the case has prosecutorial merit, and is accepted for Federal prosecution, OIG works with DOJ as the primary 
Investigations 
investigative agency.  In addition to DOJ, OIG works with State and local prosecutorial authorities.
 
Appendixes
Presently, OIGs case management system does not have the capability to distinguish between a Federal and State 
referral.  Consequently, the information provided in the table represents combined totals of Federal and State/local 
referrals.  OIG is currently addressing these database programming challenges.
Regarding (17)(D), the table provides the number of indictments/criminal informations during the semiannual reporting 
2OIG counts persons as both individuals and entities.  
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  57 APPENDIXES period, including sealed indictments/criminal informations.3   However, the information cannot be limited to only those 
that occurred as a result of a referral in a previous period.  In certain situations, the referral and charging dates are in the 
same reporting period.  OIGs case management system is currently unable to separate Federal from State/local 
indictments/criminal informations.  
  (19) a report on each investigation conducted by the Office involving a senior Government employee where  
  allegations of misconduct were substantiated, including a detailed description of-
Appendix A      (A) the facts and circumstances of the investigation; and
Appendix B      (B) the status and disposition of the matter, including-
Appendix C        (i) if the matter was referred to the Department of Justice, the date of the referral; and
Appendix D 
      (ii) if the Department of Justice declined the referral, the date of the declination;
Appendix E
To respond fully to this subparagraph, OIG would need to make a finding of misconduct.  However, OIG does not make 
findings with regard to its investigations relating to substantiated allegations of Departmental employee misconduct.  Our 
Centers for Medicare   reports relay the facts obtained during the investigations (e.g., parties involved, dates of events) related to any 
& Medicaid Services  
substantiated allegations.  At the conclusion of an OIG investigation related to substantiated allegations concerning 
 
possible employee misconduct, OIG provides a report to management in the employing agency.  The agency 
Legal and  
management makes determinations of employee misconduct.  The disposition of the matter and any resulting 
Investigative Activities 
administrative actions are taken by the agency.  
 
Public Health Agencies 
However, we request from the agency a copy of an SF-50 documenting a personnel action, if one is taken.  To the extent 
 
that we have information regarding subsequent administrative action, OIG is able to provide that information. However, 
Human Services 
after taking an administrative action as a result of an OIG investigation, the Department may enter into a settlement 
Agencies 
  agreement with the employee in order to resolve any potential litigation risk as a result of the administrative action.  Such 
Other HHS-Related  agreements sometimes change the nature of the administrative action (e.g., a termination might be replaced by a 
Reviews and   voluntary resignation). If this were to happen, OIG may not have a complete record of the disposition of the investigation.  
Investigations 
Accordingly, such information might be more efficiently and effectively provided directly from the employing agency.  
 
Appendixes
For this section, OIG describes investigations during this reporting period, both criminal and administrative, involving 
senior Government employees where allegations of misconduct were substantiated.  The descriptions below include a 
level of detail appropriate for each investigation, depending on whether the case details were available in public 
documents.  During this reporting period, OIG investigated five senior Government employees for misconduct, and OIG 
determined the allegations to be substantiated, but no prosecution resulted.  Descriptions of the investigations follow: 
 
3An information is a formal criminal charge that begins a criminal proceeding in the courts.
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  58 APPENDIXES
DOJ 
DOJ  DOJ 
Description of Investigation Status Disposition Referral 
Referral Declination
Date
A senior Government employee was 
Admonishment/
alleged to have improperly shared 
Closed Reminder of Policy  No N/A No
information regarding an HHS Quality 
(Oral/Written)
Data Online Program.   
Appendix A  A senior Government employee was 
alleged to have been involved in a policy  Admonishment/
Appendix B  violation involving the use of an HHS  Closed Reminder of Policy  No N/A No
purchase card while purchasing official/ (Oral/Written)
Appendix C  approved property for Government use.
HHS employees, including a senior HHS 
Appendix D 
official, inappropriately participated in a  Agency Policy Change 
Closed No N/A No
Appendix E private consortium, giving the  Issued
appearance of a conflict of interest.
HHS senior Government employees  Admonishment/
Centers for Medicare  
were accused of Standard of Conduct/ Closed Reminder of Policy  No N/A No
& Medicaid Services  
Behavior Unbecoming. (Oral/Written)
 
A senior HHS Government employee 
Legal and   Employee Suspended 
was accused of sharing information in  Closed No N/A No
Investigative Activities  and Transferred
advance of public release.
 
Public Health Agencies     
    (20) a detailed description of any instance of whistle blower retaliation, including information about the official  
Human Services 
  found to have engaged in retaliation and what, if any, consequences the establishment imposed to hold that  
Agencies 
  official accountable;
 
Other HHS-Related 
For departmental agencies, OIG conducts investigations and gathers facts related to whistleblower complaints.  In the 
Reviews and  
Investigations  past, OIG has not made determinations as to whether retaliatory action had been taken.  However, to better facilitate the 
  report review process, OIG changed its process in 2015 to include findings in its reports as to whether it was more likely 
Appendixes than not that whistle blowerretaliation had occurred.  While OIG now includes these findings in its reports, it does not 
make recommendations as to what, if any, corrective action(s) should be taken.  
Under this system, OIG submitted two reports that included findings of retaliation to the HHS Secretarys Office prior to 
October 1, 2016 (both prior to the semiannual reporting period).  The Department issued findings and recommendations 
with respect to both of the OIG reports at issue.   
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  59 APPENDIXES When determining the level of detail to provide for a description of any instance of whistleblower retaliation, OIG is always 
mindful of balancing the risk that a detailed description of the allegation could inadvertently reveal the whistleblowers 
identity, thus having a chilling effect on future whistleblowers. The following information is provided with this in mind. 
The first report:  The whistleblower in this matter filed numerous incident reports with IHS management at an IHS 
medical facility raising concerns about quality of care, confidentiality of patient and staff information, property incidents, 
and mismanagement.  The whistleblower also raised allegations that he/she suffered reprisal and that management was 
creating a hostile work environment.
Appendix A 
OIG found that it was more likely than not that the whistleblower was subjected to reprisal for whistle blowing activities 
Appendix B 
in this matter for the following reasons. First, the whistleblower made numerous protected communications.  Second, 
Appendix C  management was aware of those communications (because many of the communications were sent to management).  
Third, multiple adverse personnel actions were taken against the whistleblower during the relevant time period.  Fourth, 
Appendix D 
a causal connection existed between the protected communications and the adverse personnel actions because the 
personnel actions referenced the fact that the whistleblower went outside of the chain of command to raise his/her 
Appendix E
concerns and instructed the whistleblower not to do so in the future. 
Centers for Medicare   By memo dated January 12, 2017, the Deputy Secretary agreed with the proposed findings and recommendations and 
& Medicaid Services   found that the whistleblower had been subjected to reprisal for his/her protected communications and agreed with the 
 
following proposed corrective action: 1) supervisors were to be sent to training on employee supervision, performance 
Legal and  
management, and dispute resolution; 2) the whistleblower along with supervisors were to be sent to training on 
Investigative Activities 
communication and email etiquette; 3) the whistleblower was to be returned to a duty status in a position equivalent to 
 
the one the whistleblower was removed from; 4) the letters of reprimand were to be removed from the whistleblowers 
Public Health Agencies 
personnel file; and 5) supervisors were to be sent to training concerning quality of care improvements. 
 
Human Services 
The second report:  The whistleblower in this matter alleged that a senior government official attempted to intimidate 
Agencies 
  the whistleblower into accepting responsibility for the failure of a project for which the whistleblower was not 
Other HHS-Related  responsible. The whistleblower made this disclosure to the Departments Labor and Employee Relations (LER) Division, to 
Reviews and   the Departments Equal Employment Opportunity Compliance and Operations (EEOCO) Division, and to OIG.  The 
Investigations 
whistleblower alleged that he/she suffered reprisal for the disclosures when his/her security clearance was suspended 
 
and later revoked. 
Appendixes
OIG found that it was more likely than not that the whistleblower was subjected to reprisal for whistleblowing activities in 
this matter for the following reasons. First, the whistleblower made several protected communications. Second, the 
whistleblowers management was aware of those communications. Third, the whistleblowers security clearance was 
suspended and then revoked. Fourth, we found that the whistleblowers protected disclosures were a contributing factor 
in the decision to suspend and revoke his/her eligibility for access to classified information for several reasons, including: 
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  60 APPENDIXES the close proximity in time between the protected disclosures and the decision to suspend and revoke the 
whistleblowers clearance; the lack of evidence to support the stated basis for the revocation of the clearance; and the 
fact that the manager responsible for revoking the whistleblowers clearance had expressed animus towards the 
whistleblower as a result of his/her disclosures.  Fifth, OIG concluded that there was no clear and convincing evidence 
that the same action would have been taken against the whistleblower in the absence of the protected disclosures 
because similarly situated employees who engaged in conduct similar to that of the whistleblower did not have their 
clearances revoked. 
 
Appendix A  By way of an undated memo from the Acting Deputy Secretary to the whistleblower, the Department issued its findings 
and recommendations with respect to this matter. The Department concurred in the OIGs finding that the 
Appendix B 
whistleblower was subjected to retaliation in this matter and ordered the following corrective action: 1) senior 
Appendix C  government official was ordered to take training on whistleblowers rights, employee supervision, performance 
management and conduct, dispute resolution and communication; 2) all employees in the relevant Office were ordered 
Appendix D 
to take training on whistleblowers rights; 3) the Department said it would review the record to determine whether other 
Appendix E remedies were necessary related to restoration of the whistleblowers security clearance; and 4) the Department noted 
that it was conducting a further review of the management of the Office at issue and would determine if disciplinary or 
Centers for Medicare   other corrective action was necessary at the conclusion of that review.  
& Medicaid Services  
Subsequently, the Department entered into a settlement agreement with the senior government official accused of 
 
Legal and   whistleblower reprisal in this matter. The senior government official no longer works for the Department. OIG has not 
Investigative Activities  received a copy of the settlement agreement entered into by the Department and the senior government official; 
  therefore, OIG does not know what corrective action the Department ultimately took in this matter.
Public Health Agencies 
   (21) a detailed description of any attempt by the establishment to interfere with the independence of the Office,  
 
Human Services    including-
Agencies 
      (A) with budget constraints designed to limit the capabilities of the Office; and
Other HHS-Related 
Reviews and       (B) incidents where the establishment has resisted or objected to oversight activities of the Office or  
Investigations      restricted or significantly delayed access to information, including the justification of the establishment  
      for such action; and
Appendixes
Although there have been instances in which HHS agencies have questioned OIG oversight activities or have not provided 
all information in the precise content, format, and timeline as requested, OIG has not identified any instances in which 
the Department interfered with the independence of OIG during this reporting period.  OIG would immediately notify 
Congress if it were unable to resolve these issues within the Department.  
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  61 APPENDIXES   (22) detailed descriptions of the particular circumstances of each-
    (A) inspection, evaluation, and audit conducted by the Office that is closed and was not disclosed to the  
    public; and
The table below lists evaluation and audit reports for this semiannual reporting period that did not result in public 
reports.  However, in some circumstances, a public summary of these nonpublic reports was published. 
 
Appendix A  Nonpublic Reports by Category, October 1, 2016, to March 31, 2017
Appendix B 
Category/Description Number of Reports
Appendix C 
Information technology security reviews (involve information technology systems, e.g., Federal Information  5
Security Management Act audits)
Appendix D 
Homeland security issues (involve particularly sensitive topics, e.g., bioterrorism, emergency preparedness,  0
Appendix E and classified or potentially classified information)
Recipient Capability Audits (primarily in Head Start/Early Head Start programs) 0
Centers for Medicare   Reimbursable audits performed for other Federal agencies (primarily contract audits) 5
& Medicaid Services  
Confidential or proprietary information (e.g., Medicare Part B drug claims/imaging services, Medicare  2 
 
investment income)
Legal and  
Medicare Adverse Event Reviews (required by law not to disclose) 0
Investigative Activities 
  Medicare Prescription Drug Event Reviews 0
Public Health Agencies  Other 1
 
Departmental technical assistance reports4  1
Human Services 
Agencies  Finance-related attestation reviews 2
  Total 16
Other HHS-Related 
Reviews and    
Investigations 
  (B) investigation conducted by the Office involving a senior Government employee that is closed and was not 
 
  disclosed to the public.
Appendixes
In section 5(a)(19), we detail senior Government employee investigations where allegations were substantiated.  Those 
investigations are all closed and none have been disclosed to the public.  OIG interprets Section 5(a)(22)(B) as requiring 
reporting on investigations with either substantiated or unsubstantiated allegations.  As such, we refer to our section 5(a)
 
4OIG routinely provides technical assistance to the Department.  Generally, that technical assistance is not part of a formal report and is not formally tracked.  However, 
in some limited circumstances, OIG does provide technical assistance in a formal report, and only this category of technical assistance is reflected in this table. 
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  62 APPENDIXES (19) response to address senior Government employee investigations with substantiated allegations that were closed and 
not disclosed to the public.  Our section 5(a)(22)(B) response describes investigations during this reporting period, both 
criminal and administrative, involving a senior Government employee where allegations of misconduct were 
unsubstantiated by OIG.
When determining the level of detail to provide for the investigations described above, OIG is mindful of balancing the 
risk that a detailed description of the investigation could inadvertently reveal the subjects identity.  During this reporting 
period, OIG investigated five senior Government employees for misconduct, but OIG determined the allegations to be 
Appendix A  unsubstantiated.  Descriptions of the investigations are below. 
Appendix B 
DOJ 
DOJ  DOJ 
Appendix C  Description of Investigation Status Disposition Referral 
Referral Declination
Date
Appendix D 
A senior Government employee was 
Appendix E alleged to have submitted false claims  Closed No evidence to  No N/A No
support allegations.
and misused his/her position.
Centers for Medicare   A senior Government employee was 
No evidence to 
& Medicaid Services   alleged to have accessed an HHS  Closed support allegations. No N/A No
network for an unauthorized purpose.
 
Legal and   A senior Government employee was 
No evidence to 
Investigative Activities  alleged to have accessed an HHS  Closed No N/A No
support allegations.
  network for an unauthorized purpose.
Public Health Agencies  A senior Government employee was 
No evidence to 
  alleged to have accessed an HHS  Closed  No N/A No
support allegations.
Human Services  network for an unauthorized purpose. 
Agencies  A senior Government employee was 
 No evidence to 
  alleged to have accessed inappropriate  Closed  No N/A No
support allegations.
Other HHS-Related  material.
Reviews and  
Investigations 
 
Appendixes
HHS OIG Semiannual Report to Congress      |      October 1, 2016  March 31, 2017  63 U.S. Department of Health & Human Services 
Office of Inspector General 
https://oig.hhs.gov