Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023
 
 
A Message From Christi A. Grimm, Inspector General 
I am pleased to submit this Semiannual Report to Congress summarizing the 
activities of the Department of Health and Human Services (HHS), Office of 
Inspector General (OIG) for the 6-month period ending on March 31, 2023. 
 
HHS-OIGs oversight portfolio is vital, vast, and varied.  We are responsible for 
oversight of more than $2.4 trillion in HHS expenditures and more than 100 
health and human services programs.  HHS is the Federal Governments largest 
grant-making agency and the fourth largest contracting agency, with obligations 
in the hundreds of billions of dollars in grants and tens of billions of dollars in 
total contracts each year.  OIG provides independent, objective oversight of 
these substantial taxpayer investments to ensure sound fiscal management; prevent fraud, waste, and 
abuse; enhance transparency; and promote the delivery of high-quality health and human services.  
 
During this reporting period, HHS-OIG's law enforcement arm continued as a formidable force in 
combating fraud and abuse and protecting patients from harm.  OIG and its partners pursued a multi-
State, coordinated law enforcement action to apprehend individuals engaged in a brazen scheme to sell 
more than 7,600 false and fraudulent nursing degree diplomas and transcripts.  Further, across the Nation, 
our investigators worked with Federal and State law enforcement partners to bring to justice perpetrators 
of detrimental kickback, false billing, and other schemes, including an alarming scheme involving 
unnecessary prescriptions for opioids.  Another disturbing case cataloged in this Semiannual Report 
resulted in a 20-year prison sentence for the medical director of a drug and alcohol addiction treatment 
facility involved in a $746 million, multiyear scheme to bill for fraudulent tests and treatments.  HHS-OIG 
remains resolute in our commitment to aggressively combat fraud and hold wrongdoers accountable.  
 
This Semiannual Report reflects HHS-OIGs critical oversight of the nearly $130 billion in HHS grants 
awarded each year.  In January 2023, HHS-OIG released a report that examined the monitoring of research 
grants by the National Institutes of Health and EcoHealth Alliance.  This work elucidated complex grants 
oversight issues and underscored the importance of getting the fundamentals of grants management 
right, especially for risky scientific research.  Also during this reporting period, OIG continued critical 
oversight to ensure that recipients of grant funding complied with Federal requirements.  For example, OIG 
issued a report finding concerning gaps in the reporting of missing foster children to the National Center 
for Missing and Exploited Children. 
 
As our work during this reporting period demonstrates, from protecting children to improving nursing 
home care to bolstering the integrity of managed care and more, HHS-OIG delivers positive results for the 
American people.  Our capacity to shine a light on program vulnerabilities, uncover misspent funds, and 
undertake enforcement actions is limited only by our available resources.  Notwithstanding concerted 
efforts by HHS-OIG and the Departmentwith strong support from Congress for HHS-OIGs oversight and 
enforcementserious fraud, waste, and abuse continue to threaten HHS programs and the people they 
serve.  With current resources, HHS-OIG is unable to keep pace with these threats.  For example, we are 
 
 
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turning down 300 to 400 viable criminal and civil health care fraud cases each year due to lack of 
resources.  Each case means unaddressed potential fraud and missed opportunities for deterrence.  
Currently, HHS-OIG has about 2 cents to oversee every $100 of HHS spending.  The FY 2024 Presidents 
Budget requests resources for OIG that, if enacted, would substantially help address this shortfall.  
 
Since its 1976 establishment, OIG has worked collaboratively with its partners to protect and oversee HHS 
programs that touch the lives of every American.  The achievements of this office would not be possible 
without the dedication, professionalism, and adroitness of OIGs workforce.  We greatly appreciate the 
support of Congress and the Department for independent, vigorous oversight and HHS-OIGs important 
work. 
 
 
Christi A. Grimm  
Inspector General 
. 
 
 
 
   
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Table of Contents   
  
Selected Acronyms and Abbreviations  iv 
OIGs Approach to Driving Positive Change  1 
Highlights of OIG Accomplishments  5 
Medicare and Medicaid Reports and Reviews  12 
Legal and Investigative Activities Related to Medicare and Medicaid  36 
Public Health and Human Services Agency Reports and Reviews  51 
Legal and Investigative Activities Related to Public Health and Human Services Agencies  62 
Other HHS-Related Reviews and Investigative Activities  64 
Appendix A: Questioned Costs and Funds To Be Put to Better Use  69 
Appendix B: Peer Review Results  80 
Appendix C: Summary of Sanction Authorities  83 
Appendix D: Reporting Requirements in the Inspector General Act of 1978  86 
Appendix E: Reporting Requirements in the Inspector General Empowerment Act of 2016  88 
Appendix F: Anti-Kickback StatuteSafe Harbors  96 
   
 
   
iii 
   
 
Selected Acronyms and Abbreviations 
ACF  Administration for Children and Families 
ASA  Assistant Secretary for Administration 
ASP  average sales price 
ASPR  Administration for Strategic Preparedness and Response 
CDC  Centers for Disease Control and Prevention 
CIA  corporate integrity agreement 
CIGIE  Council of the Inspectors General on Integrity and Efficiency 
CIN  Client Index Number 
CMP  civil monetary penalty 
CMPL  Civil Monetary Penalties Law 
CMS  Centers for Medicare & Medicaid Services 
DMEPOS  durable medical equipment, prosthetics, orthotics, and supplies 
DOD  Department of Defense 
DOJ  Department of Justice 
DOL  Department of Labor 
FBI  Federal Bureau of Investigation 
FDA  Food and Drug Administration 
GAO  Government Accountability Office 
HHS  Department of Health and Human Services 
HIPAA  Health Insurance Portability and Accountability Act of 1996 
HRSA  Health Resources and Services Administration 
IHS  Indian Health Service 
MAC  Medicare Administrative Contractor 
MCO  managed care organization 
MFCU  Medicaid Fraud Control Unit 
NCMEC  National Center for Missing and Exploited Children 
NIDA  National Institute on Drug Abuse 
NIH  National Institutes of Health 
NIST  National Institute of Standards and Technology 
OAS  Office of Audit Services 
OASH  Office of Assistant Secretary for Health 
OCIG  Office of Counsel to the Inspector General 
OEI  Office of Evaluation and Inspections 
OI  Office of Investigations 
iv 
   
OIG  Office of Inspector General 
OS  Office of the Secretary 
PBM  pharmacy benefit manager 
PDE  prescription drug event 
SAMHSA  Substance Abuse and Mental Health Services Administration 
   
v 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
OIGs Approach to Driving Positive Change  
The Department of Health and Human Services (HHS), Office of Inspector General (OIG) provides 
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 established by the Government 
Accountability Office (GAO), Department of Justice (DOJ), and Inspector General community.  Through a 
nationwide network of audits, investigations, and evaluations, OIG carries out its mission to protect the 
integrity of HHS programs and the health and welfare of the people served by those programs.   
 
OIG Organization 
OIGs work is conducted by the Office of Audit Services (OAS), the Office of Evaluation and Inspections 
(OEI), the Office of Investigations (OI), the Office of Counsel to the Inspector General (OCIG), and Mission 
Support and Infrastructure (MSI). 
 
Office of Audit Services 
OAS provides auditing services for HHS, either by conducting audits with its own audit resources or 
by overseeing audit work done by others.  The audits examine the performance of HHS programs, 
funding recipients, and contractors in carrying out their respective responsibilities and provide 
independent assessments of HHS programs and operations to reduce waste, abuse, and 
mismanagement. 
 
Office of Evaluation and Inspections 
OEIs national evaluations provide HHS, Congress, and the public with timely, useful, and reliable 
information on significant issues.  To promote impact, OEI reports also provide practical 
recommendations for improving program operations. 
 
Office of Investigations 
OIs criminal, civil, and administrative investigations of fraud and misconduct related to HHS 
programs and operations often lead to criminal convictions, administrative sanctions, and civil 
monetary penalties (CMPs).  OIs nationwide network of investigators collaborates with DOJ and 
other Federal, State, and local law enforcement authorities.  OI works with public health entities to 
minimize adverse patient impacts following enforcement operations.  OI also provides security and 
protection for the Secretary and other senior HHS officials. 
 
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  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
Office of Counsel to the Inspector General 
OCIG provides legal advice to OIG on HHS programs and OIGs internal operations.  The law office 
also imposes exclusions and CMPs, monitors Corporate Integrity Agreements (CIAs), and 
represents HHSs interests in False Claims Act cases.  In addition, OCIG publishes advisory opinions, 
compliance program guidance documents, fraud alerts, and other resources regarding compliance 
considerations, the anti-kickback statute, and other OIG enforcement authorities. 
 
Mission Support and Infrastructure 
MSI is composed of the Immediate Office of the Inspector General and the Office of Management 
and Policy.  MSI is responsible for coordinating OIG activities and providing mission support, 
including setting vision and direction for OIGs priorities and strategic planning; ensuring effective 
management of budget, finance, human resource management, and other operations; and serving 
as a liaison with HHS, Congress, and other stakeholders.  MSI plans, conducts, and participates in a 
variety of cooperative projects within HHS and with other Government agencies.  MSI provides 
critical data analytics, data management, and information technology infrastructure that enables 
OIG components to conduct their work efficiently and effectively.  
 
OIG Strategic Publications
 
 
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  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
HHS-OIG Strategic Plan 
OIGs Strategic Plan outlines the approach to protecting the integrity of HHS programs.  The plan 
has three key goals: (1) to fight fraud, waste, and abuse; (2) to promote quality, safety, and value in 
HHS programs and for HHS beneficiaries; and (3) to advance excellence and innovation.  These 
goals drive OIGs work planning for audits and evaluations as well as OIGs approach to 
enforcement.  These goals also serve as a starting point for OIGs assessment of its own 
effectiveness. 
 
OIG Work Plan 
OIGs Work Plan sets forth projects, including audits and evaluations, that are underway or are 
planned during the fiscal year and beyond.  Projects listed in the Work Plan span HHSs Operating 
Divisions (OpDivs), which include the Centers for Medicare & Medicaid Services (CMS), public 
health agencies such as the Centers for Disease Control and Prevention (CDC) and the National 
Institutes of Health (NIH), and human services agencies such as the Administration for Children and 
Families (ACF) and the Administration for Community Living.  The Work Plan also includes 
oversight of State and local governments use of Federal funds as well as the administration of 
HHS.  Some of the projects described in the Work Plan are statutorily required. 
 
OIGs Top Unimplemented Recommendations 
OIG drives positive change by not only identifying risks, problems, abuses, and deficiencies, but 
also recommending solutions to address them.  OIG maintains a list of recommendations it has 
made to address vulnerabilities detected in its reviews, and it keeps track of whether these 
recommendations have been implemented.  OIG systematically follows up on its recommendations 
with the relevant HHS programs.  From among the recommendations that have not been 
implemented, OIG identifies the top recommendations that, if implemented, are likely to garner 
significant savings and improvements in quality, efficiency, and effectiveness.  OIG compiles these 
recommendations in OIG's Top Unimplemented Recommendations: Solutions To Reduce Fraud, 
Waste, and Abuse in HHS Programs (previously known as the Compendium of Unimplemented 
Recommendations). 
 
Top Management and Performance Challenges Facing HHS 
To focus HHSs attention on the most pressing issues, each year OIG identifies the Top 
Management and Performance Challenges Facing HHS.  These top challenges arise across HHS 
programs and cover critical HHS responsibilities, including delivering quality services and benefits, 
exercising sound fiscal management, safeguarding public health and safety, and enhancing 
cybersecurity. 
 
3 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
OIGs Semiannual Report to Congress  
OIGs Semiannual Report to Congress (Semiannual Report) describes OIGs work on identifying 
significant problems, abuses, deficiencies, remedies, and investigative outcomes relating to the 
administration of HHS programs and operations that were disclosed during the reporting period.  
In the report that follows, we present OIG expected recoveries, criminal and civil actions, and other 
statistics as a result of our work for the semiannual reporting period of October 1, 2022, through 
March 31, 2023.  We also provide data for accomplishments for fiscal year (FY) 2023 to date and 
highlight some of our work completed during this semiannual reporting period. 
 
 
4 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
Highlights of OIG Accomplishments 
In this section, we present data on OIG reports issued, expected recoveries, criminal and civil actions, and 
other statistics resulting from our work during the semiannual reporting period.  We then highlight 
significant results from selected audits, evaluations, and enforcement activities completed during the 
reporting period. 
 
At-a-Glance Highlights 
Statistic  Semiannual Reporting Period   
(10/1/20223/31/2023)   
 
Audit Reports Issued  62 
 
Evaluations Issued  19 
 
Expected Audit Recoveries  $200.1 Million 
 
Questioned Costs  $277.2 Million 
 
Potential Savings  $0 
 
New Audit and Evaluation  213 
 
Recommendations 
 
Recommendations Implemented by  253 
 
HHS OpDivs 
 
Expected Investigative Recoveries  $892.3 Million 
 
Criminal Actions  345 
 
Civil Actions  324 
 
Exclusions  1,365 
 
Results for the Semiannual Reporting Period 
During this semiannual reporting period (October 1, 2022, through March 31, 2023), we issued 62 audit 
reports and 19 evaluation reports.  Our audit work identified $200.1 million in expected recoveries, as well 
as $277.2 million in questioned costs (costs questioned by OIG because of an alleged violation, costs not 
supported by adequate documentation, or the expenditure of funds where the intended purpose is 
unnecessary or unreasonable).  During this reporting period, OIG made 213 new audit and evaluation 
recommendations, which are crucial to encourage positive change in HHS programs.  Meanwhile, HHS 
OpDivs implemented 253 prior recommendations, leading to positive impact for HHS programs and 
beneficiaries. 
 
OIG also remains at the forefront of the Nations efforts to fight fraud in HHS programs and hold 
wrongdoers accountable for their actions.  Along with our partnersincluding DOJ; Medicaid Fraud 
Control Units (MFCUs); and other Federal, State, and local law enforcement agencieswe detect, 
investigate, and prosecute fraud through a coordinated and data-driven approach.  OIGs investigative 
5 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
work led to $892.3 million in expected investigative recoveries and 345 criminal actions during this 
reporting period.  OIG also took civil actions, such as assessing monetary penalties, against 324 individuals 
and entities, and excluded 1,365 individuals and entities from Federal health care programs. 
 
OIG continues to focus on the most significant and high-risk issues in health care and human services.  Our 
mission is to provide objective oversight to promote the economy, efficiency, effectiveness, and integrity of 
HHS programs, as well as the health and welfare of the people they serve.  Below we highlight results from 
selected OIG oversight and enforcement activities from the semiannual reporting period of October 1, 
2022, through March 31, 2023, organized by subject area.  A comprehensive list of OIG work during the 
reporting period follows, and Appendices A through F provide data to meet the reporting requirements in 
the Inspector General Act of 1978. 
 
Responding to the COVID-19 Pandemic and Other Emergencies  
OIG has advanced four goals with respect to HHSs COVID-19 response and recovery: (1) protect people; 
(2) protect funds; (3) protect infrastructure; and (4) promote the effectiveness of HHS programs, now and 
into the future.  While HHSs Public Health Emergency declaration is anticipated to end in May of 2023, 
these four goals will continue to drive OIGs strategic planning and mission execution in relation to COVID-
19.  Additional information about the OIG COVID-19 strategic plan, emerging fraud schemes, and work 
related to COVID-19 is available on our COVID-19 Portal.  
 
Significant OIG oversight work completed during this reporting period related to the COVID-19 pandemic 
includes the following reports: 
 
  Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although 
Some Challenges Persist (OEI-01-21-00110), October 2022  
  IHS Did Not Always Provide the Necessary Resources and Assistance To Help Ensure That Tribal 
Programs Complied With All Requirements During Early COVID-19 Vaccination Program 
Implementation (A-07-21-04125), October 2022 
  During the Initial COVID-19 Response, HHS Personnel Who Interacted With Potentially Infected 
Passengers Had Limited Protections (OEI-04-20-00360), October 2022 
  Early Challenges Highlight Areas for Improvement in COVID-19 Vaccination Programs (OEI-04-21-
00190), January 2023 
  Challenges With Vaccination Data Hinder State and Local Immunization Program Efforts To Combat 
COVID-19 (OEI-05-22-00010), January 2023 
 
OIG continues to work with Federal partners such as DOJ to identify and criminally prosecute bad actors 
exploiting the COVID-19 response.  For example, during this reporting period, an individual was sentenced 
to 3 years of probation for creating false COVID-19 vaccine records.  The individual, who worked as a data 
entry specialist for a company providing vaccinations, created fraudulent vaccination cards and made false 
vaccination entries to recordkeeping systems for 14 individuals.  
 
6 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
Leveraging Oversight To Better Protect Nursing Home Residents 
Improving nursing home care is a top priority for OIG.  Decades of OIG oversight of nursing homes 
revealed significant challenges and vulnerabilities, and the COVID-19 pandemic brought challenges at 
nursing homes to the forefront.  To better understand contributing factors; identify fraud, inefficiency, and 
substandard care; and aid policymakers, our oversight work is guided by a three-part strategy: 
 
  Performance: Understanding what drives nursing home performance, and in particular what 
contributes to poorly performing nursing homes. 
  Residents First: Ensuring that nursing homes prioritize quality of care and quality of life for 
residents. 
  Oversight: Ensuring that entities responsible for nursing home oversightCMS and Statesdetect 
problems quickly and insist on rapid remediation.   
 
Currently, OIG has 26 ongoing audits and evaluations of nursing home issues.  We are continuing to 
monitor identified areas of concern, push for implementation of unimplemented recommendations, and 
issue new recommendations as problems and solutions are identified.  Information about ongoing nursing 
home work can be found on OIGs Nursing Homes website.  Significant OIG work completed during this 
reporting period related to protecting residents in nursing homes includes the following: 
 
  Long-Term Trends of Psychotropic Drug Use in Nursing Homes (OEI-07-20-00500), November 2022 
  More Than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First 
Year of the COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies (OEI-02-20-
00491), January 2023 
 
Promoting Program Integrity and Good Financial Stewardship in Traditional Medicare 
The 2023 Medicare Trustees report projected that assets in the Part A trust fund will be depleted by 2033, 
adding urgency to efforts to ensure good stewardship and appropriate use of scarce Medicare funds.  OIG 
recognizes the importance of identifying and mitigating fraud risks in the Medicare program and holding 
accountable those who defraud Medicare, beneficiaries, and taxpayers.  
 
Significant OIG work completed during this reporting period related to Medicare program integrity and 
financial stewardship includes the following: 
 
  Labs With Questionably High Billing for Additional Tests Alongside COVID-19 Tests Warrant Further 
Scrutiny (OEI-09-20-00510), December 2022 
  Medicare Part B Spending on Lab Tests Increased in 2021, Driven By Higher Volume of COVID-19 
Tests, Genetic Tests, and Chemistry Tests (OEI-09-22-00400), December 2022 
  Medicare Could Have Saved up to $216 Million Over 5 Years if Program Safeguards Had Prevented 
At-Risk Payments for Definitive Drug Testing Services (A-09-21-03006), February 2023 
 
7 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
OIG continues to coordinate with DOJ to identify and criminally prosecute bad actors in the Medicare 
program.  The following are two examples of successful criminal prosecutions related to traditional 
Medicare during this reporting period: 
 
  An owner and operator of five home health companies was sentenced to serve 30 months in 
Federal prison followed by 3 years of supervised release for a home health fraud scheme and was 
also ordered to pay $21,197,440 in restitution.  From 2010 to 2015, these home health companies 
submitted false claims to Medicare for home health services for patients who did not need or were 
not provided services. 
  A sales representative was sentenced to 25 months in prison and ordered to pay, along with yet-
to-be-sentenced defendants, a total of $2,954,585.90 for a kickback scheme.  The representative 
paid cash kickbacks to physicians in exchange for referrals and prescriptions directed to select 
pharmacies and clinical laboratories. 
 
OIG uses the Civil Monetary Penalties Law (CMPL) to settle liabilities with facilities who self-disclose 
inappropriate billing practices.  For example, during this reporting period, OIG entered into a 
$14,351,283.06 settlement agreement with a facility that submitted incorrect claims to Medicare for 
inpatient rehabilitation stays that did not meet coverage criteria.  
 
Preventing Prescription Drug Misuse and Strengthening Substance Abuse Care 
OIG continues to prioritize oversight and enforcement activities to protect enrollees from prescription drug 
abuse and safeguard health care services for individuals suffering from substance abuse disorder. 
 
OIG continues to coordinate with DOJ to identify and criminally prosecute bad actors in Federal health 
care programs.  The following are three examples of successful criminal prosecutions related to improper 
prescriptions and distributions during this reporting period: 
 
  A physician was sentenced to 16.5 years in prison for his role in a shots-for-pills scheme, whereby 
patients were required to receive unnecessary back injections in exchange for prescriptions of 
medically unnecessary opioids.  These unnecessary injections and prescriptions resulted in more 
than $250 million in false and fraudulent claims being submitted to Medicare, Medicaid, and other 
health insurance programs.  
  A physician was sentenced to 30 months in prison and was ordered to surrender his medical 
license, pay $2,163,995 in restitution, and pay a $50,000 fine for conspiring with others to increase 
the number of prescriptions for a specific central nervous system agent.  Between October 2011 
and April 2016, the physician received kickbacks for presentations, receiving $331,550 and writing 
10,088 prescriptions for the drugthe highest in the country. 
  A physician was sentenced to 20 years in prison for engaging in a massive multiyear scheme to bill 
health care benefit programs for fraudulent tests and treatments for vulnerable patients seeking 
treatment for drug and/or alcohol addiction.  The physician, while serving as the Medical Director 
for the treatment facility, signed standing orders for unnecessary urinalyses and blood tests, along 
8 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
with other unnecessary addiction treatments. 
 
OIG continues to exclude entities and individuals engaging in fraud and abuse from participation in health 
care programs.  For example, during this reporting period, OIG excluded an advanced practice nurse 
practitioner for a period of 45 years based on a conviction related to the distribution of controlled 
substances beyond the practice of medicine.  
 
Ensuring Proper Departmental Management  
OIG reviews programs across HHS to ensure that programs are being administered effectively, efficiently, 
and without waste.   
 
Significant OIG work completed during this reporting period related to proper departmental management 
includes the following: 
 
  FDAs Approach to Overseeing Online Tobacco Retailers Needs Improvement (OEI-01-20-00241), 
December 2022 
  The National Institutes of Health and EcoHealth Alliance Did Not Effectively Monitor Awards and 
Subawards, Resulting in Missed Opportunities to Oversee Research and Other Deficiencies (A-05-21-
00025), January 2023 
  ASPR Could Improve Its Oversight of the Hospital Preparedness Program To Ensure That Crisis 
Standards of Care Comply With Federal Nondiscrimination Laws (A-01-21-01502), January 2023 
 
Promoting Integrity and Effectiveness in Medicare Advantage and Medicaid Managed 
Care 
Almost half of people with Medicare are currently enrolled in Medicare Advantage organizations.  
Enrollment is expected to continue to grow to cover 53 percenta majority of Medicare enrolleesby 
2031. 
 
Managed care is now the predominant payment model in Medicaid.  State and Federal expenditures on 
Medicaid managed care are growing.  These expenditures totaled $421 billion and represented 59 percent 
of all Medicaid expenditures in 2021. 
 
Significant OIG work completed during this reporting period related to Medicare Advantage and Medicaid 
managed care includes the following: 
 
  CMS Generally Ensured That Medicare Part C and Part D Sponsors Did Not Pay Ineligible Providers 
for Services to Medicare Beneficiaries (A-02-20-01027), October 2022 
  Keystone First Should Improve Its Procedures for Reviewing Service Requests That Require Prior 
Authorization (A-03-20-00201), December 2022 
9 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
  The Inability To Identify Denied Claims in Medicare Advantage Hinders Fraud Oversight (OEI-03-21-
00380), February 2023 
 
Safeguarding Medicaid Program Integrity  
Medicaid is the largest Federal health care program, with nearly 93 million individuals enrolled as of 
December 2022.  Medicaid is administered by States per Federal requirements.  The program is funded 
jointly by the Federal Government and States.  CMS estimated Federal and State Medicaid expenditures of 
$734.0 billion in 2021.  
 
Significant OIG work completed during this reporting period related to Medicaid program integrity 
includes the following: 
 
  Missouri Claimed Federal Medicaid Reimbursement for Tens of Millions in Consumer-Directed 
Personal Care Assistance Services That Did Not Comply With Federal and State Requirements (A-07-
20-03243), February 2023  
 
Reducing Prescription Drug Spending for HHS Programs and Enrollees  
OIG performs work to assess areas in which HHS programs or people enrolled in them may be paying 
more than necessary for vital drugs.   
 
Significant OIG work completed during this reporting period related to prescription drug spending 
includes the following: 
 
  Comparison of Average Sales Prices and Average Manufacturer Prices: Results for the Second 
Quarter of 2022 (OEI-03-23-00070), November 2022  
  CMS Should Bolster Its Oversight of Manufacturer-Submitted Average Sales Price Data To Ensure 
Accurate Part B Drug Payments (OEI-03-21-00390), December 2022 
  Manufacturers May Need Additional Guidance To Ensure Consistent Calculations of Average Sales 
Prices (OEI-BL-21-00330), December 2022 
  Technical Assistance Brief: Implementation of Inflation-Indexed Rebates for Part B Drugs (OEI-BL-23-
00170), February 2023 
  Comparison of Average Sales Prices and Average Manufacturer Prices: Results for the Third Quarter 
of 2022 (OEI-03-23-00080), February 2023 
  Some Skin Substitute Manufacturers Did Not Comply with New ASP Reporting Requirements (OEI-
BL-23-00010), March 2023 
 
10 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
Ensuring Health and Safety of Vulnerable People Served by HHS 
OIG has devoted substantial oversight efforts to protect vulnerable peopleincluding the elderly, children, 
and adults with developmental disabilitieswho are served by HHS programs such as Medicare, Medicaid, 
the Unaccompanied Children Program, and the Child Care and Development Fund. 
 
Significant OIG work completed during this reporting period related to ensuring the health and safety of 
vulnerable people served by HHS programs includes the following: 
 
  For Medicaid-Enrolled Children Diagnosed With Lead Toxicity in Five States, Documentation 
Reviewed for Diagnoses and Treatment Services Raises Concerns (OEI-07-18-00370), December 2022 
  State Agencies Did Not Always Ensure That Children Missing From Foster Care Were Reported to the 
National Center for Missing and Exploited Children in Accordance With Federal Requirements (A-07-
21-06102), March 2023 
 
Cybersecurity Protection 
OIG continues to recognize cybersecurity vulnerabilities as major risks to effectively managing and 
safeguarding HHSs programs.  Oversight of HHSs cybersecurity is being prioritized.  Repeated 
cyberattacks focused on accessing critical information in HHS systems added urgency to the task of 
developing departmental cybersecurity safeguardsin addition to conducting normal operationsover 
the course of the COVID-19 pandemic. 
 
During this reporting period, OIG conducted work examining HHSs cybersecurity controls to strengthen 
HHSs cybersecurity posture, including: 
 
  FDA Should Improve Its Management of Contracts for the Acquisition of Information Technology (A-
18-21-11100), January 2023    
 
 
 
11 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
 
Medicare and Medicaid Reports and Reviews 
Medicare Program Reports and Reviews 
Financial Management and Improper Payments 
Payments Made to Providers Under the COVID-19 Accelerated and Advance Payments Program 
Were Generally in Compliance With the CARES Act and Other Federal Requirements (A-05-20-
00053), October 2022 
  
CMS generally made COVID-19 Accelerated and Advanced Payments (CAAP) Program payments to 
providers in compliance with the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) 
and other Federal requirements.  Of the 109 providers in our sample, CMS appropriately made 
CAAP Program payments to all 100 providers that we randomly selected.  For the nine providers 
under bankruptcy, CMS did not send a CAAP Program payment to six of the providers but did 
make a CAAP Program payment to three of the providers.  
  
The CAAP Program payments made to the three providers under bankruptcy occurred because 
two Medicare Administrative Contractors (MACs) did not correctly match the providers request 
against their bankruptcy databases, and one MAC did not update its bankruptcy database based 
on bankruptcy information that was provided by CMS prior to approving the CAAP Program 
payment request.  For the three CAAP Program payments made to providers under bankruptcy, 
the MACs immediately identified their errors after the payment and recovered the improper 
payments. 
  
Based on our sample, we found that CMS and its MACs generally made CAAP Program payments 
to providers in compliance with the CARES Act and other Federal requirements.  Although the 
MACs erroneously approved CAAP Program payments to nine providers under bankruptcy, the 
MACs immediately identified their errors, stopped payments to six providers, and recovered 
improper payments made to the other three providers.  Therefore, we do not have any 
recommendations. 
 
CMS Generally Ensured That Medicare Part C and Part D Sponsors Did Not Pay Ineligible Providers 
for Services to Medicare Beneficiaries (A-02-20-01027), October 2022  
  
CMS generally ensured that sponsors complied with Federal requirements for preventing payments 
for Medicare services to ineligible providers.  However, some sponsors submitted encounter and 
prescription drug event (PDE) data to CMS indicating that ineligible providers rendered services 
12 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
and wrote prescriptions for Medicare beneficiaries.  We identified 136 Part C sponsors and 62 Part 
D sponsors that may have paid claims for health care services associated with ineligible providers.   
  
The ineligible providers were able to submit these claims to plan sponsors because some sponsors 
may not have had effective compliance programs in place to prevent, detect, and correct 
noncompliance with CMSs program requirements.  Also, CMS may not have adequately monitored 
the sponsors to ensure that their compliance programs were effective.  Although Part D regulations 
expressly require sponsors and their pharmacy benefit managers (PBMs) to reject pharmacy claims 
unless they contain active and valid provider identification numbers, CMS does not have similar 
requirements for claims submitted to Part C sponsors.  Additionally, CMS system edits did not 
properly work to identify all ineligible providers after sponsors submitted their encounter and PDE 
data to CMS.  As a result, CMS used data from services associated with ineligible providers in its 
risk adjustment of capitation payments to the sponsors.  
 
We make a series of recommendations for CMS to direct Part C and Part D sponsors to ensure that 
only eligible providers receive payments for Medicare services.  We also recommend that CMS 
strengthen its oversight of sponsors and provider identifiers to prevent deactivated and deceased 
providers from receiving payments for Medicare services.  CMS concurred with one of our 
recommendations and requested that we remove our remaining recommendations.    
 
Medicare Improperly Paid Physicians for Co-Surgery and Assistant-at-Surgery Services That Were 
Billed Without the Appropriate Payment Modifiers (A-01-20-00503), November 2022 
  
From our 100 statistically sampled services, we found that 69 did not comply with Federal 
requirements.  These statistically sampled services included 49 that were incorrectly billed without 
the co-surgery modifier, 14 that were incorrectly billed without an assistant-at-surgery modifier, 
and 6 that were incorrectly billed as duplicate services.  These statistically sampled service errors 
resulted in overpayments of $31,545.  Based on the results of our statistical sample, we estimated 
that Medicare made $4.9 million in improper payments for physician surgical services during our 
audit period.  In addition, based on our review of the 127 corresponding services, we found that 62 
of these corresponding services did not comply with Federal requirements.  These corresponding 
service errors resulted in overpayments of $24,471.  Altogether, these errors occurred primarily 
because CMS did not have adequate system controls to identify and prevent such payments. 
  
We recommend that CMS: (1) recover the portion of the $56,016 in Medicare Part B overpayments 
that are within the 4-year claim reopening period; (2) instruct the Medicare contractors to notify 
appropriate providers so that they can exercise reasonable diligence to identify, report, and return 
any overpayments in accordance with the 60-day rule; (3) strengthen its system controls to detect 
and prevent improper payments to providers for incorrectly billed co-surgery services, assistant-at-
surgery services, and duplicate serviceswhich could have saved approximately $4.9 million 
during our audit period; and (4) update Medicare requirements and corresponding educational 
13 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
material.  CMS concurred with our recommendations and described actions that it planned to take 
to address them. 
 
The Number of Beneficiaries Who Received Medicare Part B Clinical Laboratory Tests Decreased 
During the First 10 Months of the COVID-19 Pandemic (A-09-21-03004), November 2022 
  
During the first 10 months of the COVID-19 pandemic (March through December 2020), the 
number of beneficiaries who received Medicare Part B clinical laboratory (lab) tests decreased for: 
(1) all lab tests and (2) lab tests associated with certain chronic medical conditions (i.e., diabetes, 
kidney disease, and heart disease) common among Medicare beneficiaries.  From March through 
December in 2016, 2017, and 2018, and for the immediate pre-pandemic period (March through 
December 2019), the number of beneficiaries who received lab tests paid for by Medicare 
decreased by 1 percent or less in each year.  However, for the pandemic period, the number of 
beneficiaries who received lab tests decreased by about 9 percent. 
  
Our comparison of the numbers of beneficiaries who received lab tests during the pandemic and 
pre-pandemic periods identified, among other trends, the following: (1) The number of 
beneficiaries who received lab tests had the highest percentage decreases during the first 3 
months of the pandemic period when compared with the same months during the pre-pandemic 
period; and (2) the number of beneficiaries with diabetes, kidney disease, and heart disease who 
received common lab tests for those conditions decreased during the pandemic period.  The 
results of our data analysis suggest that the COVID-19 pandemic contributed to these decreases.  
Lab tests are important for beneficiaries with chronic medical conditions, which are associated with 
hospitalizations, billions of dollars in Medicare costs, and deaths. 
  
The information in this report is provided for informational purposes only and therefore the report 
does not contain any recommendations. 
  
Medicare Providers Did Not Always Comply With Federal Requirements When Billing for Advance 
Care Planning (A-06-20-04008), November 2022 
  
Medicare providers that billed for advanced care planning (ACP) services in an office setting did 
not always comply with Federal requirements.  On the basis of our sample results, we estimated 
that Medicare providers in an office setting were paid approximately $42.3 million for ACP services 
that did not comply with Federal requirements.  These payments occurred because the providers 
did not understand the Federal requirements for billing ACP services.  
  
We recommend that CMS educate providers on documentation and time requirements for ACP 
services to comply with Federal requirements.  Had the requirements been followed, Medicare 
could have saved an estimated $42.3 million during our audit period.  In addition, CMS should 
instruct the MACs to recoup $33,332 for ACP services paid in error for claims in our sample.  Also, 
CMS should instruct the MACs to notify appropriate providers so that they can exercise reasonable 
14 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
diligence in identifying, reporting, and returning any overpayments in accordance with the 60-day 
rule.  Finally, CMS should establish Medicare requirements that address when it is appropriate to 
provide multiple ACP services for a single beneficiary and how these services should be 
documented when required to support the need for multiple ACP services.  
  
CMS concurred with our first three recommendations but not our fourth recommendation.  After 
reviewing CMSs comments, we revised our fourth recommendation to address when multiple ACP 
services are appropriate, and the documentation required to support the need for these services. 
 
National Government Services, Inc., Accurately Calculated Hospice Cap Amounts but Did Not Collect 
All Cap Overpayments (A-06-21-08004), November 2022  
 
National Government Services, Inc. (NGS) accurately calculated all cap amounts and collected or 
attempted to collect $211.3 million of the $213.4 million in total cap overpayments in accordance 
with CMS requirements.  However, NGS did not attempt to collect the remaining $2.1 million in net 
lookback overpayments because of its internal policy of not pursuing lookback cap calculation 
amounts that were less than a set threshold.  
 
Additionally, against CMS requirements, NGS instructed hospices to wait to submit the 
overpayments calculated on their cap determination notices until the hospice received a demand 
letter from NGS, which took an average of more than 2 months after the due date for hospices to 
file the cap determination notices.  Of 30 judgmentally sampled hospices, 13 reported cap 
overpayments, totaling $8.1 million, on their cap determination notices.  Nine of those 13 hospices 
did not remit their overpayments, totaling $6.1 million, when they filed their cap determination 
notices as required.   
 
We recommend that NGS: (1) collect $2.1 million in lookback overpayments and return $22,576 in 
lookback refunds resulting from 2019 hospice cap calculations for lookback years, (2) discontinue 
its internal policy of waiving certain overpayment collections related to lookback years and start 
collecting all hospice cap overpayments and paying refunds in accordance with CMS requirements, 
and (3) change its instructions on the cap determination notices to follow the CMS requirement 
that hospices remit overpayments at the time they submit their cap determination notice.  NGS 
concurred with our third recommendation but not with our first and second recommendations. 
 
Accuracy of Risk-Adjusted Payments to Medicare Advantage Organizations 
  
CMS makes risk-adjusted payments to Medicare Advantage organizations for which the payment 
level is higher based on the diagnoses that enrollees receive.  CMS relies on Medicare Advantage 
organizations to collect diagnosis codes from their providers and submit these codes to CMS.  
Some diagnoses are at higher risk for being miscoded, which may result in overpayments from 
CMS.  During this reporting period, OIG conducted six audits that were designed to assess whether 
selected diagnosis codes that Medicare Advantage organizations submitted to CMS for use in 
15 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
CMSs risk adjustment program complied with Federal requirements.  For instances in which the 
diagnoses were not supported in the medical records, we calculated the net overpayments that the 
audited Medicare Advantage organizations received.  Complete recommendations and providers 
responses can be found in the final reports summarized here.   
 
Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Blue Cross & 
Blue Shield of Rhode Island (H4152) Submitted to CMS (A-01-20-00500), November 
2022 
  
With respect to the nine high-risk groups covered by our audit, most of the 
selected diagnosis codes that Blue Cross & Blue Shield of Rhode Island (BCBS RI) 
submitted to CMS for use in CMSs risk adjustment program did not comply with 
Federal requirements.  As demonstrated by the errors found in our sample, BCBS 
RIs policies and procedures to prevent, detect, and correct noncompliance with 
CMSs program requirements could be improved.  As a result, the Hierarchical 
Condition Categories for these high-risk diagnosis codes were not validated.  Based 
on our sample results, we estimated that BCBS RI received at least $4.8 million in 
net overpayments for 2016 and 2017. 
  
Medicare Advantage Compliance Audit of Specific Diagnosis Codes That California 
Physicians Service, Inc. (Contract H0504) Submitted to CMS (A-09-19-03001), 
November 2022 
  
With respect to the seven high-risk groups covered by our audit, most of the 
selected diagnosis codes that California Physicians Service, Inc. (CPS) submitted to 
CMS for use in CMSs risk adjustment program did not comply with Federal 
requirements.  As demonstrated by the errors in our sample, the policies and 
procedures that CPS used to prevent, detect, and correct noncompliance with 
CMSs program requirements, as mandated by Federal regulations, could be 
improved.  On the basis of our sample results, we estimated that CPS received at 
least $2 million of net overpayments for these high-risk diagnosis codes for 2015 
and 2016. 
  
Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Cigna-
HealthSpring of Tennessee, Inc. (Contract H4454) Submitted to CMS (A-07-19-01193), 
December 2022 
  
With respect to the 10 high-risk groups covered by our audit, most of the selected 
diagnosis codes that Cigna-HealthSpring of Tennessee, Inc. submitted to CMS for 
use in CMSs risk adjustment program did not comply with Federal requirements.  
As demonstrated by the errors found in our sample, Cignas policies and 
procedures to prevent, detect, and correct noncompliance with CMSs program 
16 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
requirements, as mandated by Federal regulations, could be improved.  On the 
basis of our sample results, we estimated that Cigna received at least $5.9 million in 
net overpayments for 2016 and 2017. 
 
Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Geisinger 
Health Plan (Contract H3954) Submitted to CMS (A-09-21-03011), March 2023 
  
With respect to the nine high-risk groups covered by our audit, most of the 
selected diagnosis codes that Geisinger Health Plan submitted to CMS for use in 
CMSs risk adjustment program did not comply with Federal requirements.  For 224 
of the 270 sampled enrollee-years, either the medical records that Geisinger 
provided did not support the diagnosis codes, or Geisinger could not locate the 
medical records to support the diagnosis codes, resulting in $566,476 of net 
overpayments.  As demonstrated by the errors found in our sample, Geisingers 
policies and procedures to prevent, detect, and correct noncompliance with CMSs 
program requirements could be improved.  On the basis of our sample results, we 
estimated that Geisinger received at least $6.5 million of net overpayments for 2016 
and 2017.  In accordance with recently updated Federal regulations, we recommend 
that Geisinger refund the $566,476 of net overpayments. 
 
Medicare Advantage Compliance Audit of Specific Diagnosis Codes That MCS 
Advantage, Inc. (Contract H5577) Submitted to CMS (A-02-20-01008), March 2023 
  
With respect to the nine high-risk groups covered by our audit, most of the 
selected diagnosis codes for the sampled enrollee-years that MCS Advantage, Inc., 
submitted to CMS for use in CMSs risk adjustment program did not comply with 
Federal requirements.  For 183 of the 280 sampled enrollee-years, the diagnosis 
codes were not supported in the medical records, resulting in $220,577 of net 
overpayments.  These errors occurred because MCSs policies and procedures to 
prevent, detect, and correct noncompliance with CMSs program requirements, as 
mandated by Federal regulations, could be improved.  On the basis of our sample 
results, we estimated that MCS received at least $6.2 million of net overpayments 
for 2016 and 2017.  In accordance with recently updated Federal regulations, we 
recommend that MCS refund the $220,577 of net overpayments. 
  
Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Cigna-
HealthSpring Life & Health Insurance Company, Inc. (Contract H4513) Submitted to 
CMS (A-07-19-01192), March 2023 
  
With respect to the nine high-risk groups covered by our audit, most of the 
selected diagnosis codes that Cigna-HealthSpring Life & Health Insurance 
Company, Inc., submitted to CMS for use in CMSs risk adjustment program did not 
17 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
comply with Federal requirements.  Specifically, for 200 of the 300 sampled 
enrollee-years, the medical records that Cigna provided did not support the 
diagnosis codes, resulting in $468,372 in net overpayments.  As demonstrated by 
the errors found in our sample, Cignas policies and procedures to prevent, detect, 
and correct noncompliance with CMSs program requirements could be improved.  
On the basis of our sample results, we estimated that Cigna received at least $6.24 
million in net overpayments for 2016 and 2017.  In accordance with recently 
updated Federal regulations, we recommend that Cigna refund the $468,372 of net 
overpayments. 
 
Mandated Analysis of Home Health Service Utilization From January 2016 Through March 2022 (A-
05-20-00031), December 2022 
  
We determined that, during the audit period, beneficiary utilization of home health services 
decreased for urban counties and rural counties in the high utilization and all other categories, 
while utilization in the low population density category remained steady.  We further determined 
that the number of home health episodes decreased for all urban and rural county categories.  
Many variables during the audit period, including the COVID-19 pandemic, may have affected 
utilization of services.  Therefore, we could not determine the cause of any changes in utilization of 
services during this period.  
  
Lawmakers designed the new rural add-on methodology to provide higher add-on percentages to 
rural counties in the low population density and all other categories.  The methodology shifted 
the distribution of add-on payments from the high utilization category to the low population 
density and all other categories.  We originally planned to use Federal Information Processing 
Standards (FIPS) data to analyze utilization from January 2016 through March 2022, but we were 
unable to do so because the FIPS data were incomplete.  
  
We recommend that CMS take the following steps to improve FIPS code reporting: (1) update the 
home health Pricer logic to check for missing and invalid FIPS codes on all home health claims and 
work with MACs to ensure that these claims are returned to providers for correction and (2) re-
educate providers on the requirement for all home health claims to be submitted with the FIPS 
code for the county where the service was provided.  CMS concurred with our second 
recommendation but not with our first recommendation. 
 
Providers Did Not Always Comply With Federal Requirements When Claiming Medicare Bad Debts 
(A-07-20-02825), December 2022 
  
Providers did not always comply with Federal requirements when claiming Medicare 
reimbursement for Medicare bad debts.  Of the 148 Medicare bad debts in our nonstatistical 
sample, 86 were associated with beneficiaries whom providers had deemed indigent and for 
whom, therefore, no reasonable collection efforts were required.  Providers did not comply with 
18 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
Federal requirements when claiming 18 of the remaining 62 Medicare bad debts.  We identified 
four additional bad debts for which the amounts that providers claimed did not reflect the 
amounts owed by the beneficiaries.  These 22 bad debts resulted in a total of $29,787 in 
unallowable Medicare reimbursement.  CMS inappropriately reimbursed these amounts because 
the MACs did not concentrate on reviewing bad debts when performing audits of cost reports 
during our audit period. 
  
For our second objective, the 67 selected providers policies and procedures for collecting from 
beneficiaries Medicare deductible and coinsurance amounts that providers claimed as Medicare 
bad debts complied with Federal requirements.  These policies and procedures were similar to the 
providers policies and procedures for collecting non-Medicare bad debts. 
  
We recommend that CMS consider issuing instructions to the MACs that require or encourage 
more review of Medicare bad debts claimed on cost reports, such as defining thresholds beyond 
which individual Medicare bad debts would trigger an audit, and that direct the MACs to revise 
their cost report audit work plans accordingly.  CMS concurred with our recommendation and 
stated that it would consider our findings when issuing future guidance to the MACs. 
 
Medicare Part B Spending on Lab Tests Increased in 2021, Driven By Higher Volume of COVID-19 
Tests, Genetic Tests, and Chemistry Tests (OEI-09-22-00400), December 2022 
 
Medicare Part B spent $9.3 billion on laboratory tests in 2021, a 17-percent increase from 2020.  
The increase in spending was driven by increased volume in three test categories: COVID-19 tests, 
genetic tests, and chemistry tests.  Genetic tests exceeded pre-pandemic spending levels, while 
chemistry tests increased from 2020 but did not fully return to pre-pandemic spending levels.  
However, the decline between pre-pandemic levels for chemistry tests and the 2020 and 2021 
levels could indicate that people are not seeking the routine or preventive care appointments 
where these tests are ordered.  The second year in a row of low volume for chemistry tests raises 
questions about the pandemics long-term impact on Medicare enrollee health.  The data brief 
contained no recommendations. 
 
Medicare Improperly Paid Physicians for Epidural Steroid Injection Sessions (A-07-21-00618), March 
2023 
  
Medicare did not always pay physicians for epidural steroid injection sessions in accordance with 
Medicare requirements.  For our audit period, Medicare improperly paid physicians $3.6 million on 
behalf of beneficiaries who received more epidural steroid injection sessions than were permitted 
by the coverage limitations in the applicable local coverage determinations.  These improper 
payments occurred because neither CMSs oversight nor the MACs oversight was adequate to 
prevent or detect improper payments for epidural steroid injection sessions. 
  
19 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
After our audit period, all 12 MAC jurisdictions updated their local coverage determinations with 
revised coverage limitations that were specific to epidural steroid injections.    
  
We recommend that CMS: (1) direct the MACs to recover the $3.6 million in improper payments; 
(2) instruct the MACs, based on the results of this audit, to notify appropriate physicians so that 
they can exercise reasonable diligence to identify, report, and return any overpayments in 
accordance with the 60-day rule; (3) assess the effectiveness of oversight mechanisms put in place 
after our audit period that are specific to preventing or detecting improper payments to physicians 
for more than the allowed number of epidural steroid injection sessions, and modify the 
mechanisms if necessary; and (4) direct the MACs (or other designated entities) to review a sample 
of claims for injection sessions administered after our audit period but before the revised coverage 
limitations became effective to identify and recover any improper payments.  CMS concurred with 
all of our recommendations and described actions that it had taken or planned to take to address 
them.   
 
Medicare Improperly Paid Physicians an Estimated $30 Million for Spinal Facet-Joint Interventions (A-
09-22-03006), March 2023 
  
Medicare did not pay physicians for some spinal facet-joint interventions in accordance with 
Medicare requirements and guidance.  Of the 120 sampled sessions, 54 complied with Medicare 
requirements; however, the remaining 66 sessions did not comply with 1 or more of the 
requirements.  As a result, Medicare made improper payments to physicians in the amount of 
$18,084.  On the basis of our sample results, we estimated that Medicare improperly paid 
physicians $29.6 million for facet-joint interventions for our audit period. 
  
In addition, of the 120 sampled sessions, 43 had claim lines that were billed for at least 1 
therapeutic facet-joint injection.  Of these 43 sessions, 33 sessions did not meet Medicare 
guidance, i.e., had claim lines that should have been billed for diagnostic instead of therapeutic 
facet-joint injections.  This improper billing did not result in improper payments because Medicare 
pays the same amount for diagnostic and therapeutic facet-joint injections. 
  
We recommend that CMS direct the MACs to recover $18,084 in improper payments made to 
physicians for the 66 sampled sessions.  We also recommend that CMS encourage the MACs to: (1) 
develop collaborative training programs for all of the MAC jurisdictions to use that are specific to 
Medicare requirements for facet-joint interventions, which could have saved an estimated $29.6 
million for our audit period; and (2) develop solutions to prevent the incorrect billing of diagnostic 
facet-joint injections as therapeutic facet-joint injections, such as developing additional education 
or updating guidance on how each type of injection should be billed.  The report contains one 
other recommendation.  CMS concurred with our recommendations, noting that it will direct the 
MACs to recover the identified overpayments.  In addition, CMS will notify the MACs of this audit 
so that they can determine whether additional education on proper billing is necessary. 
 
20 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
 
Quality of Care, Safety, and Access 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although 
Some Challenges Persist (OEI-01-21-00110), October 2022 
 
Home health agencies (HHAs) used their own strategies to help address challenges that the 
COVID-19 pandemic presented related to staffing and infection control, and HHAs benefited from 
CMS support such as regulatory flexibilities and expanded telehealth allowances, but challenges 
with staffing and telehealth persist.  Our findings can help CMS identify how to help HHAs prepare 
for and respond to future emergencies, as well as to evaluate how changes to the home health 
landscape can better serve patients.   
 
CMS concurred with our recommendations that CMS: (1) evaluate how HHAs are using telehealth
specifically, the types of services and the characteristics of patients who benefit from these services; 
(2) inform decision making and evaluate how the regulatory flexibilities it has offered in response 
to the COVID-19 Public Health Emergency affect the quality of home health care; and (3) in 
collaboration with the Administration for Strategic Preparedness and Responses (ASPRs) Technical 
Resources, Assistance Center, and Information Exchange, apply lessons learned from the COVID-19 
pandemic to update and/or develop emergency preparedness trainings and materials for HHAs on 
responding to infectious disease outbreaks. 
 
Long-Term Trends of Psychotropic Drug Use in Nursing Homes (OEI-07-20-00500), November 2022 
 
Overall, psychotropic drug use in nursing homes was relatively constant from 2011 through 2019; 
about 80 percent of Medicares long-stay nursing home residents were prescribed a psychotropic 
drug.  While CMS focused its efforts on reducing the use of antipsychotics, the use of 
anticonvulsants increased.  Additionally, over time the number of unsupported schizophrenia 
diagnoses increased and, in 2019, these diagnoses were concentrated in relatively few nursing 
homes.  Our findings identified ways that CMS can enhance its monitoring of the use of 
psychotropic drugs in nursing homes.   
 
CMS concurred with our recommendations that CMS: (1) evaluate the use of psychotropic drugs 
among nursing home residents to determine whether additional action is needed to ensure that 
use among residents is appropriate and (2) use data to identify nursing homes or nursing home 
characteristics that are associated with a higher use of psychotropic drugs and focus oversight on 
nursing homes in which trends may signal inappropriate use. 
 
CMS did not concur with our recommendation for CMS to expand the required data elements on 
Medicare Part D claims to include a diagnosis code. 
 
21 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
More Than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First 
Year of the COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies (OEI-02-20-
00491), January 2023 
 
Nursing homes had an initial surge of COVID-19 cases during the spring of 2020 and then a 
greater surge during the fall of that year, well after they were known to be vulnerable.  More than 
1,300 nursing homes had extremely high infection rates during these surges.  In each of these 
nursing homes, 75 percent or more of the Medicare beneficiaries were diagnosed with COVID-19 
or likely COVID-19 during the 2-month surge periods.  These nursing homes were more common 
and geographically widespread during the second surge than the first, even though they were 
known to be vulnerable.  Facilities with these extremely high infection rates experienced an average 
overall mortality rate approaching 20 percentroughly double that of other nursing homes.  Our 
findings indicate that significant changes are needed to protect residents and better prepare for 
current and future health emergencies.  Moreover, our findings lend urgency to the Biden 
administrations recent initiative to improve safety and quality care in nursing homes.   
 
CMS concurred with our recommendations that CMS: (1) re-examine current nursing staff 
requirements and revise them as necessary and (2) target nursing homes in most need of infection 
control intervention and provide enhanced oversight and technical assistance to these facilities as 
appropriate. 
 
CMS neither concurred nor nonconcurred with our recommendation to improve how surveys 
identify infection control risks to nursing home residents and strengthen guidance on assessing the 
scope and severity of those risks. 
 
 
Program Integrity 
CMS Can Use OIG Audit Reports To Improve Its Oversight of Hospital Compliance (A-04-21-08084), 
October 2022 
  
Of the 387 improperly paid claims identified in our previous 12 hospital compliance audits, 333 
were inpatient claims that resulted in $5,260,147 in net overpayments, and 54 were outpatient 
claims that resulted in $53,729 in net overpayments.  Of these 387 improperly paid claims, 229 
were appealed at the first level; 22 were overturned.  In addition, 126 claims were appealed at the 
second level; 6 were overturned.  As a result, 359 overpayment determinations totaling $5,041,721 
remained.  After considering the results of the first and second levels of appeal, we determined 
that the total overpayments received by the 12 hospitals was $82 million.  CMS has taken some 
actions to ensure that the recommendations in our previous 12 audits were implemented.  
However, CMS provided us with insufficient information regarding our recommendations to repay 
funds, and we could not determine whether it had implemented our recommendations.  In 
addition, CMS provided us with insufficient information regarding our recommendations to follow 
22 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
the 60-day rule; therefore, we could not ensure that our recommendations were implemented.  
With respect to our recommendations to strengthen internal controls, CMS acted on most but not 
all of these recommendations.  
  
We make several recommendations, including that CMS: (1) continue to follow up on the 
overpayment recovery recommendations contained in the 12 audits and (2) improve tracking and 
responding on the status of claims identified in our reports as they proceed through the appeals 
process.  CMS concurred with three of our recommendations but requested we remove two others. 
 
Labs With Questionably High Billing for Additional Tests Alongside COVID-19 Tests Warrant Further 
Scrutiny (OEI-09-20-00510), December 2022 
 
In 2020, 378 labs billed Medicare Part B for questionably high levels of add-on tests alongside 
COVID-19 tests.  These outlier labs consisted of labs for which: (1) add-on tests constituted a high 
proportion of each labs total number of tests and/or (2) add-on tests constituted a high 
proportion of each labs total payments for tests.  Some outlier labs often billed for add-on tests in 
combinations that had little if any variation across patients.  The add-on tests significantly 
increased the per-claim amounts that Medicare Part B paid to these labs.  Such high levels of 
billing for add-on tests raise concern about potential waste or fraud, suggesting a need for further 
scrutiny of billing by these labs.  OIG has referred these labs to CMS for further review.  This report 
contained no recommendations. 
 
The Inability To Identify Denied Claims in Medicare Advantage Hinders Fraud Oversight (OEI-03-21-
00380), February 2023 
 
Detailed data about the services provided to enrollees are essential for combating fraud and abuse 
in Medicare and Medicaid.  We found that there is no definitive method to identify denied claims in 
the Medicare Advantage encounter data, and the lack of a denied-claim indicator in these data 
hinders program integrity oversight.  Oversight entitiesincluding CMS program integrity staff, 
OIG investigators and analysts, and DOJ health care fraud staffreported that a denied-claim 
indicator in the Medicare Advantage encounter data would enhance the efficiency, scope, and 
accuracy of their efforts to combat fraud, waste, and abuse.  However, CMS does not require 
Medicare Advantage organizations to submit a denied-claim indicator because CMSs Medicare 
Plan Payment Group does not need this indicator to determine payments to Medicare Advantage 
organizations.  To strengthen Medicare Advantage program oversight and combat fraud, we 
recommend that CMS require Medicare Advantage organizations to definitively indicate on 
Medicare Advantage encounter data records when they have denied payment for a service on a 
claim.  CMS did not concur or nonconcur with our recommendation. 
 
 
23 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
Drug Pricing and Reimbursement 
Comparison of Average Sales Prices and Average Manufacturer Prices: Results for the Second 
Quarter of 2022 (OEI-03-23-00070), November 2022, and Comparison of Average Sales Prices and 
Average Manufacturer Prices: Results for the Third Quarter of 2022 (OEI-03-23-00080), February 
2023 
 
OIG identified 7 drug codes in the second quarter of 2022 and 15 drug codes in the third quarter of 
2022 that met CMSs criteria for price substitution.  OIG compares average sales prices (ASPs) to 
average manufacturer prices every quarter and identifies Part Bcovered drug codes eligible for 
price substitutions.  If OIG finds that the ASP for a drug exceeds the average manufacturer price by 
a certain percentagecurrently, 5 percentthe ASP-based payment amount is substituted with a 
lower calculated rate.  This serves as a mechanism for monitoring market prices and limiting 
potentially excessive payment amounts.  OIG provides these drug codes to CMS for its review.  
CMS reviews this information and determines whether to implement price substitutions that would 
limit excessive payments for Part B drugs. 
 
CMS Should Bolster Its Oversight of Manufacturer-Submitted Average Sales Price Data To Ensure 
Accurate Part B Drug Payments (OEI-03-21-00390), December 2022 
 
While CMS has some oversight procedures in place to review data on ASPs for Medicare Part B 
drugs, gaps exist in its oversight that allowed inaccurate data to impact Part B payment amounts.  
Because of invalid or missing ASP data, CMS could not calculate an ASP-based payment amount 
for 8 percent of drug codes at least once between 2016 and 2020.  In total, we found that 24 
percent of drug codes were missing ASP data for one or more specific drugs within that code in at 
least one quarter between 2016 and 2020.  In addition, CMS reported that late ASP data 
submissions from manufacturers substantially hindered its ability to conduct effective oversight.  
CMS concurred with our recommendation that CMS build a strategy to strengthen its internal 
controls for ensuring the accuracy of Part B drug payments.   
 
Manufacturers May Need Additional Guidance To Ensure Consistent Calculations of Average Sales 
Prices (OEI-BL-21-00330), December 2022 
 
We identified a small number of inconsistencies in how ASPs for Medicare Part B drugs are 
calculated and nine specific areas for which manufacturers believe additional CMS guidance may 
be needed to ensure more accurate ASP calculations.  The manufacturers we surveyed also 
expressed concerns that CMS has published comparatively fewer regulations and less overall 
guidance regarding the calculation of the ASPs used in Medicare compared to the average 
manufacturer prices and best prices used in Medicaid.  As a result, manufacturers say they must 
rely on reasonable assumptions to a much greater extent when calculating ASP than they do with 
these other payment benchmarks.   
 
24 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
CMS concurred with our recommendation that CMS actively review current guidance related to the 
nine areas identified in our report and determine whether additional guidance would ensure more 
accurate and consistent ASP calculations. 
 
Technical Assistance Brief: Implementation of Inflation-Indexed Rebates for Part B Drugs (OEI-BL-23-
00170), February 2023 
 
On the basis of our prior oversight work, we anticipate that unless CMS takes action to remedy 
several administrative issues, it will face the following challenges in implementing inflation-indexed 
rebates for Part B drugs: 
 
  identifying products subject to Part B rebates and 
  excluding claims from Part B rebate calculations that were already subject to:  
  rebates under the Medicaid Drug Rebate Program and  
o
  discounts under the 340B Drug Discount Program.  
o
 
We propose potential solutions to mitigate each administrative issue.  This technical assistance 
brief contained no recommendations. 
 
Medicare Could Have Saved up to $216 Million Over 5 Years if Program Safeguards Had Prevented 
At-Risk Payments for Definitive Drug Testing Services (A-09-21-03006), February 2023  
  
From January 2016 through December 2020 (audit period), Medicare paid $704.2 million for 
definitive drug testing services that were at risk for noncompliance with Medicare requirements.  
These payments were for the definitive drug testing service with the highest reimbursement 
amount (procedure code G0483).  These payments were made to 1,062 at-risk providers that 
routinely billed this procedure code and may not have been reasonable and necessary.  
Presumptive drug testing preceded most definitive drug testing services billed by both the at-risk 
and other providers, but the at-risk providers may not have always used presumptive testing to 
determine the number of drug classes that needed to be tested using definitive drug testing.  
Although the at-risk providers billed a significantly higher percentage of definitive drug testing 
services using procedure code G0483 than the other providers, the at-risk and other providers had 
similar characteristics (such as frequency of testing).  This suggests that the at-risk providers may 
have been able to bill for definitive drug testing services using primarily procedure codes with 
lower reimbursement amounts, as the other providers did. 
  
We recommend that CMS: (1) expand program safeguards to prevent and detect at-risk payments 
to at-risk providers for procedure code G0483; (2) review at-risk payments made to at-risk 
providers during and after our audit period and recover any overpayments; (3) notify appropriate 
providers to exercise reasonable diligence to identify, report, and return any overpayments; and (4) 
educate providers that received payments that did not comply with Medicare requirements.  CMS 
25 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
concurred with our first recommendation, did not concur with our second and third 
recommendations, and did not state whether it concurred with our fourth recommendation. 
 
Medicare Part D Plan Sponsors and CMS Did Not Ensure That Transmucosal Immediate-Release 
Fentanyl Drugs Were Dispensed Only to Beneficiaries Who Had a Cancer Diagnosis 
(A092003033), February 2023 
  
Medicare Part D plan sponsors and CMS did not ensure that all transmucosal immediate-release 
fentanyl (TIRF) drugs were dispensed in accordance with Medicare requirements.  Medicare 
requires that TIRF drugs be dispensed only for the medically accepted indication of breakthrough 
cancer pain.  For 7,552 PDEs, plan sponsors approved TIRF drugs dispensed to 810 beneficiaries 
who did not have a cancer diagnosis in their Medicare claims history to support a medically 
accepted indication for use of these drugs.  As a result, plan sponsors paid $86.2 million in 
unallowable Part D total costs.  Plan sponsors also approved 2,023 PDEs totaling $19.7 million for 
TIRF drugs for 176 beneficiaries whose most recent cancer diagnosis in their Medicare claims 
history was more than 1 year before the drugs were dispensed.  Although we did not determine 
these PDEs to be unallowable, they were at high risk of being unallowable.   
  
We recommend that CMS work with its plan sponsors to: (1) delete the PDEs related to the $86.2 
million of unallowable Medicare Part D total costs and determine after reconciliation the impact to 
the Federal Government and (2) identify and delete any unallowable PDEs related to the $19.7 
million of Part D total costs for beneficiaries whose most recent Medicare claim with a cancer 
diagnosis was for services provided more than 1 year before the TIRF drugs were dispensed, and 
determine the impact to the Federal Government.  The report contains three other 
recommendations.  CMS did not concur with four of our five recommendations and did not 
explicitly state whether it concurred with our fifth recommendation. 
 
Some Skin Substitute Manufacturers Did Not Comply with New ASP Reporting Requirements (OEI-
BL-23-00010), March 2023. 
 
Despite new legislative requirements, CMS was unable to calculate ASP-based payment amounts in 
the first quarter of 2023 for 30 of 68 skin substitute billing codes because their manufacturers did 
not report the required ASP data.  According to our analysis, Part B payment amounts would be 
reduced substantially if ASPs were consistently reported and used, potentially leading to tens of 
millions of dollars in savings each quarter.  However, CMS faces several unique hurdles in 
implementing ASP-based reimbursement for skin substitutes.  For example, because skin 
substitutes are not actually prescription drugs, CMS cannot employ its usual methods and data 
sources to corroborate manufacturer-reported data on pricing and packaging.  CMS is actively 
considering changes to the payment methodology for skin substitutes and, in January 2023, 
conducted a skin substitutes Town Hall to address stakeholder concerns and discuss potential 
payment approaches. 
 
26 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
 
Medicaid Program Reports and Reviews 
Financial Management and Improper Payments 
Colorado Did Not Report and Refund the Correct Federal Share of Medicaid-Related Overpayments 
for 70 Percent of the States Medicaid Fraud Control Unit Cases (A-07-21-02834), October 2022 
  
Colorado did not report and return the correct Federal share of MFCU-determined Medicaid 
overpayments identified during the period of October 1, 2014, through December 31, 2020.  
Colorado reported $5.8 million ($3.1 million Federal share) for this period but should have reported 
MFCU-determined Medicaid overpayments totaling $13 million ($6.8 million Federal share) for the 
179 MFCU cases that we reviewed.  Colorado did not report some or all of the correct Federal share 
for 126 cases (70 percent of the 179 MFCU cases we reviewed).  Furthermore, Colorado did not 
correctly report to CMS MFCU-determined Medicaid overpayments related to fraud, waste, and 
abuse.  Although Colorado had policies and procedures for the reporting of Medicaid 
overpayments, these policies and procedures were not always adequate.  
  
We recommend that Colorado refund $3.7 million (Federal share) in unreported MFCU-determined 
Medicaid overpayments that related to paid claims and court-ordered awards that have been 
recovered and collected.  We also recommend that Colorado determine the value of overpayments 
identified after our audit period that have been recovered and collected but not reported, report 
them to CMS, and refund the Federal share.  We make additional procedural recommendations.  
Colorado agreed with the amount of unreported MFCU-determined Medicaid overpayments but 
disagreed with refunding the overpayments.  Colorado said that it would review the cases to 
ensure that the amounts are not uncollectable and return the applicable Federal share by 
September 30, 2023.  Colorado agreed with our other recommendations and described corrective 
actions.   
 
California Made Almost $16 Million in Unallowable Capitation Payments for Beneficiaries With 
Multiple Client Index Numbers (A-04-21-07097), October 2022 
  
California made unallowable capitation payments on behalf of Medicaid beneficiaries with multiple 
Client Index Numbers (CINs).  Of the 100 beneficiary matches in our sample, California correctly 
made capitation payments on behalf of individuals associated with 24 beneficiary matches.  
However, it incorrectly made capitation payments that totaled $657,057 ($328,529 Federal share) 
on behalf of individuals associated with the remaining 76 matches.  The unallowable capitation 
payments occurred because the associated beneficiaries had multiple Medicaid CINs.  According to 
California, human error caused it to assign multiple CINs to these beneficiaries.  In addition, 
California used an algorithm to create the Beneficiary Name and Date of Birth Match Report that 
was too broad and did not require county staff to review training materials.  We estimated that 
27 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
California made unallowable capitation payments totaling approximately $31.4 million ($15.7 million 
Federal share) on behalf of beneficiaries with multiple CINs.  
  
We recommend that California: (1) refund to the Federal Government approximately $15.7 million 
in unallowable payments, (2) review capitation payments that fell outside of our audit period and 
refund any unallowable payments, (3) ensure that the algorithm used to create its revised 
Beneficiary Name and Date of Birth Match Reports is effective at detecting individuals with multiple 
records, (4) require county staff to review training materials on the prevention of issuing multiple 
CINs, and (5) enhance its controls to ensure that no beneficiary is issued multiple CINs.  California 
concurred with our recommendations and described the corrective actions that it has taken or 
plans to take. 
 
Iowa Implemented Most of Our Prior Audit Recommendations and Generally Complied With Federal 
and State Requirements for Reporting and Monitoring Major Incidents (A-07-21-06105), November 
2022 
  
Iowa implemented the nine recommendations from our prior audit and generally complied with 
Federal and State requirements for reporting and monitoring critical incidents involving Medicaid 
members with developmental disabilities residing in group homes.  However, Iowas corrective 
actions for one recommendation in our prior audit were not completely effective in addressing the 
associated finding.  Iowa did not ensure that community-based providers properly reported all 
major incidents involving members in waiver programs to the State.  Although Iowa achieved 
significant progress since our prior audit, its internal controls did not ensure that providers properly 
reported all major incidents because the State did not periodically update the diagnosis code list it 
used to identify Medicaid claims involving major incidents. 
  
We recommend that Iowa continue to strengthen internal controls to ensure full compliance with 
Federal and State requirements, to include periodically updating the list of diagnosis codes used 
when reviewing the Medicaid emergency room claims data to ensure that all Critical Incident 
Reports for major incidents are submitted as required.  Iowa concurred with our findings, agreed 
with our recommendation, described corrective actions that it has taken or plans to take, and 
projected the completion dates for the corrective actions.   
 
Puerto Rico MMIS and E&E Systems Security Controls Were Generally Effective, but Some 
Improvements Are Needed (A-18-20-08005), November 2022 
  
The Puerto Rico Medicaid Management Information System (MMIS) and Eligibility and Enrollment 
(E&E) system had reasonable security controls to prevent our simulated cyberattacks from resulting 
in a successful compromise; however, some of those security controls could be further enhanced to 
better prevent certain cyberattacks.  Puerto Rico did not correctly implement five security controls 
required by the National Institute of Standards and Technology (NIST) Special Publication (SP) 800-
53, Revision 4.  We estimated that the level of sophistication required by an adversary to 
28 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
compromise the Puerto Rico MMIS and E&E system was significant.  Still, some improvements were 
needed in Puerto Rico detection controls to better identify cyberattacks against its MMIS and E&E 
system and respond appropriately.  Potential reasons why Puerto Rico did not implement these 
security controls correctly may be that software developers did not follow secure coding standards 
to prevent security vulnerabilities or system administrators were not aware of Government 
standards or industry best practices that require securely configuring systems before deployment 
to production.  Puerto Rico's procedures for periodically assessing the implementation of the NIST 
security controls were not effective. 
  
We recommend that Puerto Rico: (1) remediate the vulnerabilities related to the five security 
control findings identified by properly implementing and regularly assessing the associated NIST 
SP 800-53 controls and (2) assess the cryptographic configurations of public servers at least 
annually and adjust if the requirements have changed.  Puerto Rico concurred with our 
recommendations and stated that it has addressed and remediated our findings. 
  
The Centers for Medicare & Medicaid Services' Review Contractors Generally Conducted Medicaid 
Fee-for-Service Claim Reviews for Selected States Under the Payment Error Rate Measurement 
Program in Accordance with Federal and State Requirements (A-04-21-00132), November 2022  
  
CMSs contractors generally conducted Medicaid fee-for-service (FFS) reviews in accordance with 
Federal and State requirements.  Of the 100 sampled Medicaid Payment Error Rate Measurement 
FFS claims we reviewed, 90 claims were correctly determined and adequately documented.  
However, claim review determinations for the remaining 10 claims were not documented and 
therefore may be incorrect.  Based on our sample results, we estimated that 10 percent of the 
sampled Medicaid FFS claims reviewed by CMSs contractors were not documented, and claim 
review determinations for these claims may not have been correct.  We also estimated the total 
amount paid related to these claims to be $6,411 (Federal share) during our audit period.  
  
CMSs contractors did not always maintain documentation of their claim review determinations 
because CMS did not include specific contract language requiring its contractors to maintain all 
documentation to support the contractors Medicaid FFS claim review determinations for non-error 
claims. 
  
We are not making recommendations because CMS took action to address the deficiencies we 
identified.   
 
Illinois Generally Complied With Requirements for Claiming Medicaid Reimbursement for Telehealth 
Payments During COVID-19 (A-05-21-00035), December 2022 
  
Illinois generally made telehealth payments that were in accordance with Federal and State 
requirements.  Of the 584,492 Medicaid FFS telehealth payments in our population, 583,960 
payments were in compliance with the requirements, but the remaining 532 payments were not.  
29 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
For 249 payments not in compliance, the same provider was paid both the originating site fee and 
the distant site fee.  Additionally, there were 146 payments made as duplicate payments for the 
same services provided to the same recipient on the same day.  Also, 22 of the payments were 
inaccurately billed as both originating and distant site fees.  Finally, providers incorrectly used the 
telehealth modifier with 35 different procedure codes that are for in-person services.  A total of 115 
telehealth payments were identified with these codes that could not be performed via 
telecommunication systems.  This noncompliance occurred because the State agency did not 
adequately monitor compliance.  The State agency also did not establish a list of acceptable 
telehealth procedure codes.  Based on our testing, we calculated that the unallowable payments 
totaled approximately $16,154 ($9,832 Federal share) during our audit period. 
  
We recommend that Illinois: (1) refund up to $9,832 to the Federal Government and enhance the 
monitoring of provider compliance by conducting periodic reviews of telehealth payments for 
compliance with requirements and (2) establish a list of acceptable telehealth procedure codes.  
Illinois agreed with our findings and provided information on actions that it plans to take to 
address our recommendations. 
 
The Centers for Medicare & Medicaid Services' Review Contractor Did Not Document Medicaid 
Managed Care Payment Review Determinations Made Under the Payment Error Rate Measurement 
Program (A-04-21-09003), December 2022 
  
CMSs review contractor conducted the majority of its Medicaid managed care payment reviews in 
accordance with Federal requirements.  Of the 100 sampled Medicaid managed care payments we 
reviewed, 60 were correctly determined.  However, we were not able to determine whether the 
remaining 40 payment review determinations were correct because the payment reviews were not 
documented and therefore may be incorrect.  Based on the sample results, we estimated 40 
percent of the sampled Medicaid managed care payment determinations made by CMSs review 
contractor may not have been correct.  We also estimated the total amount related to these 40 
claims to be $229,435 ($123,520 Federal share) during our audit period.  CMSs review contractor 
did not maintain documentation of its payment review determinations because CMS did not 
include specific contract and statement-of-work language requiring its review contractor to 
maintain all documentation to support its Medicaid managed care payment review determinations 
for non-errors.  
  
We are not making recommendations because CMS took action to address the deficiencies we 
identified.  Specifically, after our audit period, for the reporting year 2020, 2021, and 2022 Payment 
Error Rate Measurement cycles, CMS exercised an optional task for the contract with the review 
contractor, which added language requiring that the review contractor maintain relevant 
documentation for non-error (i.e., correct) payments.  In its contract renewal occurring in March 
2021, CMS replaced the optional task with a permanent requirement for the review contractor to 
maintain relevant documentation for non-error payments. 
 
30 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
 
Missouri Claimed Federal Medicaid Reimbursement for Tens of Millions in Consumer-Directed 
Personal Care Assistance Services That Did Not Comply With Federal and State Requirements  
(A-07-20-03243), February 2023  
  
Missouri did not always ensure that the consumer-directed personal care assistance (PCA) services 
for which it claimed Federal Medicaid reimbursement during FYs 2018 and 2019 complied with 
Federal and State requirements.  Specifically, 17 of the 150 sampled items were at least partially 
unallowable.  Based on our sample results, we estimated that Missouri claimed at least $52.5 
million ($34.2 million Federal share) for unallowable consumer-directed PCA services during FYs 
2018 and 2019.  In addition, timesheets for 46 of the 150 sampled items did not identify the specific 
services that were performed in accordance with the plans of care.  We are setting aside an 
estimated $133.8 million ($87 million Federal share) for CMS resolution associated with these 46 
items.  
  
Additionally, Missouri did not have established and implemented pandemic emergency 
preparedness standards and protocols within the consumer-directed PCA program.  Most 
providers for the sampled items did not have any emergency preparedness documentation for a 
pandemic response.  
  
We recommend that Missouri: (1) refund the $34.2 million (Federal share) in overpayments to the 
Federal Government and (2) work with CMS to determine the allowability of the $87 million 
(Federal share) and refund any amount that is determined to be unallowable.  We also make 
procedural recommendations.  Missouri disagreed with most of our findings and recommendations 
and gave us additional documentation.  We revised the number of sampled items in error, revised 
our statistical estimate and the amount conveyed in our first recommendation, and removed one 
procedural recommendation for this final report.   
 
Florida Made Capitation Payments for Enrollees Who Were Concurrently Enrolled in a Medicaid 
Managed Care Program in Another State (A-05-21-00028), February 2023 
  
Florida made August 2020 Medicaid managed care capitation payments totaling $15.8 million on 
behalf of 55,164 enrollees who were concurrently enrolled for Medicaid benefits in another State.  
Of the 100 enrollees in our stratified random sample, we determined that 56 enrollees were 
residing and enrolled for Medicaid benefits in Florida.  However, Florida made August 2020 
capitation payments totaling $22,624 ($15,336 Federal share) on behalf of 44 Florida Medicaid 
managed care enrollees who were residing and concurrently enrolled for Medicaid in another 
State.  On the basis of our sample results, we estimated that Florida incurred costs of $6.9 million 
($4.7 million Federal share) for August 2020 capitation payments made on behalf of enrollees who 
were residing and concurrently enrolled in another State. 
  
31 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
We recommend that Florida: (1) resume and enhance procedures that are in accordance with 
Federal requirements and the States unwinding plan to identify and disenroll enrollees who are 
residing and enrolled in Medicaid managed care in another State when the Public Health 
Emergency ends and (2) work with CMS to consider the potential use of CMS's Transformed 
Medicaid Statistical Information System data to identify potential cases of concurrent enrollment.  
In written comments on our draft report, Florida concurred with our recommendations and 
described the actions that it plans to take to address them. 
 
Quality of Care, Safety, and Access 
For Medicaid-Enrolled Children Diagnosed With Lead Toxicity in Five States, Documentation 
Reviewed for Diagnoses and Treatment Services Raises Concerns (OEI-07-18-00370),December 2022 
 
In five States, most of the medical records that our study reviewed for children with a lead toxicity 
diagnosis in their Medicaid claims lacked adequate information to confirm a diagnosis of lead 
toxicity, and among children for whom there was sufficient medical record documentation to 
confirm their diagnosis, many did not receive comprehensive followup testing and treatment 
services, as recommended, for their identified blood lead level.  Our findings can help CMS address 
concerns related to oversight of the Early and Periodic Screening, Diagnostic, and Treatment 
(EPSDT) program and ensure that Medicaid-enrolled children with lead toxicity are given the best 
possible health care.  CMS concurred with our recommendations that CMS: (1) explore the 
discrepancy between Medicaid claims data and medical documentation for lead toxicity and 
implement solutions to ensure better oversight of the EPSDT program and (2) issue guidance to 
reiterate State obligations under the EPSDT benefit to ensure access to services to correct or 
ameliorate confirmed blood lead levels identified during screenings. 
 
Keystone First Should Improve Its Procedures for Reviewing Service Requests That Require Prior 
Authorization (A-03-20-00201), December 2022 
  
Keystone First did not comply with Federal and State requirements when denying 76 of the denied 
service requests in our sample.  Specifically, Keystone First should not have denied the overnight 
care portion of 10 denied pediatric skilled nursing service requests on the basis that it had not 
received work or school verification documentation for the caregiver.  For 72 denied service 
requests, Keystone Firsts denial letter, based on Pennsylvanias required form, did not inform 
beneficiaries of their right to request a State fair hearing after exhausting the managed care 
organizations (MCOs) appeals process.  
  
We recommend that Keystone First coordinate with Pennsylvania to: (1) update Keystone Firsts 
administrative process to require that medical directors assess whether overnight care requests 
meet the medical necessity requirement, even if some documentation is missing; (2) review all 
pediatric skilled nursing service requests for which overnight care was completely denied and 
determine whether overnight care requests meet the medical necessity requirement; and (3) 
32 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
implement a revised initial denial notice to explain that a beneficiary has the right to request a 
State fair hearing after exhausting the MCOs appeals process.  We also recommend that 
Pennsylvania revise its denial notice template.  In written comments on our draft report, Keystone 
First stated that it concurred with the intent of all three recommendations addressed to it.  
Pennsylvania also concurred with the recommendation addressed to it and concurred with the first 
and third recommendations addressed to Keystone First but did not concur with the second 
recommendation due, in part, to a COVID-19 waiver. 
 
Drug Spending and Reimbursement 
During this reporting period, OIG conducted a number of audits that were designed to assess 
whether States properly billed manufacturers for physician-administered drugs.  Prior OIG reviews 
and investigations have identified areas at risk for noncompliance with Medicaid billing 
requirements.  Complete recommendations and State responses can be found in the final reports 
summarized here. 
  
Mississippi Did Not Always Invoice Rebates to Manufacturers for Physician-
Administered Drugs (A-07-21-06101), October 2022 
  
Mississippi did not always comply with Federal Medicaid requirements for invoicing 
manufacturers for rebates for physician-administered drugs.  Mississippi did not 
invoice for or collect from manufacturers rebates associated with $2.2 million 
(Federal share) in physician-administered drugs.  Of this amount, $820,732 (Federal 
share) was for single-source drugs and $395,621 (Federal share) was for top-20 
multiple-source drugs.   
  
Further, we were unable to determine whether Mississippi was required to invoice 
for rebates associated with $1 million (Federal share) for other multiple-source 
physician-administered drug claims.  In addition, Mississippi did not invoice for or 
collect from manufacturers $35.6 million (Federal share) in rebates for physician-
administered drugs invoiced on crossover claims, for which beneficiaries are eligible 
for both Medicare and Medicaid.  Mississippis internal controls did not always 
ensure that the drug utilization data it collected were used to invoice manufacturers 
and collect rebates. 
 
North Carolina Did Not Always Invoice Rebates to Manufacturers for Physician-
Administered Drugs (A-07-21-07002), February 2023 
  
North Carolina did not always comply with Federal Medicaid requirements for 
invoicing manufacturers for rebates for physician-administered drugs.  North 
Carolina did not invoice for or collect from manufacturers rebates associated with 
$3.1 million (Federal share) in physician-administered drugs.  Of this amount, $2.3 
33 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
million (Federal share) was for single-source drugs and $734,000 (Federal share) 
was for top-20 multiple-source drugs.   
  
Further, we were unable to determine whether, in some cases, North Carolina was 
required to invoice for rebates for other multiple-source physician-administered 
drug claims.  North Carolina did not invoice the manufacturers for rebates 
associated with claims totaling $685,000 (Federal share) for these multiple-source 
drugs. 
  
Florida Did Not Invoice Manufacturers for Some Rebates for Physician-Administered 
Drugs Dispensed to Enrollees of Medicaid Managed-Care Organizations (A-04-21-
07098), March 2023 
  
Florida generally complied with Federal Medicaid requirements for invoicing 
manufacturers for rebates for physician-administered drugs dispensed to MCO 
enrollees.  However, Florida did not invoice for or collect from manufacturers an 
estimated $57,700 ($35,126 Federal share) in rebates for single-source physician-
administered drugs.  Furthermore, we were unable to determine whether, in some 
cases, Florida was required to invoice for rebates for other multiple-source 
physician-administered drug claims.  Florida did not invoice manufacturers for 
rebates totaling $40,635 ($24,772 Federal share) for these multiple-source drugs.   
 
Georgia Did Not Always Invoice Rebates to Manufacturers for Pharmacy and 
Physician-Administered Drugs (A-04-21-08089), March 2023  
 
Georgia did not always comply with Federal Medicaid requirements for invoicing 
manufacturers for rebates for pharmacy and physician-administered drugs.  
Georgia did not invoice for or collect from manufacturers rebates associated with 
$953,067 ($644,802 Federal share) in single-source physician-administered drug 
claims and $13,785 ($9,325 Federal share) in top-20 multiple-source physician-
administered drug claims.  Further, we were unable to determine whether, in some 
cases, Georgia was required to invoice for rebates for other multiple-source 
physician-administered drug claims.  Georgia did not invoice the manufacturers for 
rebates associated with the claims totaling $78,013 ($52,837 Federal share) for these 
multiple-source drugs.  Additionally, OIG identified $1.8 million ($1.2 million Federal 
share) in single-source pharmacy drug claims and $526,240 ($360,454 Federal 
share) in multiple-source pharmacy drug claims that were not rebated for prior to 
our audit. 
 
The District of Columbia Has Taken Significant Steps To Ensure Accountability Over Amounts 
Managed Care Organizations Paid to Pharmacy Benefit Managers (A-03-20-00200), March 2023 
  
34 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
The District of Columbia provided some oversight of its MCOs with the intent of ensuring adequate 
accountability over amounts paid for prescription benefits to its PBMs.  This oversight consisted of 
guidance requiring MCOs to report spread pricing.  However, the amounts reported were 
aggregated with other amounts and as a result did not provide transparency over the amount of 
the funds that was attributable to spread pricing.  We found that PBMs kept $23.3 million in spread 
pricing during our audit period.  Spread pricing may increase the cost of Medicaid prescriptions for 
both the MCO and the Medicaid program and, if not correctly accounted for, inflate the cost of the 
drugs.  Limiting spread pricing may decrease Federal and State spending through lower payments 
to MCOs. 
  
We recommend that the District develop policies and procedures for validating MCO, PBM, and 
pharmacy transactions on a periodic basis to ensure transparency of costs associated with the 
prescription drug program.  The District concurred with our recommendation and asked for 
clarification and guidance regarding the amounts or percentages that are deemed appropriate for 
PBMs to retain under the practice of spread pricing. 
   
35 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
Legal and Investigative Activities Related to 
Medicare and Medicaid  
OIG investigates allegations of fraud, waste, and abuse in all HHS programs.  Our largest body of work 
involves investigating matters related to the Medicare and Medicaid programs, such as patient harm; 
billing for services not rendered, medically unnecessary services, or upcoded services (i.e., services billed at 
a level higher than warranted); illegal billing, sale, and diversion of prescription drugs; marketing off-label 
uses for prescription drugs; and solicitation and receipt of kickbacks, including illegal payments to patients 
for involvement in fraud schemes and illegal referral arrangements between physicians and medical 
companies. 
 
OIG also conducts investigations regarding organized criminal activity, including medical identity theft and 
fraudulent medical schemes established for the sole purpose of stealing Medicare dollars.  Investigators 
are opening an increasing number of cases against health care providers who engage in these health care 
fraud schemes.  Those who participate in the schemes may face heavy fines, jail time, and exclusion from 
participation in Federal health care programs. 
 
One of the most common types of fraud perpetrated against Medicare, Medicaid, and other Federal health 
care programs involves filing false claims for reimbursement.  False claims may be pursued under Federal 
and State criminal statutes and, when appropriate, under the False Claims Act.  Depending on the types of 
fraud or other violations involved, OIG investigations may culminate in criminal or civil court judgments 
and decisions, administrative sanctions and decisions, and/or negotiated settlement agreements.  
Investigative outcomes take many forms, including incarceration, restitution, fines, penalties, forfeitures, 
assessments, and exclusion of individuals or entities from participation in all Federal health care programs.  
Frequently used exclusion and penalty authorities are described on our Enforcement Actions website. 
 
During this semiannual reporting period, we reported 318 criminal and 318 civil actions against individuals 
or entities that engaged in offenses related to health care.  We also reported more than $626.8 million in 
investigative receivables due to HHS and more than $207 million in non-HHS investigative receivables, 
including civil and administrative settlements or civil judgments related to Medicare, Medicaid, and other 
Federal, State, and private health care programs.   
 
 
Criminal and Civil Enforcement Activities Related to Medicare and Medicaid 
The following recently completed actions and settlements are organized by the type of provider or entity 
involved.  Additional cases appear in the Medicare Fraud Strike Force Activities section that follows. 
 
36 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
COVID-19 Enforcement Activities 
The following case example involves COVID-19 enforcement activities:  
 
Connecticut  On November 4, 2022, Zaya Powell, of Waterbury, was sentenced to 3 years 
of probation for creating false COVID-19 vaccine records for several individuals.  Judge 
Meyer also ordered Powell to pay a $5,000 fine and perform 200 hours of community 
service.  Between August and October 2021, Powell created fraudulent vaccination records 
in the Vaccine Administration Management System for 14 different individuals.  The 
fraudulent cards included lot numbers of genuine vaccines that were administered to other 
patients.    
 
Home Health 
The following case example involves home health fraud:  
  
Texas  On October 31, 2022, Felix Amos, of Houston, was sentenced to serve 30 months in 
Federal prison followed by 3 years of supervised release for conspiracy to commit health 
care fraud.  He was further ordered to pay $21,197,440 in restitution.  Oluyemisi Amos (Felix 
Amoss wife), 41, of Houston, previously pled guilty and later received a sentence of 72 
months in prison.  In addition, on March 22, a jury returned guilty verdicts against Fausat 
Adekunle, 39, of Richmond, on 10 counts following a 4-day jury trial.  Adekunle was later 
ordered to serve 144 months in Federal prison to be immediately followed by 3 years of 
supervised release, and to pay restitution of $21,197,440.14.  Evidence and testimony 
revealed that the three conspired to submit claims to Medicare for home health services for 
patients who did not need services or did not receive services and for whom physicians had 
not ordered such services.  Furthermore, billing emails showed that many of the claims 
Adekunle submitted were for Medicare beneficiaries who were dead for more than 3 years 
or incarcerated in prison and were thus not eligible for home health services. 
 
Substance Use Disorder Treatment  
The following case example involves a treatment facility: 
  
Florida  On January 9, 2023, Michael Ligotti was sentenced to 20 years in prison for 
engaging in a massive multiyear scheme to bill health care benefit programs for fraudulent 
tests and treatments for vulnerable patients seeking treatment for drug and/or alcohol 
addiction.  This case was brought as part of DOJs Sober Homes Initiative.  According to 
court documents, Ligotti, D.O., of Delray Beach, served as Medical Director or Authorizing 
Physician for more than 50 sober homes, substance use disorder treatment facilities, and 
clinical testing laboratories in the Palm Beach County area, often signing standing orders 
for expensive, medically unnecessary urine drug tests for patients at various addiction 
37 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
treatment facilities.  As a result of this conduct, which took place from 2011 to 2020, health 
care benefit programs were billed more than $746 million and paid approximately $127 
million for fraudulent urine drug tests and addiction treatments.  Ligotti pled guilty to 
conspiracy to commit health care and wire fraud in the Southern District of Florida in 
October 2022 and was ordered at sentencing to surrender his medical license. 
 
Prescription Drugs 
The following case examples involve prescription drugs: 
 
Michigan  On January 30, 2023, Francisco Patino, M.D., was sentenced to 16.5 years in 
prison for his role in a health care fraud scheme that resulted in more than $250 million in 
false and fraudulent claims being submitted to Medicare, Medicaid, and other health 
insurance programs.  Patino exploited patients suffering from addiction by administering 
unnecessary injections, illegally distributed more than 6.6 million doses of medically 
unnecessary opioids, and engaged in money laundering.  Patino played a critical role in 
developing and implementing a shots-for-pills protocol at several pain clinics, whereby 
patients were required to receive unnecessary back injections in exchange for prescriptions 
for high doses of medically unnecessary and addictive opioids.  In September 2021, Patino 
was convicted at trial in the Eastern District of Michigan of conspiracy to commit health 
care fraud and wire fraud, health care fraud, conspiracy to defraud the United States and 
pay and receive health care kickbacks, conspiracy to commit money laundering, and money 
laundering. 
 
Pennsylvania  On January 19, 2023, Larry J. Goisse, Jr., was sentenced to 24 months in 
prison to be followed by 3 years of supervised release on charges of drug diversion and 
health care fraud.  On October 4, 2022, Goisse pled guilty to one count of an indictment 
charging him with drug diversion and five counts of an information charging him with 
health care fraud. 
 
In connection with the guilty plea, the court was advised that in September 2018 through 
January 2019, Goisse, a former certified nurse practitioner, illegally prescribed the scheduled 
drug Adderall after his State medical license was revoked and he lost his Drug Enforcement 
Administration registration.  In order to continue to receive payments from Medicare, 
Goisse submitted claims to Medicare for office visits under a coworkers license after 
suspension. 
 
Kickbacks 
The following case examples involve kickbacks: 
   
38 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
Florida  On November 1, 2022, Modernizing Medicine, Inc. (ModMed), an electronic health 
record (EHR) technology vendor located in Boca Raton, Florida, agreed to pay $45 million 
to resolve allegations that it violated the False Claims Act by accepting and providing 
unlawful remuneration in exchange for referrals and by causing its users to report 
inaccurate information in connection with claims for Federal incentive payments.  In a 
complaint filed in conjunction with the settlement, the United States alleged that ModMed 
violated the False Claims Act and the anti-kickback statute through three marketing 
programs.  First, ModMed solicited and received kickbacks from Miraca Life Sciences, Inc. 
(Miraca) in exchange for recommending and arranging for ModMeds users to utilize 
Miracas pathology lab services.  Second, ModMed conspired with Miraca to improperly 
donate ModMeds EHR to health care providers in an effort to increase lab orders to Miraca 
and simultaneously add customers to ModMeds user base.  Third, ModMed paid kickbacks 
to its current health care provider customers and to other influential sources in the health 
care industry to recommend ModMeds EHR and refer potential customers to ModMed.  As 
a result of this conduct, the Government alleged that ModMed improperly generated sales 
for itself and for Miraca, while causing health care providers to submit false claims for 
reimbursement to the Federal Government for pathology services and for incentive 
payments from HHS for the adoption and meaningful use of ModMeds EHR technology.  
In January 2019, Miraca (known as Inform Diagnostics as of 2018) agreed to pay $63.5 
million to resolve allegations that it violated the anti-kickback statute and the physician 
self-referral law (Stark Law) by providing referring physicians with subsidies for EHR systems 
and free or discounted technology consulting services.   
 
Massachusetts  On January 20, 2023, DePuy Synthes, Inc. (DePuy), a subsidiary of Johnson 
& Johnson, agreed to pay $9.75 million to resolve allegations that it violated the False 
Claims Act by paying kickbacks to an orthopedic surgeon based in Massachusetts to induce 
the use of DePuy products.  DePuy violated the anti-kickback statute and caused the 
submission of false or fraudulent claims to Medicare by paying the orthopedic surgeon 
kickbacks in the form of free spinal implants and tools for use in surgeries that the surgeon 
performed overseas to induce that surgeon to use DePuy products in surgeries performed 
in the United States.  DePuy has admitted that from at least July 2013 through February 
2018, DePuy, acting through certain former sales representatives, gave the Massachusetts 
surgeon thousands of dollars worth of free DePuy implants and instruments, including 
cages, rods, screws, plates, and surgical instrumentation, that the surgeon used to perform 
surgeries overseas for patients who were not Federal health care beneficiaries.  Of the $9.75 
million to be paid by DePuy, approximately $7.23 million will be returned to the Federal 
Government, and approximately $2.52 million will be returned to Massachusetts, which 
jointly funded claims for surgeries involving DePuy devices that were submitted to the 
Massachusetts Medicaid program. 
 
New York  On December 1, 2022, two New York diagnostic testing facility owners were 
sentenced to 3 years in prison for their roles in a more than $18 million health care fraud 
39 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
scheme.  According to court documents, Tea Kaganovich, 50, and Ramazi Mitaishvili, 62, 
both of Brooklyn, are a married couple that co-owned several diagnostic testing facilities in 
Brooklyn.  The couple paid more than $18 million in kickbacks for the referral of 
beneficiaries who submitted themselves to diagnostic testing and other purported medical 
services.  Kaganovich and Mitaishvili also falsely reported to the Internal Revenue Service 
that the illegal kickback payments were legitimate business expenses and therefore 
submitted tax forms that underreported business income and claimed deductions to which 
they were not entitled. 
 
Ohio  On February 3, 2023, Deepak Raheja, of Hudson, was sentenced to 30 months in 
prison and ordered to surrender his medical license, pay $2,163,995 in restitution, and pay a 
$50,000 fine.  Between February 2011 and July 2016, Raheja and co-defendants Frank 
Mazzucco, Gregory Hayslette, and Bhupinder Sawhny conspired together to increase the 
number of prescriptions that Raheja and Sawhny wrote for Nuedexta, a prescription drug 
that treats pseudobulbar affect (PBA), in exchange for the payment of monetary kickbacks 
and other items of value.  Mazzucco and Hayslette were employed as pharmaceutical sales 
representatives by Avanir Pharmaceuticals (Avanir) in the region where Raheja and Sawhny 
practiced medicine.  Avanir promoted Nuedexta through a speakers bureau, under which 
Avanir representatives engaged doctors to speak about and promote Nuedexta to other 
medical professionals.  Raheja received approximately $1,500 for each of these purported 
presentations.  During this timeframe, Raheja received approximately $331,550 in payments 
from Avanir and wrote approximately 10,088 Nuedexta prescriptionsthe highest in the 
country.  Raheja and Sawhny took steps in return, including writing more Nuedexta 
prescriptions, which caused the submission of bills to Medicare and Medicaid for Nuedexta 
prescriptions for patients that did not have PBA, falsely diagnosing patients with PBA, and 
recording fictitious symptoms in patient records to support a diagnosis of PBA. 
 
Texas  On November 23, 2022, Lindell King and Ynedra Diggs were sentenced for a $1 
million Medicare fraud scheme, including violations of the Federal anti-kickback statute.  
King, of Missouri City, was sentenced to 60 months in prison.  Diggs, also of Missouri City, 
was sentenced to 70 months in prison.  King and Diggs were also ordered to pay 
$537,992.55 in restitution.  According to court documents and evidence presented at trial, 
both Diggs and King were patient recruiters who owned and operated group homes in 
which Medicare beneficiaries lived.  In exchange for sending their group home residents to 
Behavioral Medicine of Houston (BMH), a community mental health center that purported 
to provide partial hospitalization services, BMH paid Diggs, King, and other patient 
recruiters illegal kickbacks in cash and by check, often concealed as payment for 
transportation or other sham services.  During the conspiracy, BMH fraudulently billed 
approximately $1 million to Medicare in claims related to patients it received in exchange 
for the kickbacks paid to Diggs and King. 
 
40 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
Nursing Homes 
The following case example involves a nursing home: 
 
California  On November 29, 2022, Tranquility Incorporated, a corporation doing business 
as San Miguel Villa, a 190-bed nursing home located in Concord, agreed to pay $2.3 million 
to settle allegations that it submitted false claims by billing the Medicare and Medi-Cal 
programs for substandard nursing home services.  The settlement resolves allegations that 
from 2012 to 2017 San Miguel Villa submitted, or caused to be submitted, claims to the 
Medicare and Medi-Cal programs for payment of its services that were grossly substandard 
and failed to meet minimum required standards of skilled nursing care in multiple ways.  
The United States alleges that nursing home residents at San Miguel Villa were 
overmedicated with psychotropic drugs, suffered excessive falls, were exposed to resident-
on-resident altercations, and experienced other mental and physical harm. 
 
Durable Medical Equipment  
The following case example involves durable medical equipment: 
 
Illinois  On January 4, 2023, Jet Medical, Inc. (Jet) agreed to pay $200,000 to resolve 
criminal allegations relating to a migraine headache treatment device, and Jet and two 
related companies agreed to pay another $545,000 in a civil settlement involving the same 
device.  Between April 2014 and April 2019, Jet introduced into interstate commerce devices 
that were misbranded under the Federal Food, Drug, and Cosmetic Act because Jet did not 
obtain approval or clearance from the Food and Drug Administration (FDA) prior to 
distributing the devices.  Jets device, the Allevio SPG Nerve Block Catheter (Allevio), was 
intended to treat migraine headaches by administering nerve blocks to the sphenopalatine 
ganglion (SPG), a collection of nerves located deep in the midface of the skull.  The 
information alleges that Jet never sought approval or clearance from FDA to distribute the 
Allevio for this intended use, nor did Jet conduct an investigational study regarding the 
Allevios safety and effectiveness when used as intended. 
 
Medicare Fraud Strike Force Activities 
In 2007, Medicare Fraud Strike Force teams began an effort to combine resources of Federal, State, and 
local law enforcement entities to prevent and combat health care fraud, waste, and abuse.  These 
partnerships among OIG and HHS, DOJ, U.S. Attorneys Offices, the Federal Bureau of Investigation (FBI), 
and State and local law enforcement agencies have a common goal: to analyze health care fraud data and 
investigative intelligence to quickly identify fraud and bring prosecutions.  Strike Force teams operate in 11 
areas: Miami and Tampa/Orlando, Florida; Dallas and Houston, Texas; Los Angeles, California; Detroit, 
Michigan; Brooklyn, New York; Baton Rouge and New Orleans, Louisiana; Chicago, Illinois; and Newark, 
New Jersey/Philadelphia, Pennsylvania; along with a Corporate Strike Force located in Washington, DC.  
41 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
During this semiannual reporting period, Strike Force efforts resulted in the filing of charges against 97 
individuals or entities, 98 criminal actions, and more than $239 million in investigative receivables. 
In October 2018, DOJ announced the creation of a new initiative to combat the Nations opioid 
epidemic.  The Appalachian Regional Prescription Opioid Strike Force covers 10 Federal judicial districts 
in Alabama, Kentucky, Ohio, Tennessee, Virginia, and West Virginia.  OIGs Office of Investigations is 
working closely with its law enforcement partners at the Drug Enforcement Administration, FBI, and 
the MFCUs to provide investigative support.  Cases involve physicians and pharmacies that are 
responsible for medically unnecessary opioid prescriptions and dangerous drug combinations that are 
being paid for by Medicare and Medicaid.  In many instances, there are other allegations of 
wrongdoing relating to kickbacks, health care fraud, and quality of care, including patient overdoses 
and deaths. 
 
The following case examples involve Strike Force cases: 
 
Maryland  On November 18, 2022, Edward T. Buford, III, was sentenced to 30 months in Federal 
prison followed by 3 years of supervised release for conspiracy to commit mail fraud and health 
care fraud.  Buford was also ordered to pay $1,267,630 in restitution.  Buford was a licensed dentist 
in Washington, DC and the owner and Chief Executive Officer of International Dental Associates, 
Inc. (IDA), a dental clinic located in Washington, DC.  According to his guilty plea, from January 
2013 to May 2018, Buford led a scheme to file fraudulent Medicaid claims for dental services to 
Medicaid beneficiaries and recruited Medicaid beneficiaries to fuel the scheme through the 
payment of kickbacks and bribes.  Buford caused the submission of Medicaid claims for a variety of 
dental services, including dentures.  As part of the conspiracy, Buford paid kickbacks to patient 
recruiters in exchange for referring Medicaid beneficiaries to IDA for dental services.  Buford stored 
hundreds of undelivered dentures on IDAs premises, many of which had been billed to and paid 
for by Medicaid.  As part of the scheme, Buford maintained a post office box in Silver Spring, 
Maryland as IDAs billing address and received the fraudulently obtained payments at that location.  
This was a joint investigation with the FBI, the Social Security Administration-OIG, and the MFCU. 
 
Mississippi  On October 18, 2022, sales representative Logan Power was sentenced to 25 months 
in prison and ordered to pay a total of $2,954,585.90 in restitution jointly with other yet-to-be-
sentenced defendants.  Power worked as a sales representative for a pharmacy in Baton Rouge, 
Louisiana that dispensed "foot bath" medications, as well as a laboratory in Glen Allen, Virginia that 
performed expensive genetic testing on toenail samples.  Power was paid kickbacks for steering 
referrals and prescriptions from podiatrists with whom he had relationships to select pharmacies 
and laboratories.  Power then paid cash kickbacks to those podiatrists in exchange for their 
referrals and prescriptions.  In total, Power paid approximately $133,000 in cash kickbacks to three 
Mississippi podiatrists: Dr. Carey Williams, Dr. Marion Lund, and Dr. Jared Spicer.  In July 2020, 
Power was captured on video paying a cash kickback to a cooperating doctor.  On October 5, 2021, 
Power pled guilty to one count of conspiracy to defraud the United States.  In August 2022, Dr. 
Spicer pled guilty to one count of conspiracy to commit health care fraud, and in February 2023 he 
42 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
was sentenced to 3 years of probation.  In September 2022, Dr. Williams pled guilty to one count 
of conspiracy to commit health care fraud and is awaiting sentencing.  In February 2023, Dr. Lund 
pled guilty to one count of conspiracy to commit health care fraud and is awaiting sentencing.  
This was a joint investigation with the Department of Defense OIG (DOD-OIG)/Defense Criminal 
Investigative Service.  
 
Compliance Trainings 
Health Care Provider Compliance Training  
OIG provides free training on our website for health care providers, compliance professionals, and 
attorneys.  OIGs Provider Compliance Training was an initiative developed in 2011 that continues to 
reach the health care community with OIGs message of compliance and prevention via free 
downloadable comprehensive training materials and podcasts.  OIGs provider compliance training 
resources are available on OIG's Compliance Guidance website. 
 
American Indian/Alaska Native Compliance Trainings 
OIG provides a free online training series, Improving Health and Well-Being in American Indian and 
Alaska Native Communities Through Compliance, for grantees and health care providers who serve 
American Indian/Alaska Native (AI/AN) communities.  The training series covers topics such as 
compliance; fraud, waste, and abuse; and health care quality, including how OIG works with the 
AI/AN community to combat the opioid epidemic and to protect patients from sexual abuse.  The 
training series includes web-based trainings, job aids, and videos, which can be accessed on OIGs 
IHS Training website.  
 
Whistleblower Protection Training  
In addition to training for health care providers, OIG provides training to HHS employees, 
contractors, and award recipients on Federal whistleblower protections and prohibitions against 
retaliation.  This training is provided by the HHS Whistleblower Protection Coordinator within OIGs 
Office of Counsel to the Inspector General and is conducted in coordination with HHS OpDivs and 
Staff Divisions (StaffDivs).  OIG also provides training videos, materials, and FAQs about 
whistleblower protections, which can be accessed on OIGs Whistleblower Protection website.  
 
Most Wanted Fugitives List 
OIGs Most Wanted Fugitives website continues to garner national and international attention and has 
greatly assisted in helping to capture fugitives charged with defrauding Federal health care programs and 
stealing millions of taxpayer dollars.  The Most Wanted Fugitives website is continually updated and 
features a profile for each fugitive as well as an online tip form and a hotline number for individuals to 
43 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
report fugitive-related information to OIG, in English or Spanish, 24 hours a day, 365 days a year.  The 
Most Wanted Fugitives list is available on OIGs Fugitives website.  During this semiannual reporting 
period, 2 fugitives were captured. 
 
The following case examples involve a captured fugitive: 
 
Florida  On November 16, 2022, Jeyker Herrera Felipe (Herrera), the owner of AD Pharmacy, was 
sentenced to 24 months in prison and 3 years of supervised release for one count of health care 
fraud.  Herrera was also ordered to pay $615,725 in restitution plus $100 in court assessments.  
Herrera was indicted on October 2, 2012, in the Southern District of Florida and was charged with 
five counts of health care fraud.  Herrera had already left the United States when HHS-OIG and FBI 
agents executed Herreras arrest warrant and were unable to locate him.  On March 2, 2022, 
Herrera was arrested entering the United States in El Paso, Texas based on the outstanding arrest 
and indictment from 2012.  On September 13, 2022, Herrera pled guilty to one count of health care 
fraud; all other counts were dismissed by the United States. 
 
Florida  On February 22, 2023, Emilio Mendez, the owner of Complete Pharmacy, was sentenced 
to 34 months in prison followed by 3 years of supervised release after pleading guilty to conspiracy 
to commit health care fraud and wire fraud.  Mendez was also ordered to pay $1,779,246 in 
restitution and $100 in court assessments.  On January 23, 2014, Mendez was indicted by a Federal 
Grand Jury in the Southern District of Florida on 12 counts of health care fraud for his role in 
submitting more than $1.7 million in false claims to Medicare.  After the indictment, Mendez fled to 
Cuba.  On July 24, 2022, Mendes was arrested in the Western District of Texas as he tried to 
reenter the United States. 
 
HHS-OIG Hotline 
As part of OIGs Office of Investigations, the Hotline is the public-facing division for OIGs intake and 
evaluation of fraud tips.  The mission of the Hotline is to support OIGs oversight responsibilities in 
safeguarding the integrity of all programs and personnel under HHSs purview and protecting them from 
fraud, waste, and abuse.  The Hotline achieves its mission through its staffs dedication to timely intake and 
analysis of information received from various sources, such as the Submit a Complaint link on the HHS-
OIG website.  During this semiannual reporting period, the Hotline reported expected recoveries of 
$8,622,602 as a direct result of cases originating from hotline complaints. 
 
OIG Hotline Activity (10/1/20223/31/2023) 
Contacts to 1-800-HHS-TIPS phone line, including  61,804 
callers seeking information 
Total tips evaluated  20,347 
Tips referred for action  12,576 
44 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
Closed; no basis provided for further action  533 
Closed; no HHS violation  636 
Closed; other administrative reason  6,602 
 
Sources of Tips Referred for Action 
Phone  4,120 
OIG website  6,789 
Letters or faxes  542 
Other  1,125 
 
 
Medicaid Fraud Control Units 
OIG Oversight of Medicaid Fraud Control Units 
MFCUs are key partners with OIG in the fight against fraud, waste, and abuse in State Medicaid 
programs.  OIG has oversight responsibility for MFCUs and administers grants that provide Federal 
funding for their operations.  Currently, all 50 States, the District of Columbia, Puerto Rico, and the 
U.S. Virgin Islands operate MFCUs.  The Federal Government reimburses 90 percent of a MFCUs 
total expenditures during the first 3 years of operation and 75 percent thereafter.  MFCUs 
investigate and prosecute Medicaid provider fraud as well as abuse or neglect of residents in 
health care facilities and board and care facilities and of Medicaid beneficiaries in noninstitutional 
or other settings. 
 
Medicaid Fraud Control Units Fiscal Year 2022 Annual Report (OEI-09-23-00190), March 
2023 
This annual report provides statistics that highlight the accomplishments of the 53 MFCUs 
during FY 2022.  In FY 2022, MFCUs reported 1,327 convictions (946 convictions for fraud; 
381 convictions for patient abuse or neglect).  Fraud convictions involved more personal 
care attendants than any other provider type.  Nurses aides and nurses/physician assistants 
had the highest numbers of convictions for patient abuse or neglect.  Criminal recoveries 
from convictions totaled $416 million.  MFCUs reported 553 civil settlements and 
judgments.  Pharmaceutical manufacturers accounted for more civil settlements and 
judgments than any other provider type.  MFCUs reported civil recoveries of $641 million.  
Combined recoveries from criminal and civil cases totaled nearly $1.1 billion.  MFCUs 
achieved a return of $3.08 for each dollar spent.  The report appendix summarizes 
beneficial practices that may be useful to other MFCUs.  This report contained no 
recommendations. 
45 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
 
OIG Onsite Reviews of MFCUs 
In addition to an annual recertification review of each MFCU, OIG conducts reviews of a sample of 
MFCUs.  OIG evaluates MFCU operations based on 12 performance standards and assesses 
compliance with laws, regulations, and OIG policy guidance.  During the reporting period, OIG 
issued reports of onsite reviews of the following MFCUs: 
 
Rhode Island Medicaid Fraud Control Unit: 2022 Inspection (OEI-07-22-00370), March 2023 
 
 
Advisory Opinions and Other Industry Guidance 
Advisory opinions, which are developed in consultation with DOJ, are issued to requesting parties 
regarding the interpretation and applicability of certain statutes relating to Federal health care programs.  
The Health Insurance Portability and Accountability Act of 1996 (HIPAA),  205, allows OIG to provide case-
specific formal opinions on the application of the anti-kickback statute and safe harbor provisions, in 
addition to other OIG health care fraud and abuse sanctions.  During this semiannual reporting period, 
OIG received 16 requests for advisory opinions and issued 16 advisory opinions. 
 
Sanction Authorities and Other Administrative Actions  
Various Federal laws provide authorities the ability to impose administrative sanctions for fraud and abuse 
as well as other activities that pose a risk to Federal health care programs and their beneficiaries.  
Sanctions include the exclusion of individuals and entities from Federal health care programs and the 
imposition of CMPs for submitting false and fraudulent claims to a Federal health care program or for 
violating the anti-kickback statute, the physician self-referral law (Stark Law), or the Emergency Medical 
Treatment and Labor Act, also known as the patient dumping statute.  Sanctions also include referrals for 
suspension and debarment in cases of grant and contract fraud. 
 
During this semiannual reporting period, OIG imposed 1,435 administrative sanctions in the form of 
program exclusions or administrative actions for alleged fraud or abuse or other activities that posed a risk 
to Federal health care programs and their beneficiaries.  
 
Exclusion and penalty authorities are described in Appendix C and on OIGs Enforcement Actions website. 
 
Program Exclusions 
During this semiannual reporting period, OIG excluded 1,365 individuals and entities from 
Medicare, Medicaid, and other Federal health care programs.  Most of the exclusions resulted from 
convictions for crimes relating to Medicare or Medicaid, patient abuse or neglect, financial 
misconduct, controlled substances, or as a result of license revocation.  OIG completed the 
46 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
deployment of a new service for MFCUs to report convictions through a central web-based portal 
for exclusions.  OIG is also responsible for reinstating providers who apply and have met the 
requirements of their exclusions.  For a list of excluded individuals and entities, see OIGs Exclusions 
website. 
 
The following are case examples of program exclusions:  
 
California  On November 20, 2022, OIG excluded an owner of an ambulatory surgery 
center that specialized in plastic and cosmetic surgery for 40 years based on her conviction 
for conspiracy to commit health care fraud.  From 2008 until 2013, this business owner 
convinced patients that they could use Preferred Provider Organization health care benefits 
to pay for cosmetic procedures (e.g., tummy tucks, liposuction, breast lifts, varicose vein 
treatment) when in fact she submitted false claims for medically unnecessary procedures 
using fictitious company names and addresses to defraud private insurance companies.  
Some patients even suffered severe medical complications after being forced to undergo 
multiple cosmetic procedures in a short timeframe.  The court sentenced the owner to 97 
months in prison and ordered her to pay approximately $14,025,900 in restitution.     
  
Florida  On December 20, 2022, OIG excluded a registered nurse for 45 years based on his 
conviction of sexual battery on a helpless victim.  The nurse administered medication to the 
hospitalized victim before raping her.  As a result, the court sentenced the nurse to 30 
years in prison, and the Florida Board of Nursing revoked his license to practice as a 
registered nurse.    
 
Illinois  On November 20, 2022, OIG excluded the owner of a licensed childcare business 
for 20 years due to her conviction for wire fraud and money laundering.  From 2009 until 
2019, this individual participated in a scheme to defraud the State of Illinois of its general 
revenue funds as well as block grant funding received from HHS intended to assist low-
income families with affordable childcare by submitting false records and eligibility 
information.  The court sentenced her to 22 months in prison and ordered her to pay 
approximately $421,800 in restitution.   
  
Pennsylvania  On December 20, 2022, OIG excluded a medical doctor for 23 years based 
on his conviction for conspiracy to commit health care fraud.  Between 2016 and 2018, the 
doctor conspired with a telemedicine company to defraud Medicare by submitting false 
and fraudulent claims for medically unnecessary services as well as claims for items or 
services that were not eligible for Medicare reimbursement in order to divert the proceeds 
for his own personal use.  The court sentenced the provider to 6 months of home 
detention with electronic monitoring and ordered him to pay approximately $3,354,000 in 
restitution.  Moreover, the North Carolina Board of Medicine suspended his license while 
the West Virginia Board of Medicine, the Pennsylvania Board of Medicine, and the 
Washington State Board of Medicine accepted the surrender of his licenses.   
47 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
 
Wisconsin  On October 20, 2022, OIG excluded an advanced practice nurse practitioner 
for 45 years based on a conviction related to the distribution of controlled substances 
beyond the practice of medicine.  From 2015 through 2016, this individual owned and 
operated a medical clinic that only accepted cash or credit card payments from patients in 
order to prescribe excessive amounts of controlled substances (e.g., oxycodone, morphine) 
without insurance oversight.  These excessive prescriptions lacked legitimate medical 
purposes and caused widespread distribution and addiction to controlled substances 
throughout the State of Wisconsin, leading to the death of one patient.  As a result of this 
conviction, a court sentenced the practitioner to 240 months in prison.  The excluded 
provider also lost nursing licenses by revocation, suspension, and surrender in three 
different states.   
  
Suspensions and Debarments  
Suspensions and debarments are administrative tools used by HHS and other Federal agencies to 
protect the Government from individuals and entities that have engaged in contract fraud, have 
misused grant funds, or are otherwise not presently responsible.  Because these are 
Governmentwide sanctions, an individual or entity that has been suspended or debarred by HHS or 
any other agency is ineligible to participate in any future funding opportunities across the Federal 
Government for a specified period of time. 
 
OIG refers individuals and entities that have potentially engaged in grant or contract fraud or 
misconduct to the HHS suspension and debarment official, who is responsible for determining 
whether to impose a suspension or debarment.  OIG continues to develop a robust suspension and 
debarment program and uses this tool to protect Government programs against fraud, waste, poor 
performance, and noncompliance with contract provisions or applicable law.  
 
The following case example involves debarment:  
  
Tennessee  Patrick Martin, the former executive director of the Community Prevention 
Coalition of Jackson County, Tennessee (CPCJC), was debarred for 3 years.  The debarment 
was imposed based on a referral from OIG.  CPCJC received a Federal grant from the 
Substance Abuse and Mental Health Services Administration (SAMHSA) for the purpose of 
preventing and reducing underage alcohol abuse and substance use among youth in 
Jackson County.  Martin was convicted of wire fraud, willful failure to collect or pay over tax, 
and willful filing of false tax returns related to theft of grant monies, and he was sentenced 
to 15 months in prison after an OIG investigation found that Martin embezzled CPCJC funds 
by overpaying himself, duplicating payments, and paying for personal expenses including 
travel and supplies.  Martin also diverted CPCJC funds to a personal bank account.  Martin 
made materially false statements and misrepresentations to SAMHSA to obtain continued 
48 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
funding of the grant and caused SAMHSA to wire $375,000 to CPCJC in 30 separate 
requests to draw down funds. 
 
Civil Monetary Penalties Law 
The CMPL authorizes OIG to impose administrative penalties, assessments, and exclusions against 
a person who, among other things, submits, or causes to be submitted, claims to a Federal health 
care program that the person knows, or should know, are false or fraudulent.  The exclusions 
statute also authorizes OIG to exclude a person who violates the CMPL.  During this semiannual 
reporting period, OIG concluded cases involving more than $39.4 million in CMPs and 
assessments. 
 
Affirmative Litigation 
The CMPL authorizes OIG to use its administrative remedies to affirmatively pursue cases.  OIG 
may also exclude individuals under the exclusions statute for engaging in conduct that violates the 
CMPL; this is known as an affirmative exclusion.   
 
The following case examples involve affirmative litigation under the CMPL:  
  
New Jersey  Gem Ambulance, LLC, entered into a $1,060,513.82 settlement agreement with 
OIG.  The agreement settled its liability under the CMPL arising from its submission of 
claims to Medicare Part B with dates of service from January 2, 2014, through December 28, 
2018, for ambulance transportation to and from skilled nursing facilities, where such 
transportation was covered by the skilled nursing facility consolidated billing payment 
under Medicare Part A. 
 
Texas  Vi Dang, M.D., entered into a $132,078.00 settlement agreement with OIG.  The 
agreement resolved allegations that he solicited and received remuneration from various 
telemedicine and staffing companies in the form of monetary payments related to 
purported telemedicine consultations.  Specifically, that he solicited and received the 
remuneration in exchange for ordering medically unnecessary durable medical equipment 
and prescription medications for Medicare beneficiaries with whom he had no physician
patient relationship and never examined.  
 
Self-Disclosure Programs  
Health care providers, suppliers, or other individuals or entities subject to CMPs can apply for 
acceptance into the Health Care Fraud Self-Disclosure Protocol, a program created in 1998 for 
voluntary disclosure of self-discovered evidence of potential fraud.  The Health Care Fraud Self-
49 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
Disclosure Protocol may give individuals and entities the opportunity to avoid costs or disruptions 
associated with Government-directed investigations and civil or administrative litigation.  
 
Application processes for two additional self-disclosure programs were recently added to the OIG 
website for HHS contractors and grantees.  The OIG contractor self-disclosure program provides 
contractors the opportunity to self-disclose when they have potentially violated the False Claims 
Act or other Federal criminal laws prohibiting fraud, conflict of interest, bribery, or gratuity.  This 
self-disclosure process is only available to those with a Federal Acquisition Regulationbased 
contract with HHS.  The OIG grant self-disclosure program is available by application to HHS 
grantees or HHS grant subrecipients and provides the opportunity for voluntary disclosure to OIG 
of potential fraud.  OIG evaluates the reported results of each internal investigation under the 
provider self-disclosure protocol to determine the appropriate course of action.  Self-disclosure 
guidelines are available on the OIG Self-Disclosure website.  During this semiannual reporting 
period, provider self-disclosure cases resulted in more than $38.6 million in HHS receivables. 
 
The following case examples pertain to provider self-disclosure settlements:  
 
Connecticut  Andrew J. Parker, M.D., LLC, entered into an agreement with OIG in the 
amount of $985,385.10 to resolve allegations that, between January 1, 2012, and April 1, 
2018, the medical practice submitted claims for outpatient services as if those services were 
rendered by Dr. Parker when in fact those services were provided by employee 
practitioners that were not enrolled in the applicable Federal health care program at the 
time the claims were submitted. 
 
Washington State  Kadlec Regional Medical Center (Kadlec) entered into a $14,351,283.06 
settlement agreement with OIG.  The agreement settled its liability under the CMPL arising 
from its submission of claims to Medicare Part A, during the period of October 24, 2015, 
through October 26, 2021, for inpatient rehabilitation stays that did not meet Medicare 
coverage criteria.  This self-disclosure was based on conduct Kadlec identified after a 
related audit by OAS.   
 
Corporate Integrity Agreements  
Many health care providers elect to settle their cases before litigation.  As part of the settlements, 
providers often agree to enter into CIAs with OIG to avoid exclusions from Medicare, Medicaid, 
and other Federal health care programs.  Under a CIA, a provider commits to establishing a 
compliance program and taking other specified steps to ensure future compliance with Medicare 
and Medicaid rules.  The compliance programs are designed, in part, to prevent future fraud.  OIG 
monitors providers compliance with these agreements and may impose penalties on parties that 
fail to comply with the requirements of their CIAs. 
 
There were no cases involving CIA enforcement during this semiannual reporting period. 
50 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
Public Health and Human Services Agency 
Reports and Reviews  
Public Health Agency Reports and Reviews 
Centers for Disease Control and Prevention 
During the Initial COVID-19 Response, HHS Personnel Who Interacted With Potentially Infected 
Passengers Had Limited Protections (OEI-04-20-00360), October 2022 
 
As a result of CDCs initially limited protections, HHS personnel may have been at increased risk of 
COVID-19 exposure and may have inadvertently spread COVID-19.  Though CDCs understanding 
of COVID-19 was evolving and the protections improved during our review period, they still 
contained some vulnerabilities.  Our findings can help CDC strengthen its protections for personnel 
interacting with potentially infected passengers during future infectious disease outbreaks.  
 
CDC concurred with our recommendations that CDC: (1) update its guidance recommending 
protections for personnel who interact with potentially infected passengers, (2) ensure that its 
personal protective equipment trainings meet standards set by the Occupational Safety and Health 
Administration, and (3) develop a comprehensive plan for recommending travel-related 
containment measures that weighs the risks relative to the public health benefits. 
 
Early Challenges Highlight Areas for Improvement in COVID-19 Vaccination Programs (OEI-04-21-
00190), January 2023 
 
State and local immunization programs that are funded by CDC to distribute COVID-19 vaccines 
faced numerous challenges, including achieving logistical efficiency, obtaining complete vaccine 
data, combating vaccine hesitancy with public health messaging, and overseeing vaccine providers.  
(We refer to these CDC-funded programs as awardees.)  While CDC addressed some of these 
challenges during the early stages of the COVID-19 vaccination program, there are still areas for 
improvement.  Our findings can help CDC strengthen the COVID-19 vaccination program and 
improve future pandemic vaccination programs.   
 
CDC concurred with our recommendations that CDC: (1) update its plans for mass vaccination 
programs with strategies that address awardee-reported logistical challenges, (2) strengthen 
reporting of vaccine allocation data and administration data, (3) clarify roles and responsibilities 
within HHS for vaccine public health messaging during a pandemic, and (4) work with awardees to 
enhance current and future capabilities for provider training and oversight. 
 
51 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
Challenges With Vaccination Data Hinder State and Local Immunization Program Efforts To Combat 
COVID-19 (OEI-05-22-00010), January 2023 
 
Many State and local immunization programs reported having incomplete individual-level data for 
the more than 250 million COVID-19 vaccine doses administered by Federal agencies and retail 
pharmacy partners (retail pharmacies that receive vaccines directly from CDC).  Without complete 
individual-level vaccination data, immunization programs reported that they struggled to 
accurately measure vaccination coverage and target outreach to unvaccinated and vulnerable 
populations.  Because State and local immunization databases contain data on all types of 
vaccinations, if left unresolved, these challenges will likely hinder the ongoing COVID-19 
vaccination campaign, responses to future public health emergencies, and routine vaccination 
campaigns (e.g., flu shots). 
 
CDC concurred with our recommendation for it to provide educational outreach to ensure that 
State and local immunization programs are aware of existing tools to address vaccination 
campaign needs.  CDC did not concur with our recommendation for it to work with State and local 
immunization programs and retail pharmacy partners to mitigate reported data gaps and 
timeliness challenges.   
 
Administration for Strategic Preparedness and Response 
ASPR Could Improve Its Oversight of the Hospital Preparedness Program To Ensure That Crisis 
Standards of Care Comply With Federal Nondiscrimination Laws (A-01-21-01502), January 2023  
  
Although ASPR has taken steps to improve its oversight of the Hospital Preparedness Program 
(HPP) by promoting the adoption of nondiscriminatory Crisis Standards of Care (CSCs) that comply 
with Federal nondiscrimination laws, it can take additional steps.  The HPP cooperative agreement 
did not previously specify that States should consider Federal nondiscrimination laws when 
developing CSCs because prior to the COVID-19 pandemic, ASPR did not identify CSC compliance 
with Federal nondiscrimination laws as a high-risk area.  Additionally, ASPR stated that it is not 
required to review CSCs for legal and regulatory compliance.  CSCs that do not comply with 
Federal nondiscrimination laws increase the risk that individuals could be denied access to 
lifesaving care during a public health emergency.  
  
We recommend that ASPR consider additional updates to the current HPP cooperative agreement 
to promote that HPP recipients adopt CSCs that comply with Federal nondiscrimination laws.  We 
acknowledge that ASPR has taken steps in previous HPP updates to promote compliance with 
Federal nondiscrimination laws; however, we believe that additional steps can be taken.  Such steps 
could include an additional update to the HPP cooperative agreement to encourage recipients to 
engage with advocacy groups in decision making related to crisis care planning.  ASPR said that it 
accepts our recommendation to include additional updates in the HPP cooperative agreement to 
promote the adoption of CSCs that comply with Federal nondiscrimination laws.  
52 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
 
Food and Drug Administration 
FDAs Approach to Overseeing Online Tobacco Retailers Needs Improvement (OEI-01-20-00241), 
December 2022 
 
For the 16,000 online tobacco websites that FDAs contractor flagged for review from 2010 through 
2020, FDA issued warning letters to 899 websites but took no enforcement actions.  FDA faces 
challenges, many unique to the online retailer environment, but also has not taken certain steps 
that could help it address gaps in its oversight.  This review raises questions about the effectiveness 
of FDAs efforts to prevent youth access to tobacco products online.   
 
FDA concurred with our recommendations that FDA: (1) collaborate with the Bureau of Alcohol, 
Tobacco, Firearms and Explosives on oversight of online tobacco retailers; and (2) publish 
information and performance data on its oversight of online tobacco retailers. 
 
FDA neither concurred nor nonconcurred with our recommendations that FDA: (1) complete its 
rulemaking on nonface-to-face sales of tobacco products, as required by the Family Smoking 
Prevention and Tobacco Control Act; and (2) collect data to support process and outcome 
measures for its oversight of online tobacco retailers.  
 
FDA Should Improve Its Management of Contracts for the Acquisition of Information Technology (A-
18-21-11100), January 2023   
  
FDA contracting officers generally administered the delivery and call orders we reviewed for the 
acquisition of information technology in accordance with Federal regulations and policies.  
However, we identified areas within FDAs management of these orders that were not conducted 
consistent with applicable Federal and HHS acquisition regulations and policies.  Specifically, the 
contracting officers did not: (1) properly designate a contracting officers representative or 
complete all required duties for contracts for which there was no designated contracting officers 
representative, (2) complete required contractor performance evaluations, (3) properly document 
all key contracting decisions or activities and obtain all required signatures on key documents, and 
(4) include the required acquisition strategy statement in the orders acquisition plans.  
Additionally, FDA did not fully comply with the HHS Competition Advocacy Directive for FYs 2018 
and 2019.  
  
These conditions occurred because FDA did not always: (1) follow existing FDA acquisition and 
procurement policies and procedures, including ensuring the completeness of contract documents; 
or (2) work with HHS to meet its obligation to comply with an HHS directive. 
  
We make procedural and administrative recommendations to improve compliance with Federal 
acquisition requirements related to contracting officers representative duties, contractor 
53 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
performance assessments, documentation of contracting decisions and activities, and acquisition 
strategies.  The full recommendations are in the report.  In written comments on our draft report, 
FDA concurred with all of our recommendations and described actions it has taken or plans to take 
to address the findings. 
 
Indian Health Service 
IHS Did Not Always Provide the Necessary Resources and Assistance To Help Ensure That Tribal 
Programs Complied With All Requirements During Early COVID-19 Vaccination Program 
Implementation (A-07-21-04125), October 2022  
 
Indian Health Service (IHS) did not fulfill all of the provisions outlined in a Memorandum of 
Agreement that specified the conditions for receiving COVID-19 vaccines from CDC and in its 
Vaccine Plan for operationalizing delivery of the vaccines to help ensure that the vaccination 
program was implemented appropriately at Tribal programs.  Consequently, Tribal programs did 
not always comply with all program requirements during early program implementation.  
Specifically, IHS did not always provide the necessary resources and assistance to help ensure that 
Tribal programs: (1) met reporting requirements for vaccine administration data, (2) used billing 
practices that conformed to CMS and CDC requirements and American Medical Association 
guidance regarding reimbursement for vaccine administration fees, and (3) did not enter into 
unallowable dual-program agreements with both a State jurisdiction and IHS.  
  
We recommend that IHS: (1) ensure that Tribal programs comply with vaccine program 
requirements by establishing formal reconciliation processes to ensure that the data that the Tribal 
programs submit on doses administered are correct and by addressing data management system 
incompatibilities, (2) work with CMS to disseminate guidance to Tribal programs on vaccine coding 
and billing, (3) work with CDC and one Tribal program to ensure that it returns funds to individuals 
who were billed inappropriately, and (4) work with CDC to develop and disseminate additional 
guidance related to dual enrollment and together implement a formal monitoring process to help 
ensure that Tribal programs do not enter into unallowable dual-program agreements for Federal 
programs.  IHS concurred with all of our recommendations and described corrective actions that it 
has taken and plans to take. 
  
Three Tribes in New England and Their Health Programs Did Not Conduct Required Background 
Investigations on All Individuals in Contact With Indian Children (A-01-20-01504), November 2022 
  
The 3 New England Tribes and their health programs did not comply with Federal and Tribal 
requirements for performing background investigations on 65 employees, 12 contractors, and 1 
volunteer in contact with Indian children.  IHS officials stated that they recalled providing 
background investigation training prior to 2015 but could not produce documentation to support 
their recollections.  Current Tribal officials said they were not aware of, or misinterpreted, their 
obligations under the Indian Child Protection and Family Violence Prevention Act (the Act).  
54 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
Because the three Tribes and their health programs did not always collect the necessary 
employment information and did not conduct the required criminal history investigations, they 
could not compare complete criminal history results to the minimum standards of character for 
individuals in contact with Indian children.  As a result, Indian children faced an increased risk of 
harm. 
  
We recommend that the three Tribes: (1) perform background investigations on individuals who 
currently have contact with Indian children and (2) develop and implement policies and procedures 
to ensure that each Tribe conducts required background investigations and assesses results to 
verify that applicants meet the required minimum character standards.  We also recommend that 
IHS provide additional training and technical assistance to help Tribes comply with the background 
investigation and character assessment requirements of the Act.  Two Tribes concurred with our 
findings and the third generally concurred with our findings.  IHS concurred with our 
recommendations. 
 
National Institutes of Health 
The National Institutes of Health and EcoHealth Alliance Did Not Effectively Monitor Awards and 
Subawards, Resulting in Missed Opportunities to Oversee Research and Other Deficiencies (A-05-21-
00025), January 2023  
  
Despite identifying potential risks associated with research being performed under the EcoHealth 
Alliance awards, we found that NIH did not effectively monitor or take timely action to address 
EcoHealths compliance with some requirements.  Using its discretion, NIH did not refer the 
research to HHS for an outside review for enhanced potential pandemic pathogens because it 
determined the research did not involve and was not reasonably anticipated to create, use, or 
transfer an enhanced potential pandemic pathogen.  However, NIH added a special term and 
condition in EcoHealths awards and provided limited guidance on how EcoHealth should comply 
with that requirement.  We found that NIH was only able to conclude that research resulted in virus 
growth that met specified benchmarks based on a late progress report from EcoHealth that NIH 
failed to follow up on until nearly 2 years after its due date.  We conclude that NIH missed 
opportunities to monitor research more effectively.  
  
We identified several other deficiencies in the oversight of the awards, including NIHs improper 
termination of a grant; EcoHealths inability to obtain scientific documentation from Wuhan 
Institute of Virology (WIV); and EcoHealths improper use of grant funds, resulting in $89,171 in 
unallowable costs.  Although WIV cooperated with EcoHealths monitoring for several years, WIVs 
lack of cooperation following the COVID-19 outbreak limited EcoHealths ability to monitor its 
subrecipient.  
  
We make several recommendations, including that NIH: (1) ensure that EcoHealth accurately and in 
a timely manner report award and subaward information; (2) implement enhanced monitoring, 
55 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
documentation, and reporting requirements for recipients with foreign subrecipients; (3) consider 
whether it is appropriate to refer WIV to HHS for debarment; and (4) ensure any future NIH grant 
awards to EcoHealth address the deficiencies noted in the report.  NIH stated that it concurred or 
generally concurred with our recommendations and provided actions it has taken or plans to take 
to address them.  
  
We also recommend EcoHealth submit progress reports by the required due dates, comply with 
immediate notification requirements, ensure access to all subrecipient records, properly account 
for subawards, and refund to the Federal Government $89,171 in unallowable costs.  EcoHealth 
concurred with our recommendation to prepare accurate subaward and consultant agreements 
but did not directly state whether it concurred with the other recommendations. 
 
Drug Control Attestation Reports 
  
Federal law and the Office of National Drug Control Policy (ONDCP) Circular National Drug Control 
Program Agency Compliance Reviews, dated September 9, 2021 (ONDCP Compliance Reviews 
Circular), require OIG to conduct reviews of OpDivs drug control activities.  During this reporting 
period, OIG conducted three such attestations, which are summarized here. 
  
Independent Attestation Review: National Institutes of Health Fiscal Year 2022 
Detailed Accounting Submission and Budget Formulation Compliance Report for 
National Drug Control Activities, and Accompanying Required Assertions (A-03-23-
00351), January 2023 
  
This report provides the results of our review of NIHs National Institute on Drug 
Abuse (NIDA) and National Institute on Alcohol Abuse and Alcoholism (NIAAA) 
ONDCP Detailed Accounting Reports, which include the table of Drug Control 
Obligations, related disclosures, and management's assertions for the fiscal year 
ended September 30, 2022.  We also reviewed the Budget Formulation Compliance 
Reports, which include budget formulation information for the fiscal year ending 
September 30, 2024, and the Chief Financial Officer's or accountable senior 
executive's assertions relating to the budget formulation information. 
  
Based on our review, we are not aware of any material modifications that should be 
made to NIDA and NIAAA's Detailed Accounting Reports for FY 2022 and NIDA and 
NIAAA's Budget Formulation Compliance Reports for FY 2024 and management's 
assertions for them to be in accordance with the ONDCP Compliance Reviews 
Circular. 
  
Independent Attestation Review: Centers for Disease Control and Prevention Fiscal 
Year 2022 Detailed Accounting Submission and Budget Formulation Compliance 
56 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
Report for National Drug Control Activities and Accompanying Required Assertions 
(A-03-23-00352), January 2023 
  
This report provides the results of our review of CDCs ONDCP Detailed Accounting 
Report, which includes the table of Drug Control Obligations, related disclosures, 
and management's assertions for the fiscal year ended September 30, 2022.  We 
also reviewed the Budget Formulation Compliance Report, which includes budget 
formulation information for the fiscal year ending September 30, 2024, and the 
Chief Financial Officer's or accountable senior executive's assertions relating to the 
budget formulation information.  
  
Based on our review, we are not aware of any material modifications that should be 
made to CDC's Detailed Accounting Report for FY 2022 and CDC's Budget 
Formulation Compliance Report for FY 2024 and management's assertions for them 
to be in accordance with the ONDCP Compliance Reviews Circular. 
  
Independent Attestation Review: Food and Drug Administration Fiscal Year 2022 
Detailed Accounting Submission and Budget Formulation Compliance Report for 
National Drug Control Activities and Accompanying Required Assertions (A-03-23-
00353), January 2023 
  
This report provides the results of our review of FDAs ONDCP Detailed Accounting 
Report, which includes the table of Drug Control Obligations, related disclosures, 
and management's assertions for the fiscal year ended September 30, 2022.  We 
also reviewed the Budget Formulation Compliance Report, which includes budget 
formulation information for the fiscal year ending September 30, 2024, and the 
Chief Financial Officer's or accountable senior executive's assertions relating to the 
budget formulation information. 
  
Based on our review, we are not aware of any material modifications that should be 
made to FDA's Detailed Accounting Report for FY 2022 and FDA's Budget 
Formulation Compliance Report for FY 2024 and management's assertions for them 
to be in accordance with the ONDCP Compliance Reviews Circular. 
 
Human Services Agency Reports and Reviews 
Administration for Children and Families 
The Municipality of Manati Did Not Always Manage Its Head Start Disaster Assistance Awards in 
Accordance With Federal and Commonwealth Requirements (A-04-20-02032), December 2022 
  
57 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
The Municipality of Manati did not always manage its Head Start disaster assistance awards in 
accordance with Federal and Commonwealth requirements.  Specifically, the Municipality claimed 
unallowable costs totaling $153,052 related to the purchase of four vehicles and did not comply 
with all requirements related to criminal background checks for 25 employees hired with award 
funds.  These deficiencies occurred because the Municipality did not have written procurement 
policies and procedures for determining the most reasonable approach for making vehicle 
purchases or for ensuring that criminal background checks were conducted within required 
timeframes.  As a result, the Municipality did not show that the purchase of the four vehicles was 
necessary or reasonable and it potentially jeopardized the safety of children by not complying with 
background check requirements.  
  
We recommend that the Municipality: (1) work with ACF to develop a viable plan for refunding 
$153,052 in unallowable costs to the Federal Government; (2) develop and implement procurement 
policies and procedures, including a requirement to perform analyses to determine the most 
reasonable approach for vehicle acquisitions; and (3) develop and implement written policies and 
procedures to ensure that criminal background checks are completed within required timeframes.  
In written comments on our draft, the Municipality did not indicate concurrence or nonconcurrence 
with our recommendations.  However, the Municipality stated it did not concur with our findings.  
We maintain that our findings and recommendations are valid. 
  
Greater Bergen Community Action, Inc., Did Not Manage Its Head Start Awards in Accordance With 
Federal and State Requirements (A-02-19-02008), January 2023 
  
Greater Bergen Community Action, Inc. (GBCA) drew down Head Start funds in excess of 
immediate cash needs and used the funds to temporarily cover non-Head Start expenditures.  In 
addition, GBCA claimed unallowable costs totaling $394,733 for: (1) rental income that was not 
properly credited as program income, (2) unallowable rent costs, (3) unallowable salary and fringe 
benefit costs, and (4) non-Head Start program costs.  GBCA also claimed $92,678 in potentially 
unallowable vehicle costs.  Further, GBCA overstated its non-Federal share contributions (e.g., 
volunteer services) and did not perform required background checks and health screenings on 
some of its volunteers.  These deficiencies occurred because GBCA had inadequate policies in 
place to ensure that: (1) its Head Start grant funds were used to reimburse current, allowable Head 
Start expenses; (2) its financial reports to ACF accurately accounted for non-Federal contributions 
to its Head Start program; and (3) background checks and health screenings were performed. 
  
We recommend that GBCA: (1) refund $394,733 to the Federal Government for unallowable costs 
charged to the Head Start awards, (2) work with ACF to determine the amount of allowable vehicle 
costs or refund $92,678 to the Federal Government for potentially unallowable vehicle costs, and 
(3) strengthen its policies and procedures to address the issues identified in the report.  GBCA 
concurred with some of our findings, did not concur with others, and disagreed with our 
recommendation that it refund $394,733. 
 
58 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
Marylands Child Support Administration Generally Claimed Administrative Costs That Were 
Allowable and Allocable (A-01-22-02500), March 2023 
  
Maryland generally claimed Maryland Administrative Office of the Courts (AOC) administrative 
costs for the Child Support Enforcement Program (CSE Program) that were allowable and allocable, 
and the overall effect of the errors we identified during our audit period were immaterial.  
However, we determined that Maryland did not have an adequate invoice review process to ensure 
that AOC salary and fringe benefits allocated to the CSE Program were accurate and supported 
and that the AOC properly calculated indirect costs charged to the CSE Program.  
  
We recommend that Maryland: (1) periodically review the allocation and support of payroll costs 
invoiced by the AOC and (2) verify that the AOC calculates indirect costs charged to the CSE 
Program by applying the de minimis rate of 10 percent to the correct allocation base. 
  
In written comments on our draft report, Maryland concurred with our recommendations.  
Maryland also described the actions it will take to address the recommendations.  For example, 
Maryland said it would periodically conduct site reviews, beginning April 1, 2023, and evaluate the 
AOC billing process, internal controls, and supporting documentation to verify the allocation and 
support of payroll costs that AOC invoiced. 
 
Safety of Children in Foster Care 
Michigan Did Not Comply With Requirements for Documenting Psychotropic and Opioid Medications 
Prescribed for Children in Foster Care (A-05-21-00030), February 2023 
  
Michigan did not always comply with State requirements related to the psychotropic and opioid 
medications prescribed for children in foster care who were eligible for assistance under the Social 
Security Act.  Specifically, we found that: (1) the electronic case records for 18 of the 115 children in 
the sample who were prescribed psychotropic or opioid medications did not contain the required 
medical information, (2) the electronic case records for 14 of the 85 children in the sample who 
were prescribed psychotropic medications did not include consent forms for psychotropic 
medications, and (3) opioid medications prescribed for 60 children in the sample were not 
recorded in the Michigan Statewide Automated Child Welfare Information System (MiSACWIS). 
  
We make multiple recommendations, including that Michigan ensure that electronic case records 
for children in foster care are maintained in accordance with requirements by: (1) modifying 
procedures for the monitoring of caseworkers to ensure that the required medical information is 
maintained in MiSACWIS; (2) implementing policies to document when consent forms are not 
required in non-emergency situations, monitoring Medicaid claim data to ensure consent forms 
are obtained and documented, and implementing procedures to monitor other medications 
prescribed for children, including opioids, for potential medication interaction and adverse side 
effects for children who are prescribed psychotropic medications; and (3) implementing 
59 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
procedures to monitor Medicaid claim data for opioid medications prescribed for children and 
providing training for documenting the opioid medications prescribed for children due to medical 
procedures or emergency treatment.  Michigan generally agreed with our recommendations and 
described actions it has taken or plans to take to address our recommendations. 
  
State Agencies Did Not Always Ensure That Children Missing From Foster Care Were Reported to the 
National Center for Missing and Exploited Children in Accordance With Federal Requirements (A-07-
21-06102), March 2023  
  
During our audit period, State agencies did not always ensure that children missing from foster 
care were reported to the National Center for Missing and Exploited Children (NCMEC) as required 
by Federal statute.  Of the 100 missing children episodes in our sample, the State agencies 
reported 33 episodes to NCMEC in a timely manner (i.e., within 24 hours after the State agency 
received information that the child was missing) in accordance with Federal requirements.  
However, 45 missing children episodes were never reported to NCMEC, and 22 missing children 
episodes were not reported in a timely manner.  On the basis of our sample results, we estimated 
that the State agencies did not report 51,115 of the 74,353 missing children episodes in accordance 
with Federal requirements.  Specifically, an estimated 34,869 missing children episodes during our 
audit period were never reported to NCMEC, and an additional estimated 16,246 missing children 
episodes during our audit period were not reported within 24 hours after the State agencies were 
notified that the child was missing. 
  
State agencies generally lacked adequate systems to readily identify whether or not they had 
correctly reported missing children episodes to NCMEC.  The opportunity exists for ACF to improve 
outcomes for missing children by working with State agencies to ensure compliance with Federal 
reporting requirements and guidance.   
  
We recommend that ACF work with State agencies to ensure compliance with Federal 
requirements to report missing children episodes to NCMEC in a timely manner.  ACF concurred 
with our recommendation and described corrective actions.   
 
Health Resources and Services Administration 
The Health Resources and Services Administration Should Improve Preventive and Detective Controls 
To More Effectively Mitigate the Risk of Compromise (A-18-20-08200), February 2023  
  
Although the Health Resources and Services Administration (HRSA) implemented some security 
controls for detecting and preventing threats on its network, HRSAs cybersecurity controls needed 
improvements to better detect and prevent cyber threats on its network.  We found multiple 
security controls at HRSA that were not operating effectively.  Although we did not identify 
evidence of a past breach, we found three active threats on the HRSA network.  We promptly 
shared these significant findings with HRSA during our audit period.  We concluded that HRSA was 
60 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
able to detect certain breaches and respond appropriately.  We based this conclusion on the fact 
that HRSA was already in the process of investigating two of the three active threats that we had 
identified before we notified it of our findings. 
  
The security control failures that we identified occurred because HRSA had not updated security 
configurations to align with the most recent National Institute of Standards and Technology (NIST) 
Special Publication (SP) 800-53 security controls and had not implemented procedures to assess 
and monitor the NIST controls on its endpoints.  As a result of HRSA not correctly implementing 
these controls, these threats could increase the endpoint or network attack surfaces, or they could 
bypass current organizational security policies and controls.   
  
We recommend that HRSA: (1) remediate the security control findings we identified, (2) update 
security configurations to align with the most current NIST SP 800-53 security controls, and (3) 
implement policies and procedures to periodically identify and assess whether security controls are 
in place and operating effectively in accordance with the most current NIST SP 800-53 and 
remediate weak controls timely. 
   
61 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
 
Legal and Investigative Activities Related to 
Public Health and Human Services Agencies 
Health Education Assistance Loan Program Exclusions 
OIG excludes from Federal health care programs individuals who have defaulted on Health Education 
Assistance Loan (HEAL) Program loans.  Under the HEAL Program, which stopped granting loans in 1998, 
HRSA guaranteed commercial loans to students seeking education in health-related fields.  The students 
could then defer repayment of the loans until after they graduated and began to earn income.  Although 
HHSs Program Support Center takes steps to ensure repayment, some loan recipients do not resolve their 
debt.  After the Program Support Center has exhausted efforts to secure repayment of a debt, it declares 
an individual in default.  The Social Security Act permits that thereafter, such individuals may not receive 
reimbursement under Medicare, Medicaid, and all other Federal health care programs for nonpayment of 
the loans. 
 
Currently, there is a moratorium on collection activities.  Accordingly, the Program Support Center is not 
referring any individuals in default at this time.  Therefore, OIG has no figures to report for this semiannual 
reporting period.  
 
Child Support Enforcement Activities 
OIG Investigations 
OIG investigates noncustodial parents who violate 18 U.S.C.  228 by failing to pay court-ordered 
child support.  OIG works with ACFs Office of Child Support Enforcement; DOJ; U.S. Attorneys 
Offices; the U.S. Marshals Service; and Federal, State, and local partners to address egregious child 
support enforcement cases with appropriate law enforcement and prosecutorial action.  During this 
semiannual reporting period, OIG investigations of child support enforcement cases nationwide 
resulted in one criminal action and court-ordered restitution and settlements of $5,600.   
 
The following case example involves child support enforcement:  
 
Puerto Rico  On or about 2019 through May 2022, Yamil Fonseca Salgado willfully failed to 
pay his child support obligation to his child who resides on the State of Florida.  Such 
obligation remained unpaid for a period longer than 2 years and amounted to more than 
$107,000.00.  With the purpose of executing a scheme to defraud his minor child and the 
Court who imposed the child support obligation, Salgado concealed assets, resources, and 
income.  In order to execute said scheme, Salgado made false and fraudulent 
representations concerning and in relation to a proceeding under Title 11 in the United 
62 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
States Bankruptcy Court in multiple occasions.  Salgado was arrested on August 2, 2022, 
after a grand jury indicted him on July 28, 2022, in the United States Court, District of 
Puerto Rico, for charges related to failure to pay child support and bankruptcy fraud.  On 
November 3, 2022, Salgado pled guilty to one count of willful failure to pay child support 
and five counts of bankruptcy fraud.  This case was worked jointly with the United States 
Trustee's Office. 
 
Engaging the Public in Capturing Deadbeat Parents 
Because of the success of OIGs Most Wanted Fugitives website, OIG launched its Child Support 
Enforcement website.  The site identifies parents who fail to pay court-ordered child support for 
their children and thereby put an unnecessary strain on the custodial parents and the children as 
well as on agencies that enforce these matters.  The site, which is updated frequently, includes 
information on OIGs role in pursuing parents who fail to pay court-ordered child support. 
 
 
63 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
Other HHS-Related Reviews and Investigative 
Activities 
General Departmental 
U.S. Department of Health and Human Services Met the Requirements of the Digital Accountability 
and Transparency Act of 2014, With Areas That Require Improvement (A172254000), October 
2022 
  
Ernst & Young, under its contract with HHS-OIG, determined that HHS generally complied with the 
requirements for completeness, timeliness, quality, and accuracy of the data, as well as the 
requirements for implementation and use of the Governmentwide financial data standards 
established by the Office of Management and Budget and Treasury.  Overall, HHS is in compliance 
with the Digital Accountability and Transparency Act requirements. 
  
Ernst & Young recommended that HHS focus on refreshing the OpDivs understanding of 
Departmental guidance and identifying those areas for which OpDiv training would be developed 
to prevent and detect future accuracy issues related to the performance dates, award types, and 
award descriptions.  Ernst & Young identified the following: (1) 33 accuracy exceptions for data 
element 26, the period of performance start date; (2) 25 accuracy exceptions for data element 22, 
Award Description; (3) 18 accuracy exceptions for data element 16, Award Type; and (4) 12 accuracy 
exceptions for data element 37, Business Types.  In these exceptions, the information in Files D1/D2 
did not agree with the supporting documentation provided. 
 
 
Report on the Financial Statement Audit of the Centers for Medicare & Medicaid Services for Fiscal 
Year 2022 (A-17-22-53000), November 2022 
  
Based on its audit, Ernst & Young, under its contract with HHS-OIG, found that the FY 2022 CMS 
consolidated balance sheets and the related consolidated statements of net cost and changes in 
net position and combined statement of budgetary resources were presented fairly, in all material 
respects, in conformity with U.S. generally accepted accounting principles.  Ernst & Young was 
unable to obtain sufficient audit evidence for the amounts presented in the statements of social 
insurance as of January 1, 2022, 2021, 2020, 2019, and 2018, and the related statements of changes 
in social insurance amounts for the periods ended January 1, 2022, and 2021.  As a result, Ernst & 
Young was not able to, and did not, express an opinion on the financial condition of the CMS 
social insurance program and related changes in the social insurance program for the specified 
periods.  
  
64 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
Ernst & Young also noted two matters involving internal controls with respect to the financial 
reporting.  Under the standards established by the American Institute of Certified Public 
Accountants and GAOs Government Auditing Standards, Ernst & Young identified significant 
deficiencies in CMSs financial reporting processes and information systems controls.  Ernst & 
Young also identified several instances of noncompliance with laws and other matters. 
 
Financial Statement Audit of the Department of Health and Human Services for Fiscal Year 2022 
(A172200001), November 2022 
  
Based on its audit, Ernst & Young, under its contract with HHS-OIG, found that the FY 2022 HHS 
consolidated balance sheets and the related consolidated statements of net cost and changes in 
net position and combined statements of budgetary resources were presented fairly, in all material 
respects, in conformity with U.S. generally accepted accounting principles.  Ernst & Young was 
unable to obtain sufficient audit evidence for the amounts presented in the statements of social 
insurance as of January 1, 2022, 2021, 2020, 2019, and 2018, and the related statements of changes 
in social insurance amounts for the periods ended January 1, 2022, and 2021.  As a result, Ernst & 
Young was not able to, and did not, express an opinion on the sustainability statements for the 
specified periods. 
  
Ernst & Young also noted two matters involving internal controls with respect to financial 
reporting.  Under the standards established by the American Institute of Certified Public 
Accountants and GAOs Government Auditing Standards, Ernst & Young did not identify any 
deficiencies in internal control that it considered a material weakness.  Ernst & Young noted 
improvements over internal controls but continued to identify two significant deficiencies related to 
HHSs Financial Reporting Systems, Analyses, and Oversight, and HHSs Financial Information 
Systems. 
 
Grants and Contracts 
HHS is the largest grantmaking organization and one of the largest contracting agencies in the Federal 
Government.  In FY 2022, HHS awarded more than $792 billion in grants and more than $33 billion in 
contracts across all program areas.  OIGs direct annual discretionary appropriation funding is used to 
conduct program integrity and enforcement activities with regard to the more than 100 public health and 
human services programs carried out by more than 80,000 employees worldwide.  The size and scope of 
departmental awards make their operating effectiveness crucial to the success of programs designed to 
improve the health and well-being of the public. 
 
Grant Fraud Investigations 
The following case example relates to misuse of grant funds:  
  
65 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
California  On December 18, 2022, the United States entered into a False Claims Act 
settlement agreement with iSense, LLC (iSense), Specific Diagnostics, Inc. (Specific), and Dr. 
Paul Andrew Rhodes.  The settlement agreement resolves allegations that between July 1, 
2014, and June 30, 2019, iSense submitted costs for employee hours that the United States 
contends were at a salary rate in excess of the applicable salary cap.  The total amount of 
the settlement to be paid is $10,068,875.  Of that amount, iSense will pay $4,000,000, 
Specific will pay $4,000,000, and Dr. Rhodes will pay $2,068,875.  The United States also 
contends that iSense knowingly overcharged costs for employee hours at a salary rate not 
reduced for uncompensated overtime.  These allegations pertain to claims submitted for 
payment under multiple grants awarded by NIH.  All of the grants at issue were Small 
Business Innovation Research (SBIR) grants.  This settlement agreement also resolves 
allegations that between February 1, 2017, and December 31, 2018, Specific submitted costs 
for employee hours that the United States contends were a salary rate in excess of the 
applicable salary cap.  Additionally, the United States contends that Specific knowingly 
overcharged costs for employee hours at a salary rate not reduced for uncompensated 
overtime.  The allegations pertain to claims submitted for payment under two grants 
awarded by NIH.  These two grants were SBIR grants.  The settlement agreement further 
resolves allegations that between February 1, 2018, and July 28, 2020, Specific and Dr. 
Rhodes knowingly submitted a services agreement between Specific and iSense as properly 
dated, which were knowingly backdated.  These allegations pertain to claims for payment 
that were caused to be submitted under an award from ASPR.  Specific was a subrecipient 
of this award, which is known as Combating Antibiotic-Resistant Bacteria (CARB-X).  Lastly, 
the settlement agreement resolves allegations that between January 1, 2015, and December 
31, 2019, Dr. Rhodes and iSense submitted as accurately dated to the United States cost-
sharing agreements between Specific and iSense that were knowingly backdated.  
 
Small Business Innovative Research Program  
The National Defense Authorization Act for Fiscal Year 2012,  5143, requires OIG to report annually 
on the number of cases referred to OIG for fraud, waste, or abuse in the Small Business Innovation 
Research/Small Business Technology Transfer (SBIR/STTR) program.  OIG must also report on: (1) 
the actions taken in each case; (2) justification for not taking action on a case; and (3) an 
accounting of funds used to address waste, fraud, and abuse in this program.  From October 1, 
2021, through September 30, 2022, OIG received one referral related to potential fraud, waste, or 
abuse with respect to SBIR/STTR programs, and no cases were opened.  For FY 2022, there was 
one SBIR civil settlement for $541,531.  In FY 2022, OIG spent approximately $316,800 in salaries on 
auditing, investigating, and training activities related to fraud, waste, and abuse in the SBIR/STTR 
programs.  At the end of FY 2022, OIG was working on two SBIR/STTR investigations.  
 
66 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023
Recovery Act Retaliation Complaint Investigations 
The American Recovery and Reinvestment Act,  1553 (Recovery Act) prohibits non-Federal 
employers that have received Recovery Act funding from retaliating against employees who 
disclose evidence of mismanagement of Recovery Act funds or any violation of law related to 
Recovery Act funds.  OIGs are required to include in their Semiannual Report the retaliation 
complaint investigations that they decided not to conduct or continue during the reporting period.  
During this semiannual reporting period, OIG did not close, decline, or give extensions on Recovery 
Act Retaliation Complaint investigations of whistleblower retaliation. 
Contract Audits 
Pursuant to the National Defense Authorization Act for FY 2008,  845, OIGs appointed under the 
Inspector General Act of 1978 are required to submit information on final completed contract audit 
reports issued during the period to the contracting activity as part of their semiannual report, 
pursuant to section 5 of the Inspector General Act.  This information must contain significant audit 
findings.  OIG issued no final reports meeting  845 criteria during this semiannual reporting 
period. 
OIG Reviews of Non-Federal Audits 
OIG reviews audits conducted by non-Federal auditors of entities receiving Federal awards.  During 
this semiannual reporting period, OIGs Single Audit Division reviewed 265 reports covering $2.1 
trillion in audited costs.  Federal dollars covered by these audits totaled $678.3 billion, of which 
about $298.3 billion were HHS funds. 
Uniform guidance at 2 CFR 200 Subpart F establishes audit requirements for State and local 
governments, colleges and universities, and nonprofit organizations receiving Federal awards.  
Under the uniform guidance, covered entities must conduct annual organizationwide single 
audits of all Federal money they receive.  These audits are conducted by non-Federal auditors, 
such as public accounting firms and State auditors.  OIG reviews the quality of these audits and 
assesses the adequacy of the entities management of Federal funds. 
OIGs oversight of non-Federal audit activity informs Federal managers about the soundness of 
management of Federal programs and identifies any significant areas of internal control weakness, 
noncompliance, and questioned costs for resolution or followup.  We identify entities for high-risk 
monitoring, alert program officials to any trends that could indicate problems in HHS programs, 
and profile non-Federal audit findings of a particular program or activity over time to identify 
systemic problems.  We also provide training and technical assistance to grantees and members of 
the auditing profession.  OIG maintains a process to assess the quality of the non-Federal reports 
received and the audit work that supports the selected reports. 
67  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
OIGs reports on non-Federal audits reviewed during this reporting period are categorized in the 
following table. 
 
Non-Federal Audits, October 1, 2022, Through March 31, 2023 
 
Not requiring changes or having minor changes   254 
Requiring major changes  10 
Having significant technical inadequacies  1 
Total Number of Non-Federal Audits  265 
 
Other Reporting Requirements and Reviews  
Legislative and Regulatory Reviews  
Pursuant to the Inspector General Act,  4(a)(2), OIG is required to review existing and proposed 
legislation and regulations relating to HHSs programs and operations and make recommendations 
concerning their impact on economy and efficiency or the prevention and detection of fraud and 
abuse.  Most audits and other reviews that we conduct are designed to test compliance with 
and/or assess the administration and oversight of existing laws and regulations.  Our reports of 
such reviews describe findings, which include questioned costs, inefficiencies, vulnerabilities to 
fraud, inconsistencies, errors in application, or weaknesses in oversight or supporting systems.  Our 
corresponding recommendations tell HHS and its OpDivs or StaffDivs what administrative, 
regulatory, or legislative actions we believe are needed to effectively respond to the findings.  Our 
regularly published core publications reflect the relationship between our work and laws and 
regulations. 
 
  This report, like our previous Semiannual Reports to Congress, describes findings and 
recommendations from recently completed reviews, many of which focus on existing laws and 
regulations.   
  OIGs Top Unimplemented Recommendations: Solutions To Reduce Fraud, Waste, and Abuse 
in HHS Programs describes priority findings and recommendations from past periods that 
remain to be implemented.   
  Our Work Plan provides citations to laws and regulations that are the subject of ongoing or 
future reviews. 
 
We also review proposed legislation and regulations related to HHS programs and operations.  In 
addition, we provide independent, objective technical assistance on a bipartisan, bicameral basis to 
congressional committees and members who request it. 
   
68 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
Appendix A: Questioned Costs and Funds To 
Be Put to Better Use 
The following tables summarize OIGs monetary recommendations and HHSs responses to them.  This 
information is 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 Supplemental Appropriations and Rescissions Act of 1980. 
  
The lists of issued reports includes all reports and is provided in accordance with the Inspector General Act, 
 5(a)(6). 
 
Audit Reports With Questioned Costs 
As defined by the Inspector General Act, the term questioned cost means a cost that is questioned by 
OIG because of: (1) an alleged violation of a provision of law, regulation, contract, grant, cooperative 
agreement, or other agreement or document governing the expenditure of funds; (2) a cost that is not 
supported by adequate documentation at the time of the audit; or (3) the expenditure of funds for the 
intended purpose is unnecessary or unreasonable.  Questioned costs that HHS program officials have, in a 
management decision, sustained or agreed should not be charged to the Government are disallowed 
costs.  Superscripts indicate end notes that follow the tables below. 
 
Table 1: Audit Reports With Questioned Costs 
Number of  Dollar Value  Dollar Value 
Description  Reports  Questioned  Unsupported 
Section 1          
Reports for which no management decisions had been 
made by the beginning of the reporting period1  50  $1,600,255,000  $558,210,000 
Issued during the reporting period2  28  $277,236,000  $89,769,000 
Total Section 1  78  $1,877,491,000  $647,979,000 
Section 2        
Reports for which management decisions were made 
during the reporting period3        
Disallowed costs  9  *$200,828,000  $0 
Costs not disallowed  14  $757,365,000  $559,212,000 
Total Section 2  23  $958,193,000  $559,212,000 
* Audit receivables (expected recoveries).       
Section 3       
Reports for which no management decisions had been 
made by the end of the reporting period 
(Section 1 - Section 2)  55  $919,298,000  $88,767,000 
69 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
Section 4       
Reports for which no management decisions were made   
within 6 months of issuance4  31  $650,607,000  $0 
 
Table 1 End Notes 
1 The opening balance was adjusted upward by $4,000 because of a reevaluation of previously issued 
recommendations.  
 
2 Four issued reports containing recommendations for both questioned costs and funds put to better use are 
counted in Table 1 and Table 2. 
3 Revisions to previously reported management decisions: 
 
A-05-18-00040, Medicare Hospital Provider Compliance Audit: St. Vincent Hospital.  CMSs subsequent review 
determined that disallowed costs should be reduced by $802,000. 
A-06-20-04003, Vanderbilt University Medical Center: Audit of Outpatient Outlier Payments.  CMSs subsequent review 
determined that disallowed costs should be increased by $124,865. 
4  Because of administrative delays, some of which were beyond management control, resolution of the following 31 
audits were not completed within 6 months of issuance of the reports; however, agency management has informed 
us that the agency is working to resolve the outstanding recommendations before the end of the next semiannual 
reporting period. 
 
Audits For Which No Management Decision Was Received Within 6 Months of Issuance 
Audit CIN  Audit Title 
A-07-16-01165  Medicare Advantage Compliance Audit of Diagnosis Codes That Humana, Inc. 
(Contract H1036), Submitted to CMS, APR 2021, $197,720,651 
A-02-14-02017  New York Misallocated Costs to Establishment Grants for a Health Insurance 
Marketplace, NOV 2016, $149,654,512 
A-07-17-01169  Medicare Advantage Compliance Audit of Diagnosis Codes That SCAN Health Plan 
(Contract H5425) Submitted to CMS, FEB 2022, $54,318,154 
A-05-19-00039  Medicare Advantage Compliance Audit of Specific Diagnosis Codes That 
HumanaChoice (Contract R5826) Submitted to CMS, SEPT 2022, $34,414,828 
A-01-14-02503  Maryland Misallocated Millions to Establishment Grants for a Health Insurance 
Marketplace, MAR 2015, $28,400,000 
A-04-14-07050  Kentucky Misallocated Millions to Establishment Grants for a Health Insurance 
Marketplace, FEB 2017, $25,530,429 
A-07-18-04111  Mississippi Needs To Improve Oversight of Its Child Care Payment Program, APR 
2020, $22,284,900 
A-02-15-02008  New York Did Not Comply With Federal Grant Requirements for Allocating and 
Claiming Marketplace Contract Costs, DEC 2017, $20,415,344 
70 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
A-07-15-04226  Not All of Missouri's Child Care Subsidy Program Payments Complied With Federal 
and State Requirements, NOV 2017, $19,076,167 
A-02-18-01028  Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Blue Cross 
Blue Shield of Michigan (Contract H9572) Submitted to CMS, FEB 2021, $14,534,375 
A-01-15-02500  Vermont Did Not Properly Allocate Millions to Establishment Grants for a Health 
Insurance Marketplace, SEPT 2016, $11,243,006 
A-02-20-01009  Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Cariten 
Health Plan, Inc., (Contract H4461) Submitted to CMS, JULY 2022, $9,212,531 
A-01-20-00006  More Than 90 Percent of the New Hampshire Managed Care Organization and Fee-
for-Service Claims for Opioid Treatment Program Services Did Not Comply With 
Medicaid Requirements, JUNE 2022, $7,943,271 
A-07-19-01195  Medicare Advantage Compliance Audit of Specific Diagnosis Codes That BlueCross 
BlueShield of Tennessee, Inc. (Contract H7917) Submitted to CMS, SEPT 2022, 
$7,784,540 
A-07-19-01188  Medicare Advantage Compliance Audit of Specific Diagnosis Codes That UPMC 
Health Plan, Inc. (Contract H3907) Submitted to CMS, NOV 2021, $6,401,297 
A-03-19-00001  Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Highmark 
Senior Health Company (H3916) Submitted to CMS, SEPT 2022, $6,227,005 
A-05-18-00020  Medicare Advantage Compliance Audit of Diagnosis Codes That Inter Valley Health 
Plan, Inc. (Contract H0545), Submitted to CMS, SEPT 2022, $5,372,998 
A-02-18-01029  Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Healthfirst 
Health Plan, Inc., (Contract H3359) Submitted to CMS, JAN 2022, $5,221,901 
A-01-19-00500  Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Tufts Health 
Plan (Contract H2256) Submitted to CMS, FEB 2022, $3,758,335 
A-04-19-07084  Medicare Advantage Compliance Audit of Specific Diagnosis Codes That WellCare of 
Florida, Inc., (Contract H1032) Submitted to CMS, AUG 2022, $3,518,465 
A-07-19-01187  Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Anthem 
Community Insurance Company, Inc. (Contract H3655) Submitted to CMS, MAY 2021, 
$3,468,954 
A-06-18-05002  Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Peoples 
Health Network (Contract H1961) Submitted to CMS, MAY 2022, $3,312,219 
A-02-16-02013  The Children's Village, Inc., an Administration for Children and Families Grantee, Did 
Not Always Comply With Applicable Federal and State Policies and Requirements, 
APR 2019, $2,623,785 
A-07-17-02808  The Colorado Health Insurance Marketplaces Financial Management System Did Not 
Always Comply With Federal Requirements, JULY 2018, $2,567,604 
A-09-20-03009  Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Regence 
BlueCross BlueShield of Oregon (Contract H3817) Submitted to CMS, SEPT 2022, 
$1,890,855 
A-05-14-00045  The Minnesota Marketplace Misallocated Federal Funds and Claimed Unallowable 
Costs, NOV 2016, $1,279,677 
A-02-18-02011  Gateway Community Action Partnership Claimed Unallowable Costs, Did Not 
Comply With Federal Regulations on Construction and Major Renovations, and Did 
Not Accurately Account for Grant Funds, MAY 2021, $932,907 
71 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
A-09-14-01007  Nevada Misallocated Costs for Establishing a Health Insurance Marketplace to Its 
Establishment Grants, FEB 2016, $893,464 
A-07-17-01173  Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Coventry 
Health Care of Missouri, Inc. (Contract H2663) Submitted to CMS, OCT 2021, 
$548,852 
A-03-18-00002  Medicare Advantage Compliance Audit of Diagnosis Codes That Cigna HealthSpring 
of Florida, Inc. (Contract H5410) Submitted to CMS, AUG 2022, $39,612 
A-03-16-00250  Youth for Tomorrow  New Life Center, Inc., an Administration for Children and 
Families Grantee, Did Not Comply With All Applicable Federal Policies and 
Requirements, SEPT 2020, $16,851 
 
TOTAL CINS: 31 
TOTAL AMOUNT: $650,607,489 
 
 
Audit Reports With Funds Recommended To Be Put to Better Use 
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, de-obligation of funds, and/or avoidance of unnecessary expenditures.  Table 2 reports HHS 
program officials decisions to take action on these audit recommendations.   
 
Table 2: Audit Reports With Funds Put to Better Use 
Number of 
Description  Reports  Dollar Value 
 
Section 1   
Reports for which no management decisions had been made by the 
beginning of the reporting period  8  $17,121,659,000 
Reports issued during the reporting period1  5  $328,116,000 
Total Section 1  13  $17,449,775,000 
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  0  $0 
Based on proposed legislative action  0  $0 
Value of recommendations not agreed to by management  5  $2,089,668,000 
Total Section 2  5  $2,089,668,000 
Section 3     
Reports for which no management decisions had been made by the 
end of the reporting period1 (Section 1 - Section 2)2,3  8  $15,360,107,000 
 
72 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
 
Table 2 End Notes 
1 Four issued reports containing recommendations for both questioned costs and funds put to better use are counted 
in Table 1 and Table 2. 
2 Included is a management decision submitted during the period on $15 billion that is under management review. 
3 Because of administrative delays, some of which were beyond management control, three of the eight audits open 
at end of the period were not resolved within 6 months of report issuance.  OIG is working with management to 
reach resolution on these recommendations before the end of the next semiannual reporting period. 
 
Audits For Which No Management Decision Was Received Within 6 Months of Issuance 
Audit CIN  Audit Title 
A-03-13-03002  HHS Did Not Identify and Report Antideficiency Act Violations, MAY 2017, $49,445,025 
A-07-17-01176  Incorrect Acute Stroke Diagnosis Codes Submitted by Traditional Medicare Providers Resulted in 
Millions of Dollars in Increased Payments to Medicare Advantage Organizations, SEPT 2020, 
$14,417,533 
A-09-20-03016  Medicare Improperly Paid Durable Medical Equipment Suppliers an Estimated $8 Million of the $40 
Million Paid for Power Mobility Device Repairs, MAY 2022, $3,739,346 
TOTAL CINS: 3 
TOTAL AMOUNT: $67,601,904 
 
Audit Reports by Issue Date  
 
Report Number  Title  Issued  Questioned  Funds Put to 
Costs  Better Use 
A-17-22-54000  U.S. Department of Health and Human Services Met  10/12/2022  -  - 
the Requirements of the Digital Accountability and 
Transparency Act of 2014, With Areas That Require 
Improvement 
A-07-21-04125  IHS Did Not Always Provide the Necessary Resources  10/17/2022  -  - 
and Assistance To Help Ensure That Tribal Programs 
Complied With All Requirements During Early COVID-
19 Vaccination Program Implementation 
A-05-20-00053  Payments Made to Providers Under the COVID-19  10/24/2022  -  - 
Accelerated and Advance Payments Program Were 
Generally in Compliance With the CARES Act and 
Other Federal Requirements 
A-02-20-01027  CMS Generally Ensured That Medicare Part C and Part  10/25/2022  -  - 
D Sponsors Did Not Pay Ineligible Providers for 
Services to Medicare Beneficiaries 
73 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
A-04-21-07097  California Made Almost $16 Million in Unallowable  10/25/2022  $15,722,587   - 
Capitation Payments for Beneficiaries With Multiple 
Client Index Numbers 
A-07-21-02834  Colorado Did Not Report and Refund the Correct  10/25/2022  $3,669,738   - 
Federal Share of Medicaid-Related Overpayments for 
70 Percent of the State's Medicaid Fraud Control Unit 
Cases 
A-04-21-08084  CMS Can Use OIG Audit Reports To Improve Its  10/26/2022  -  - 
Oversight of Hospital Compliance 
A-07-21-06101  Mississippi Did Not Always Invoice Rebates to  10/27/2022  $2,218,202   $35,611,451  
Manufacturers for Physician-Administered Drugs 
A-01-20-01504  Three Tribes in New England and Their Health  11/4/2022  -  - 
Programs Did Not Conduct Required Background 
Investigations on All Individuals in Contact With Indian 
Children 
A-17-22-53000  Report on the Financial Statement Audit of the Centers  11/7/2022  -  - 
for Medicare & Medicaid Services for Fiscal Year 2022 
A-07-21-06105  Iowa Implemented Most of Our Prior Audit  11/9/2022  -  - 
Recommendations and Generally Complied With 
Federal and State Requirements for Reporting and 
Monitoring Major Incidents 
A-09-21-03004  The Number of Beneficiaries Who Received Medicare  11/9/2022  -  - 
Part B Clinical Laboratory Tests Decreased During the 
First 10 Months of the COVID-19 Pandemic 
A-09-19-03001  Medicare Advantage Compliance Audit of Specific  11/10/2022  $2,033,039   - 
Diagnosis Codes That California Physicians' Service, 
Inc. (Contract H0504) Submitted to CMS 
A-17-22-00001  Financial Statement Audit of the Department of Health  11/14/2022  -  - 
and Human Services for Fiscal Year 2022 
A-01-20-00500  Medicare Advantage Compliance Audit of Specific  11/16/2022  $4,894,595   - 
Diagnosis Codes That Blue Cross & Blue Shield of 
Rhode Island (H4152) Submitted to CMS 
A-04-21-00132  The Centers for Medicare & Medicaid Services' Review  11/17/2022  -  - 
Contractors Generally Conducted Medicaid Fee-for-
Service Claim Reviews for Selected States Under the 
Payment Error Rate Measurement Program in 
Accordance with Federal and State Requirements 
A-06-21-08004  National Government Services, Inc., Accurately  11/17/2022  $2,138,011   - 
Calculated Hospice Cap Amounts but Did Not Collect 
All Cap Overpayments 
A-18-20-08005  Puerto Rico MMIS and E&E Systems Security Controls  11/18/2022  -  - 
Were Generally Effective, but Some Improvements Are 
Needed 
74 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
A-01-20-00503  Medicare Improperly Paid Physicians for Co-Surgery  11/22/2022  $56,016   $4,883,570  
and Assistant-at-Surgery Services That Were Billed 
Without the Appropriate Payment Modifiers 
A-06-20-04008  Medicare Providers Did Not Always Comply With  11/22/2022  $33,332   $42,233,599  
Federal Requirements When Billing for Advance Care 
Planning 
A-04-21-09003  The Centers for Medicare & Medicaid Services' Review  12/8/2022  -  - 
Contractor Did Not Document Medicaid Managed 
Care Payment Review Determinations Made Under the 
Payment Error Rate Measurement Program 
A-07-20-02825  Providers Did Not Always Comply With Federal  12/15/2022  -  - 
Requirements When Claiming Medicare Bad Debts 
A-03-20-00201  Keystone First Should Improve Its Procedures for  12/20/2022  -  - 
Reviewing Service Requests That Require Prior 
Authorization 
A-05-20-00031  Mandated Analysis of Home Health Service Utilization  12/20/2022  -  - 
From January 2016 Through March 2022 
A-04-20-02032  The Municipality of Manati Did Not Always Manage Its  12/21/2022  $153,052   - 
Head Start Disaster Assistance Awards in Accordance 
With Federal and Commonwealth Requirements 
A-05-21-00035  Illinois Generally Complied With Requirements for  12/21/2022  $9,832   - 
Claiming Medicaid Reimbursement for Telehealth 
Payments During COVID-19 
A-07-22-00624  National Government Services, Inc., Claimed Some  12/21/2022  $636,197   - 
Unallowable Medicare Postretirement Benefit Plan 
Costs Through Its Incurred Cost Proposals 
A-07-22-00625  National Government Services, Inc., Claimed Some  12/21/2022  $209,543   - 
Unallowable Medicare Supplemental Executive 
Retirement Plan Costs Through Its Incurred Cost 
Proposals 
A-07-22-00628  National Government Services, Inc., Claimed Some  12/21/2022  $657,765   - 
Unallowable Medicare Nonqualified Plan Costs 
Through Its Incurred Cost Proposals 
A-07-19-01193  Medicare Advantage Compliance Audit of Specific  12/22/2022  $5,987,509   - 
Diagnosis Codes That Cigna-HealthSpring of 
Tennessee, Inc. (Contract H4454) Submitted to CMS 
A-07-22-00620  National Government Services, Inc., Understated Its  1/5/2023  $54,544   - 
Plan A Medicare Segment Pension Assets and 
Overstated Medicare's Share of the Medicare Segment 
Excess Pension Liabilities as of December 31, 2018 
A-07-22-00621  National Government Services, Inc., Overstated Its Plan  1/5/2023  -  - 
B Medicare Segment Pension Assets and Overstated 
Medicare's Share of the Medicare Segment Excess 
Pension Assets as of December 31, 2018 
75 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
A-07-22-00622  National Government Services, Inc., Overstated Its  1/6/2023  -  - 
United Government Services, LLC, Medicare Segment 
Pension Assets and Understated Medicare's Share of 
the Medicare Segment Excess Pension Liabilities as of 
December 31, 2018 
A-07-22-00623  National Government Services, Inc., Claimed Some  1/7/2023  $73,307   - 
Unallowable Medicare Pension Costs Through Its 
Incurred Cost Proposals 
A-01-21-01502  ASPR Could Improve Its Oversight of the Hospital  1/13/2023  -  - 
Preparedness Program To Ensure That Crisis Standards 
of Care Comply With Federal Nondiscrimination Laws 
A-18-21-11100  FDA Should Improve Its Management of Contracts for  1/13/2023  -  - 
the Acquisition of Information Technology 
A-03-23-00351  Independent Attestation Review: National Institutes of  1/18/2023  -  - 
Health Fiscal Year 2022 Detailed Accounting 
Submission and Budget Formulation Compliance 
Report for National Drug Control Activities, and 
Accompanying Required Assertions 
A-03-23-00352  Independent Attestation Review: Centers for Disease  1/18/2023  -  - 
Control and Prevention Fiscal Year 2022 Detailed 
Accounting Submission and Budget Formulation 
Compliance Report for National Drug Control 
Activities, and Accompanying Required Assertions 
A-03-23-00353  Independent Attestation Review: Food and Drug  1/18/2023  -  - 
Administration Fiscal Year 2022 Detailed Accounting 
Submission and Budget Formulation Compliance 
Report for National Drug Control Activities, and 
Accompanying Required Assertions 
A-05-21-00025  The National Institutes of Health and EcoHealth  1/25/2023  $89,171   - 
Alliance Did Not Effectively Monitor Awards and 
Subawards, Resulting in Missed Opportunities to 
Oversee Research and Other Deficiencies 
A-02-19-02008  Greater Bergen Community Action, Inc., Did Not  1/26/2023  $487,411   - 
Manage Its Head Start Awards in Accordance With 
Federal and State Requirements 
A-07-21-07002  North Carolina Did Not Always Invoice Rebates to  2/7/2023  $3,742,833   - 
Manufacturers for Physician-Administered Drugs 
A-05-21-00030  Michigan Did Not Comply With Requirements for  2/8/2023  -  - 
Documenting Psychotropic and Opioid Medications 
Prescribed for Children in Foster Care 
A-05-21-00028  Florida Made Capitation Payments for Enrollees Who  2/16/2023  -  - 
Were Concurrently Enrolled in a Medicaid Managed 
Care Program in Another State 
A-18-20-08200  The Health Resources and Services Administration  2/22/2023  -  - 
Should Improve Preventive and Detective Controls To 
More Effectively Mitigate the Risk of Compromise 
76 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
A-07-20-03243  Missouri Claimed Federal Medicaid Reimbursement for  2/23/2023  $121,189,991   - 
Tens of Millions in Consumer-Directed Personal Care 
Assistance Services That Did Not Comply With Federal 
and State Requirements 
A-09-21-03006  Medicare Could Have Saved up to $216 Million Over 5  2/27/2023  -  $215,839,412  
Years if Program Safeguards Had Prevented At-Risk 
Payments for Definitive Drug Testing Services 
A-09-20-03033  Medicare Part D Plan Sponsors and CMS Did Not  2/28/2023  $105,951,927   - 
Ensure That Transmucosal Immediate-Release 
Fentanyl Drugs Were Dispensed Only to Beneficiaries 
Who Had a Cancer Diagnosis 
A-07-21-06102  State Agencies Did Not Always Ensure That Children  3/2/2023  -  - 
Missing From Foster Care Were Reported to the 
National Center for Missing and Exploited Children in 
Accordance With Federal Requirements 
A-04-21-07098  Florida Did Not Invoice Manufacturers for Some  3/3/2023  $59,898   - 
Rebates for Physician-Administered Drugs Dispensed 
to Enrollees of Medicaid Managed-Care Organizations 
A-06-17-09004  Texas Could Not Support the Permissibility of the  3/8/2023  -  - 
Funds Used as the State Share of the Medicaid Delivery 
System Reform Incentive Payment Program 
A-18-20-08004  Michigan MMIS and E&E Systems Security Controls  3/9/2023  -  - 
Were Generally Effective, but Some Improvements Are 
Needed 
A-07-21-00618  Medicare Improperly Paid Physicians for Epidural  3/10/2023  $3,585,422   - 
Steroid Injection Sessions 
A-04-21-08089  Georgia Did Not Always Invoice Rebates to  3/13/2023  $2,308,312   - 
Manufacturers for Pharmacy and Physician-
Administered Drugs 
A-04-22-00134  Georgia Did Not Comply With Federal Waiver and  3/14/2023  -  - 
State Requirements at All 20 Adult Day Health Care 
Facilities Reviewed 
A-03-20-00200  The District of Columbia Has Taken Significant Steps  3/16/2023  -  - 
To Ensure Accountability Over Amounts Managed Care 
Organizations Paid to Pharmacy Benefit Managers 
A-09-21-03011  Medicare Advantage Compliance Audit of Specific  3/16/2023  $566,476   - 
Diagnosis Codes That Geisinger Health Plan (Contract 
H3954) Submitted to CMS 
A-07-21-03247  Missouri's Oversight of Certified Individualized  3/21/2023  -  - 
Supported Living Provider Health and Safety Could Be 
Improved in Some Areas 
A-09-22-03006  Medicare Improperly Paid Physicians an Estimated $30  3/22/2023  $18,084   $29,548,088  
Million for Spinal Facet-Joint Interventions 
A-01-22-02500  Maryland's Child Support Administration Generally  3/23/2023  -  - 
Claimed Administrative Costs That Were Allowable 
and Allocable 
77 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
A-02-20-01008  Medicare Advantage Compliance Audit of Specific  3/24/2023  $220,577   - 
Diagnosis Codes That MCS Advantage, Inc. (Contract 
H5577) Submitted to CMS 
A-07-19-01192  Medicare Advantage Compliance Audit of Specific  3/28/2023  $468,372   - 
Diagnosis Codes That Cigna-HealthSpring Life & 
Health Insurance Company, Inc. (Contract H4513) 
Submitted to CMS 
  Total Reports: 62    $277,235,743  $328,116,120 
 
Evaluation Reports by Operating Division  
 
Report Number  Title  Operating  Issue Date 
Division 
OEI-04-20-00360  During the Initial COVID-19 Response, HHS Personnel Who Interacted  CDC  Oct-22 
With Potentially Infected Passengers Had Limited Protections 
OEI-05-22-00010  Challenges With Vaccination Data Hinder State and Local  CDC  Jan-23 
Immunization Program Efforts To Combat COVID-19 
OEI-04-21-00190  Early Challenges Highlight Areas for Improvement in COVID-19  CDC  Jan-23 
Vaccination Programs 
OEI-01-21-00110  Home Health Agencies Used Multiple Strategies To Respond to the  CMS  Oct-22 
COVID-19 Pandemic, Although Some Challenges Persist 
OEI-07-20-00500  Long-Term Trends of Psychotropic Drug Use in Nursing Homes  CMS  Nov-22 
OEI-03-23-00070  Comparison of Average Sales Prices and Average Manufacturer Prices:  CMS  Nov-22 
Results for the Second Quarter of 2022 
OEI-07-18-00370  For Medicaid-Enrolled Children Diagnosed With Lead Toxicity in Five  CMS  Dec-22 
States, Documentation Reviewed for Diagnoses and Treatment 
Services Raises Concerns 
OEI-09-20-00510  Labs With Questionably High Billing for Additional Tests Alongside  CMS  Dec-22 
COVID-19 Tests Warrant Further Scrutiny 
OEI-03-21-00390  CMS Should Bolster Its Oversight of Manufacturer-Submitted Average  CMS  Dec-22 
Sales Price Data To Ensure Accurate Part B Drug Payments 
OEI-BL-21-00330  Manufacturers May Need Additional Guidance To Ensure Consistent  CMS  Dec-22 
Calculations of Average Sales Prices 
OEI-09-22-00400  Medicare Part B Spending on Lab Tests Increased in 2021, Driven By  CMS  Dec-22 
Higher Volume of COVID-19 Tests, Genetic Tests, and Chemistry Tests 
OEI-02-20-00491  More Than a Thousand Nursing Homes Reached Infection Rates of 75  CMS  Jan-23 
Percent or More in the First Year of the COVID-19 Pandemic; Better 
Protections Are Needed for Future Emergencies 
OEI-03-21-00380  The Inability To Identify Denied Claims in Medicare Advantage  CMS  Feb-23 
Hinders Fraud Oversight 
OEI-03-23-00080  Comparison of Average Sales Prices and Average Manufacturer Prices:  CMS  Feb-23 
Results for the Third Quarter of 2022 
OEI-BL-23-00170  Technical Assistance Brief: Implementation of Inflation-Indexed  CMS  Feb-23 
Rebates for Part B Drugs 
78 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
OEI-BL-23-00010  Some Skin Substitute Manufacturers Did Not Comply with New ASP  CMS  Mar-23 
Reporting Requirements 
OEI-01-20-00241  FDA's Approach to Overseeing Online Tobacco Retailers Needs  FDA  Dec-22 
Improvement 
OEI-09-23-00190  Medicaid Fraud Control Units Fiscal Year 2022 Annual Report  MFCU  Mar-23 
OEI-07-22-00370  Rhode Island Medicaid Fraud Control Unit: 2022 Inspection  MFCU  Mar-23 
  Total Reports: 19     
 
   
79 
 
 
  Department of  Health and Human Services, Office  of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023  
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 an OIG of other OIGs in the semiannual reporting period.  
Peer reviews are conducted by member organizations of the Council of the Inspectors General on Integrity 
and Efficiency (CIGIE).   
 
Office of Audit Services  
During this semiannual reporting period, no peer reviews involving OAS were completed.  As such, 
information concerning OASs peer review activity during prior reporting periods is listed here. 
 
OAS  Date   Reviewing Office   Office Reviewed  
 
September 2022  HHS-OIG, OAS  Department of Labor (DOL) OIG  
 
The system  of quality control for the  audit organization of DOL-OIG in effect for the fiscal year 
ending September 30, 2021, has been suitably designed and complied with to provide DOL-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.  DOL-OIG received a peer review rating of pass. 
 
OAS   Date   Reviewing Office   Office Reviewed  
March 2021   General Services  HHS-OIG, OAS 
Administration OIG 
The system  of quality control for the  audit organization of HHS-OIG in effect for the fiscal year 
ending September 30, 2020, has been suitably designed and complied with to provide HHS-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.  HHS-OIG received a peer review rating of pass. 
 
Office of Investigations 
During this semiannual reporting period, no peer reviews involving OI were completed.  As such, 
information concerning OIs peer review activities during prior reporting periods is listed here. 
 
OI  Date   Reviewing Office   Office  Reviewed  
February 2023  HHS-OIG, OI  DOD-OIG 
80  
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023
The system of internal safeguards and management procedures for the investigative function of 
DOD-OIG in effect for the year ending December 31, 2022, was in full compliance with the quality 
standards established by CIGIE and the Attorney Generals guidelines.  
OI  Date  Reviewing Office  Office Reviewed 
October 2018  Social Security  HHS-OIG, OI 
Administration OIG 
The system of internal safeguards and management procedures for the investigative function of 
HHS-OIG in effect for the year ending September 30, 2018, was in full compliance with the quality 
standards established by CIGIE and the Attorney Generals guidelines. 
OI  Date  Reviewing Office  Office Reviewed 
August 2017  HHS-OIG, OI  U.S. Postal Service OIG 
The system of internal safeguards and management procedures for the investigative function of 
the U.S. Postal Service OIG in effect for the year ending September 30, 2015, was in full compliance 
with the quality standards established by CIGIE and the Attorney Generals guidelines.  
Office of Evaluation and Inspections 
During this semiannual reporting period, one peer review involving OEI was completed.  Information 
concerning OEIs peer review activity during a prior reporting period is also listed here. 
OEI  Date  Reviewing Office  Office Reviewed 
March 2023  HHS-OIG, OEI  Special Inspector General for 
Afghanistan Reconstruction 
(SIGAR) OIG 
The SIGAR Audits and Inspections Directorate and the Lessons Learned Program (collectively, 
SIGAR-OIG) policies and procedures complied with CIGIEs Quality Standards for Inspection and 
Evaluation (known as the Blue Book), December 2020.  In addition, each of the three reviewed 
SIGAR-OIG reports complied with those standards and the SIGAR-OIGs internal policies and 
procedures.  SIGAR concurred with the three recommendations issued in the Letter of Comment 
regarding the Blue Book standards for independence, competence, and planning. 
OEI  Date  Reviewing Office  Office Reviewed 
November 2020  Department of State,  HHS-OIG, OEI 
OIG 
A CIGIE external peer review team assessed the extent to which HHS-OIG, OEI met CIGIEs seven 
Blue Book standards: Quality Control, Planning, Data Collections and Analysis, Evidence, Records 
Maintenance, Reporting, and Follow-up.  The assessment included a review of OEIs internal 
81  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
policies and procedures documented in the OEI procedures manual.  It also included a review of 
four reports issued between June 1, 2019, and June 1, 2020, to determine whether the reports 
compiled with the seven standards and internal policies and procedures.  The review team 
determined that OEIs policies and procedures generally met the seven standards.  The four reports 
reviewed generally met the standards and complied with OEIs internal policies and procedures.  
 
OEI  Date  Reviewing Office  Office Reviewed 
 
June 2020  HHS-OIG, OEI  Department of Veterans Affairs 
 
(VA) OIG 
The VA Office of Inspector General, Office of Audits and Evaluations, and Office of Healthcare 
Inspections (collectively, VA-OIG) policies and procedures addressed CIGIEs seven Blue Book 
standards: Quality Control, Planning, Data Collections and Analysis, Evidence, Records 
Maintenance, Reporting, and Follow-up.  In addition, each of the four reviewed VA-OIG reports 
complied with those standards and the VA-OIGs internal policies and procedures.  As a result of 
our findings, there are no recommendations associated with this external peer review.  The report 
also noted a VA-OIG beneficial practice of using specialized staff to conduct independent 
referencing reviews of its reports to achieve greater consistency in its quality assurance processes. 
 
OEI  Date  Reviewing Office  Office Reviewed 
September 2019  HHS-OIG, OEI  Department of Interior (DOI) 
OIG 
The DOI-OIG Inspection and Evaluation components policies and procedures mostly met CIGIEs 
Blue Book standards.  We reviewed four reports: two fully met the applicable Blue Book standards 
and two did not.  DOI-OIG concurred with recommendations related to Evidence, Planning, and 
Data Collection and Analysis but did not concur with recommendations related to Reporting. 
 
OEI  Date  Reviewing Office  Office Reviewed 
September 2018  HHS-OIG, OEI  DoD-OIG 
The DOD-OIG Inspection and Evaluation components policies and procedures generally met 
CIGIEs Blue Book standards.  The 10 reports reviewed generally met the applicable Blue Book 
standards.  Onsite visits for these reviews were conducted from October 2, 2017, through 
 
November 17, 2017.
82 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
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 of Health and Human Services for transmittal to Congress.  A selection of other authorities 
appears below.  
 
Program Exclusions 
Section 1128 of the Social Security Act (42 U.S.C.  1320a-7), provides numerous grounds for excluding 
individuals and entities from participation in Medicare, Medicaid, and other Federal health care programs.  
Exclusions are required (mandatory exclusion) for individuals and entities convicted of the following types 
of criminal offenses: (1) Medicare or Medicaid fraud; (2) patient abuse or neglect; (3) felonies for other 
health care fraud; and (4) felonies for illegal manufacture, distribution, prescription, or dispensing of 
controlled substances.   
 
OIG is authorized (permissive exclusion) to exclude individuals and entities on 17 other grounds, including 
misdemeanors for health care fraud other than Medicare or Medicaid fraud; 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; submission of false or fraudulent 
claims to a Federal health care program; or engaging in unlawful kickback arrangements.  
 
Providers subject to exclusion are granted due process rights.  These include a hearing before an 
administrative law judge and appeals to the HHS Departmental Appeals Board and Federal district and 
appellate courts regarding the basis for and the length of the exclusion.  
 
Civil Monetary Penalties Law 
The CMPL, found at section 1128A of the Social Security Act (42 U.S.C.  1320a-7a), authorizes 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 $20,000 for each item or service falsely or fraudulently 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, and payment or receipt of remuneration in violation of the Federal anti-kickback statute (42 
U.S.C.  1320a-7b(b)).   
83 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
 
The 21st Century Cures Act (enacted on December 13, 2016) added more grounds for imposing CMPs, 
assessments, and exclusions from Federal health care programs for fraudulent and other improper conduct 
related to HHS grants, contracts, and other agreements.  OIG may impose a CMP of up to $10,000 per 
specified claim, an assessment of up to three times the amount claimed, and an exclusion upon any person 
who knowingly presents a specified claim under an HHS grant, contract, or other agreement that they 
know or should know is false or fraudulent.  In addition, OIG may impose a CMP of up to $50,000, an 
assessment of up to three times the amount of funds at issue, and an exclusion upon any person who: (1) 
knowingly makes a false statement in a document required to be submitted to receive funds under an HHS 
contract, grant, or other agreement; (2) knowingly makes or uses a false record or statement that is 
material to a false or fraudulent claim; or (3) knowingly makes or uses a false record or statement material 
to an obligation to pay or transmit funds or property owed to HHS.  OIG may also impose a CMP of up to 
$10,000 per day, an assessment of up to three times the amount at issue, and an exclusion upon any 
person who knowingly conceals, or knowingly and improperly avoids or decreases, an obligation owed to 
HHS with respect to an HHS grant, contract, or other agreement.  Finally, OIG may impose a penalty of up 
to $15,000 per day and an exclusion upon any person who fails to grant timely access to OIG upon 
reasonable request for the purpose of audits, investigations, evaluations, or other statutory functions of the 
OIG in matters involving HHS grants, contracts, or other agreements.   
 
Patient Dumping 
Section 1867 of the Social Security Act (42 U.S.C.  1395dd) provides that when an individual goes to the 
Emergency Department 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 when the hospital does not have the capabilities to 
stabilize the condition. 
 
If a transfer is ordered, the transferring hospital must provide stabilizing treatment to minimize the risks of 
transfer and 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 $53,484 against small hospitals (fewer than 100 beds) and up to 
$106,965 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 $106,965 
from a responsible physician for each negligent violation of any of the section 1867 requirements and, in 
some circumstances, may exclude a responsible physician.   
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Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
 
Anti-Kickback Statute and Civil False Claims Act Enforcement Authorities 
The Anti-Kickback Statute 
The Federal anti-kickback statute makes it a criminal offense to knowingly and willfully offer, pay, 
solicit, or receive any remuneration to induce, or in return for, the referral of an individual to a 
person for the furnishing of, or arranging for the furnishing of, any item or service reimbursable 
under a Federal health care program.  The statutes prohibition also extends to remuneration to 
induce, or in return for, the purchasing, leasing, or ordering of, or arranging for or recommending 
the purchasing, leasing, or ordering of, any good, facility, service, or item reimbursable by a Federal 
health care program (Social Security Act,  1128B(b) (42 U.S.C.  1320a-7b(b))).  
 
Individuals and entities who engage in conduct prohibited by the anti-kickback statute may be 
subject to criminal penalties and fines under the anti-kickback statute; CMPs under OIGs authority 
pursuant to the Social Security Act, section 1128A(a)(7) (42 U.S.C.  1320a-7a(a)(7)); and/or program 
exclusion under OIGs permissive exclusion authority under the Social Security Act, section 
1128(b)(7) (42 U.S.C.  1320a-7(b)(7)).  In addition, a conviction under the anti-kickback statute leads 
to mandatory exclusion under the Social Security Act, section 1128(a)(1) (42 U.S.C.  1320a-7a(a)(1)).  
Finally, a claim that includes items or services resulting from a violation of the Federal anti-kickback 
statute constitutes a false or fraudulent claim for purposes of the False Claims Act (Social Security 
Act,  1128B(b)(g) (42 U.S.C.  1320a-7b(b)(g))). 
 
The False Claims Act 
OIG investigates alleged violations of the False Claims Act (31 U.S.C.  37293733).  Under the 
False Claims Act, a person or an entity is liable for up to treble damages and a penalty between 
$11,181 and $22,363 for each false claim it knowingly submits, or causes to be submitted, to a 
Federal program.  Similarly, a person or an entity is liable under the False Claims Act if they 
knowingly make or use, or cause to be made or used, a false record or statement to have a false 
claim paid.  Similar to the CMPL, the False Claims Act defines knowing to include instances in 
which the person acted in deliberate ignorance or reckless disregard of the truth or falsity of the 
information.  Further, the False Claims Act contains a qui tam, or whistleblower, provision that 
allows a private individual to file a lawsuit on behalf of the United States and entitles that 
whistleblower to a percentage of any fraud recoveries.  The False Claims Act was amended in 2009.  
Among other things, the amendments clarified the reach of the False Claims Act to false claims 
submitted to contractors or grantees of the Federal Government.   
85 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
Appendix D: Reporting Requirements in the 
Inspector General Act of 1978 
The reporting requirements of the Inspector General Act of 1978, as amended, along with the location of 
the required information, are listed in the following table.  
 
Section  Requirement  Location 
Section 4 
(a)(2)  Review of legislation and regulations  Other HHS-Related 
Reviews and Investigative 
Activities section   
Section 5 
(a)(1)  Significant problems, abuses, and deficiencies  Throughout this report 
(a)(2)  Recommendations with respect to significant problems,  Throughout this report 
abuses, and deficiencies 
(a)(3)  Prior significant recommendations on which corrective  OIG's Top Unimplemented 
Recommendations: 
action has not been completed 
Solutions To Reduce Fraud, 
Waste, and Abuse in HHS 
Programs 
(a)(4)  Matters referred to prosecutive authorities  Legal and Investigative 
Activities Related to the 
Medicare and Medicaid 
section 
(a)(5)  Summary of instances in which information requested by  None for this reporting 
OIG was refused  period 
(a)(6)  List of audit reports  Throughout this report 
and Appendix A 
(a)(7)  Summary of significant reports  Throughout this report 
(a)(8)  Statistical Table 1Audit Reports With Questioned Costs  Appendix A 
(a)(9)  Statistical Table 2Audit Reports with Funds Put to Better  Appendix A 
Use 
(a)(10)  Summary of previous audit reports without management  Appendix A 
decisions, in which no establishment comment was returned 
within 60 days, and in which there are any outstanding 
unimplemented recommendations 
(a)(11)  Description and explanation of revised management  Appendix A 
decisions 
86 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
Section  Requirement  Location 
(a)(12)  Management decisions with which the Inspector General  None for this reporting 
disagrees  period 
(a)(13)  Information required by the Federal Financial Management  Nothing to report 
Improvement Act of 1996   
 
(a)(14)-(16)  Results of peer reviews of HHS-OIG conducted by other  Appendix C 
OIGs or the 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 F 
(a)(18)  Metrics description for statistical tables  Appendix F 
(a)(19)  Investigations on senior Government employees  Appendix F  
(a)(20)  Description of whistleblower retaliation instances  Appendix F 
(a)(21)  Description of attempts to interfere with OIG independence  Appendix F 
(a)(22)  Description of closed and nondisclosed reports and  Appendix F 
investigations regarding senior Government employees 
 
Other Reporting Requirements 
Section  Requirement  Location 
845  Significant contract audits required to be reported pursuant  Other HHS-Related 
to the National Defense Authorization Act for FY 2008 (P.L.  Reviews and Investigative 
No. 110181), section 845.  Activities section 
   205  Pursuant to HIPAA (P.L. No. 104191), section 205, the  Appendix G  
Inspector General is required to solicit proposals annually via 
a Federal Register notice for developing new and modifying 
existing safe harbors to the anti-kickback statute of the 
Social Security Act, section 1128(b) and for developing 
special fraud alerts.  The Inspector General is also required 
to report annually to Congress on the status of the 
proposals received related to new or modified safe harbors. 
1553  Pursuant to the American Recovery and Reinvestment Act of  Other HHS-Related 
2009, P.L. No. 1115, section 1553, OIG reports to Congress  Reviews and Investigative 
the retaliation complaint investigations it decided not to 
Activities section 
conduct or continue during the period. 
 
87 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
Appendix E: Reporting Requirements in the 
Inspector General Empowerment Act of 2016 
The Inspector General Empowerment Act of 2016 establishes new reporting requirements for the 
Semiannual Reports.  These requirements amend portions of section 5 of the Inspector General Act.  The 
requirements are below in italics, followed by OIGs responses.  
Each Inspector General shall, not later than April 30 and October 31 of each year, prepare 
semiannual reports summarizing the activities of the Office during the immediately preceding 6 
month periods ending March 31 and September 30.  Such reports shall include, but need not be 
limited to . . .  
(10) A summary of audit, inspection, and evaluation reports issued before the 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 been made, and a statement concerning the desired timetable for achieving a management 
decision on each such report . . .   
 
For audit and evaluation reports issued from FY 2011 through FY 2022, OIG had a total of 86 
reports with overdue final management decisions (FMDs) as of the end of this reporting period.  
The breakdown of those 86 reports by HHS OpDiv is as follows: 
 
OpDiv  Overdue FMDs 
ACF   13 
ASA  1 
ASPR   1 
CMS  52 
IHS   14 
NIH   2 
OASH   1 
OS   5 
 
OIG is unable to provide reasons and timetables for each of these overdue management decisions 
because of the volume and the fact that OIG did not historically track this information.  
 
(B) for which no establishment comment was returned within 60 days of providing the report to the 
establishment . . .   
 
88 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
For 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 
timeframe, OIG typically issues the report and notes the lack of establishment comments.   
 
For this semiannual reporting period, OIG had no reports for which no establishment comment 
was returned within 60 days of providing the report to the establishment. 
 
(C) for which there are any outstanding unimplemented recommendations, including the aggregate 
potential cost savings of those recommendations . . .  
 
OIG is actively tracking 1,379 unimplemented recommendations made in reports issued since FY 
2011.  Given the volume of recommendations OIG makes each year, the table below reflects 
summary data by fiscal year: 
 
Number of Reports 
Number of 
FY (2011 With  Dollar Value of Aggregate 
Unimplemented 
2023)  Unimplemented  Potential Cost Savings 
Recommendations 
Recommendations 
2011  12  17  $408,135,515 
2012  18  21  $369,932,148 
2013  24  36  $232,841,797 
2014  22  38  $15,072,080,989 
2015  20  32  $296,314,747 
2016  16  30  $181,809,287 
2017  25  65  $1,100,592,712 
2018  32  94  $1,675,138,695 
2019  53  151  $718,126,811 
2020  66  204  $1,394,187,117 
2021  73  171  $834,922,145 
2022  94  328  $2,475,128,152 
2023  60  192  $505, 914,370 
515  1,379  $25,265,124,485 
Totals 
 
 
OIG annually produces OIG's Top Unimplemented Recommendations: Solutions To Reduce Fraud, 
Waste, and Abuse in HHS Programs which constitutes OIGs response to a specific requirement of 
the Inspector General Act, as amended ( 5(a)(3)).  The report identifies significant 
recommendations with respect to problems, abuses, or deficiencies for which corrective actions 
have not been completed.  It also includes an appendix that lists OIGs significant unimplemented 
89 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
recommendations, which represent opportunities to achieve expected impact through cost savings, 
improvements in program effectiveness and efficiency, or increasing quality of care and safety for 
beneficiaries.  In OIGs view, these recommendations would most positively 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; 
(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 information during the reporting period that 
resulted from any prior referral to prosecuting authorities . . . 
 
Total number of investigative reports issued during the reporting period,  None 
including Management Implication Reports and Investigative Advisories 
Total number of persons referred3 to Federal prosecuting authorities for  1,192 
criminal prosecution during the reporting period4 
Total number of persons referred to State and local prosecuting authorities  130 
for criminal prosecutions during the reporting period  
Total number of Federal indictments and criminal informations during the  276 
reporting period that resulted from any prior referral to prosecuting 
authorities 
Total number of State and local indictments and criminal informations during  74 
the reporting period that resulted from any prior referral to prosecuting 
authorities 
 
 
(18) A description of the metrics used for developing the data for the statistical tables under 
paragraph (17) . . .  
 
Regarding (17)(A), OIG considers Investigative Reports as Management Implication Reports and 
Investigative Advisories.  A Management Implication Report identifies systemic weaknesses or 
vulnerabilities within HHS programs, which are generally identified during the course of an OIG 
investigation and could lead to fraud, waste, or abuse.  It provides recommendations to correct or 
minimize the problem.  Corrective actions may require administrative, procedural, policy, 
regulatory, or legislative change.  When a Management Implication Report is issued to an HHS 
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  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
OpDiv or StaffDiv, it is generally signed by the Inspector General.  Investigative Advisories are 
similar documents that bring renewed attention to an identified HHS issue and are generally signed 
by the Deputy Inspector General for Investigations.  
 
Regarding (17)(B) and (C), OIG defines this measure as the term presentations to both Federal and 
State/local prosecuting jurisdictions as the representation of the work we do.  For example, when 
OIG opens an investigation, it evaluates the complaint and decides whether to present the matter 
for prosecution.  Generally, if the case has prosecutorial merit, and is accepted for Federal 
prosecution, OIG works with DOJ as the primary investigative agency, as opposed to referring the 
matter to DOJ without further involvement on OIG's part.  OIG works with State and local 
prosecutorial authorities in addition to working with DOJ.  
 
Regarding (17)(D), the table in the previous section provides the number of indictments and 
criminal informations during the semiannual reporting period, including sealed indictments and 
criminal informations.  However, the informations cannot be limited to only those that occurred as 
a result of a presentation in a previous period.  In certain situations, the presentation and charging 
dates are in the same reporting period.  
 
(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-  
(A) the facts and circumstances of the investigation; and  
(B) the status and disposition of the matter, including-  
(i) if the matter was referred to the Department of Justice, the date of the referral; and  
(ii) if the Department of Justice declined the referral, the date of the declination . . .   
 
For this section, OIG describes investigations, both criminal and administrative, involving senior 
Government employees for whom allegations of misconduct were investigated and substantiated.  
For the reporting period, the OIG investigated two senior Government employees for misconduct 
that was substantiated.  Descriptions of the investigations are below: 
 
The OIG investigated a senior official (GS-15) for allegedly receiving improper prescription drug 
medications, which were prescribed by other employees.  It was alleged that the senior official 
directed subordinate employees to provide the senior official with prescriptions for controlled 
substances without medical examinations.  The investigation was presented for Federal prosecution 
on July 18, 2022, and was initially accepted.  After further investigation, criminal prosecution of the 
senior official was declined on February 8, 2023.    
  
The OIG investigated a senior official (GS-15) for alleged financial conflict of interest.  It was alleged 
that ethics officials directed the senior official to recuse themself from any matters involving a 
private company in which their spouse was employed; however, the senior official did not.  In 
addition, the senior official did not disclose their spouses financial interest with the company.  This 
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  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
investigation was referred to the appropriate HHS operational division for evaluation and 
administrative action.  The investigation was not presented for prosecution. 
 
OIG provides investigative facts for the purpose of referring a matter or allegation to the 
appropriate deciding authority (Department, OpDiv, DOJ, etc.).  OIG does not make findings 
regarding its investigations of departmental employees.  Our reports relay the facts obtained 
during the investigations (e.g., parties involved, dates of events).  At the conclusion of an OIG 
investigation related to allegations concerning possible employee misconduct, OIG provides a 
report to management in the employing agency.  The agency management makes determinations 
of employee misconduct.  The disposition of the matter and any resulting administrative actions 
are taken by the agency.  Although, we request from the agency a copy of an SF-50 documenting 
a personnel action, if one is taken, there are sometimes settlement agreements that may impact 
the final action.  Therefore, OIG may not have a complete record of the disposition of the 
investigation.  
 
(20) A detailed description of any instance of whistleblower retaliation, including information about 
the official found to have engaged in retaliation and what, if any, consequences the establishment 
imposed to hold that official accountable . . . 
 
OIG conducts investigations into whistleblower retaliation against current and former HHS 
employees; applicants for HHS employment; and HHS contractors, subcontractors, personal 
services contractors, grantees, and subgrantees who disclose information to OIG, and other 
protected sources, under the authority of the Whistleblower Protection Act of 1989 (41 U.S.C.  
4712), the Military Whistleblower Protection Act (10 U.S.C.  1034), and Presidential Policy Directive 
19.  OIG determines whether retaliatory action has been taken and includes these findings in 
reports, along with recommendations for corrective action.  OIG provides a summary of any 
substantiated retaliation report on the OIG website to enhance transparency and employer 
accountability.  In the reporting period, OIG submitted two report(s) to the Office of the Secretary 
of Health and Human Services that included findings of retaliation.  
 
When determining the level of detail to provide for a description of any instance of whistleblower 
retaliation, OIG is always mindful of the risk that a detailed description of the allegation could 
inadvertently reveal the whistleblowers identity, thus having a chilling effect on future 
whistleblowers.   
 
OIG conducted an investigation in response to allegations brought forth by a complainant at the 
Orangeburg-Calhoun-Allendale-Bamberg (OCAB) Community Action Agency - Bamberg Head 
Start Center, an ACF grantee.  The complainant alleged that while working in the Bamberg Center, 
the complainants supervisors and responsible management officials (RMOs) terminated the 
complainant for reporting that Federal grant laws were being repeatedly violated by OCAB staff 
and management.  Specifically, investigators found that the complainant made protected 
disclosures to the RMOs at OCAB and in a written complaint submitted to ACFs Office of Head 
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  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
Start alleging what the complainant believed to be grant mismanagement and threats to public 
health and safety.  OIG investigators found that the RMOs terminated the complainant in 
retaliation for making protected disclosures.  The OIG investigative report that was issued to the 
Secretary of Health and Human Services included recommendations to make the complainant 
whole and to provide whistleblower training for OCAB employees, ACF employees who work in the 
Head Start program, and Head Start grantee agencies. 
  
OIG conducted an investigation in response to allegations brought forth by a complainant at 
Jacobs Technologies, a contractor for DOD.  DOD entered into an agreement with HHS to provide 
acquisition assistance under an HHS contract with Jacobs Technologies.  The complainant alleged 
that while working at DOD as a contract employee, the complainants supervisors and RMOs 
terminated the complainant for notifying Army personnel of possible security breaches.  OIG 
investigators found that the RMOs terminated the complainant in retaliation for making protected 
disclosures.  The OIG investigative report that was issued to the Secretary of Health and Human 
Services included recommendations to make the complainant whole and to provide whistleblower 
training to employees of HHS contractors.  A copy of the report was also provided to DOD.  The 
OIG investigative report also included recommendations to DOD to provide whistleblower 
protection training to management officials and to consider whether DOD employees should be 
disciplined for committing prohibited personnel actions under applicable laws and/or regulations. 
 
(21) A detailed description of any attempt by the establishment to interfere with the independence of 
the Office, including: 
(A) with budget constraints designed to limit the capabilities of the Office; and 
(B) incidents where the establishment has resisted or objected to oversight activities of the Office 
or restricted or significantly delayed access to information, including the justification of the 
establishment for such action . . . 
 
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 HHS interfered with the independence of 
OIG during this reporting period.  OIG would immediately take appropriate action in accordance 
with the Inspector General Act if it were unable to resolve these issues within HHS.   
 
(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 . . . 
 
The table that follows lists inspection, evaluation, and audit reports for this semiannual reporting 
period that did not result in public reports.   
 
93 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
Nonpublic Reports by Category, October 1, 2022, Through March 31, 2023 
 
Number of 
Category/Description 
Reports 
IT security reviews (involve IT systems, e.g., penetration test audits)  0 
Other  0 
HHS technical assistance reports  0 
Finance-related attestation reviews  0 
Total  0 
 
 
(B) Investigation conducted by the Office involving a senior Government employee that is closed and 
was not 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)(19) response to address 
investigations of senior Government employees in which allegations were substantiated that were 
closed and not disclosed to the public.  Our section 5(a)(22)(B) response describes five 
investigations closed during this reporting period involving senior Government employees for 
whom allegations of misconduct were investigated and not substantiated.  
 
When determining the level of detail to provide for the investigations defined above, OIG is 
mindful of the risk that a detailed description of the investigation could inadvertently reveal the 
subjects identity.  During this reporting period, OIG investigated seven senior Government 
employee(s) for misconduct, but OIG determined the allegations to be unsubstantiated.  
Descriptions of the investigations follow. 
 
OIG investigated two senior officials (SES) for alleged financial conflict of interest.  It was alleged 
that the senior officials pressured subordinate employees to sign contracts with a company for 
which one of the senior officials family members had a financial interest.  OIG did not find any 
evidence to support the allegations.    
  
OIG investigated a senior official (GS-15) for alleged fraud and prohibited personnel actions.  It was 
alleged that the senior official retaliated against an employee for reporting fraud and 
discrimination.  The senior official allegedly harassed and terminated the employee after the 
employee reported administrative fraud, abuse, and sabotage.  OIG did not identify any evidence 
to support the allegation.  
  
94 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
OIG investigated a complaint alleging that a senior official (SES) provided false educational 
credentials for employment.  OIG did not identify any evidence to support the allegation.  The 
senior official did in fact have the appropriate and required educational credentials.  
  
OIG investigated a complaint alleging that a senior official (SES) violated Federal law and agency 
policies.  It was alleged that the senior official authorized subordinate employees to commit time 
and attendance fraud.  OIG did not identify any evidence to support the allegation.  
  
OIG investigated two senior officials (GS-15 and SES) for allegedly steering patients to a specific 
medical air transport company when patients could have been transported at a lesser cost via 
ground ambulance.  OIG did not find any evidence to support these allegations.   
 
 
 
 
 
 
   
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  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
 
Appendix F: Anti-Kickback StatuteSafe 
Harbors 
Pursuant to HIPAA,  205, the Inspector General is required to solicit proposals annually via a Federal 
Register notice for developing new and modifying existing safe harbors to the Federal anti-kickback 
statute, section 1128B(b) of the Social Security Act, and for developing special fraud alerts.  The Inspector 
General is also required to report annually to Congress on the status of the proposals received related to 
new or modified safe harbors.   
 
In crafting safe harbors for a criminal statute, it is incumbent upon OIG to engage in a complete and 
careful review of the range of factual circumstances that may fall within the proposed safe harbor subject 
area to uncover all potential opportunities for fraud and abuse by unscrupulous industry stakeholders.  
Having done so, OIG must then determine, in consultation with DOJ, whether it can develop effective 
regulatory limitations and controls, not only to foster beneficial or innocuous arrangements, but also to 
protect Federal health care programs and their beneficiaries from abusive practices. 
 
Public Proposals for New and Modified Safe Harbors  
Annual Solicitation  
 
In December 2021, OIG published its annual solicitation in the Federal Register (Annual Solicitation).1  In 
response to the Annual Solicitation, OIG received the following proposals related to safe harbors:  
 
Proposal  OIG Response 
Repeal or modify existing safe harbors (e.g., the  OIG is not adopting commenters suggestions to 
group purchasing organization [GPO] safe  repeal or modify the GPO safe harbor, among 
harbor, 42 CFR  1001.952(f)) to address  others, to address their comments and concerns 
comments and concerns regarding the manner  about the financial arrangements for which GPOs 
in which GPOs and PBMs may be using such safe  and PBMs may be using these safe harbors.  We 
harbors to protect purportedly abusive  may consider this topic in future rulemaking or in 
arrangements.  future guidance.  OIG highlights that there is a 
statutory exception addressing GPOs at section 
1128B(b)(3)(C) of the Social Security Act. 
 
 
1 OIG, Solicitation of New Safe Harbors and Special Fraud Alerts, 86 FR 71611 (Dec. 17, 2021).  Accessed at 
https://www.govinfo.gov/content/pkg/FR-2021-12-17/pdf/2021-27314.pdf on April 24, 2023. 
96 
 
 
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Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
Modification of the Cooperative Hospital  OIG is not adopting this suggestion.  We may 
Services Organization (CHSO) safe harbor, 42  consider this topic in future rulemaking. 
CFR  1001.952(q), to: (i) protect only CHSO 
arrangements that involve the provision of items 
or services that are components of the direct or 
indirect overhead costs associated with the 
inpatient or outpatient hospital services of the 
nonprofit patron-hospitals; and (ii) exclude 
protection for the creation of revenue-producing 
joint venture arrangements for nonhospital, 
postdischarge home care services and the 
distribution of CHSO revenues to patrons based 
on referrals. 
A new safe harbor to protect: (i) value-based  OIG is not adopting this suggestion.  We 
price-adjustment arrangements that are  appreciate learning about ways in which 
dependent on the achievement of a measurable  pharmaceutical manufacturers, medical device 
clinical or cost outcome associated with the  manufacturers, and durable medical equipment, 
value of a sellers reimbursable items or services;  prosthetics, orthotics, and supplies (DMEPOS) 
and (ii) the provision of value-based services,  entities believe that they could contribute to the 
such as services that enable parties to measure  coordination of care and the overall delivery of 
outcome measures associated with value-based  high-value care through, for example, value-
price-adjustment arrangements.   based price-adjustment arrangements or value-
based services arrangements.  However, we 
continue to have concerns about the offer of 
remuneration by these entities, which raises 
many of the traditional fraud and abuse risks 
under the Federal anti-kickback statute.  We may 
consider this topic in future rulemaking.  
A new safe harbor to protect drug copayment  OIG is not adopting this suggestion.  The offer of 
assistance in situations in which a less expensive  cost-sharing assistance for a drug, particularly by 
and equally effective alternative drug does not  the manufacturer of such drug (either directly or 
exist.  indirectly), presents many of the traditional risks 
of fraud and abuse that the Federal anti-kickback 
statute is designed to prevent. 
New safe harbors to protect: (i) value-based  OIG is not adopting these suggestions.  We 
purchasing arrangements between  continue to evaluate the ways in which 
pharmaceutical manufacturers and payors or  pharmaceutical manufacturers may be able to 
PBMs; and (ii) the provision of data analytics by a  contribute to the coordination of care and the 
drug, biologic, or device manufacturer.  overall delivery of high-value care through, for 
example, value-based purchasing arrangements 
or data-sharing arrangements.  However, we 
continue to have concerns about the offer of 
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  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
remuneration through these programs, which 
raises many of the traditional fraud and abuse 
risks under the Federal anti-kickback statute.  We 
may consider this topic in future rulemaking. 
Modifications to the safe harbors for value-based  As explained in the preamble to the final rule at 
arrangements, including the safe harbors for  85 Fed. Reg. 77684 (Dec. 2, 2020) (referred to in 
arrangements for patient engagement and  this appendix as the 2020 final rule), 
support to improve quality, health outcomes,  remuneration exchanged by pharmaceutical 
and efficiency, 42 CFR  1001.952(hh), to protect  manufacturers and, in certain circumstances, 
the exchange of remuneration by certain entities  medical device manufacturers and DMEPOS 
that currently cannot use the safe harbors (e.g.,  entities, are not eligible for protection under the 
pharmaceutical manufacturers, medical device  value-based safe harbors due to (among other 
manufacturers, laboratory companies, and  reasons) concerns that such entities could use 
DMEPOS suppliers).  the safe harbor to protect arrangements that are 
intended to market their products or 
inappropriately tether clinicians to the use of a 
particular product.2  Consequently, OIG declines 
to adopt this suggestion.     
New safe harbors to implement the Final Rule for  OIG is not adopting this suggestion.  Section 
the Removal of Safe Harbor Protection for  11301 of the Inflation Reduction Act of 2022 
Rebates Involving Prescription Pharmaceuticals  extended the moratorium on the implementation 
and Creation of New Safe Harbor Protection for  of the Final Rule for the Removal of Safe Harbor 
Certain Point-of-Sale Reductions in Price on  Protection for Rebates Involving Prescription 
Prescription Pharmaceuticals and Certain  Pharmaceuticals and Creation of New Safe 
Pharmacy Benefit Manager Service Fees.  Harbor Protection for Certain Point-of-Sale 
Reductions in Price on Prescription 
Pharmaceuticals and Certain Pharmacy Benefit 
Manager Service Fees until January 1, 2032. 
 
New safe harbor for charitable assistance  OIG is not adopting this suggestion.  We may 
programs to protect the provision of medical  consider this topic in future rulemaking. 
products and pharmaceutical products at no 
charge to patients in financial need. 
Modification to existing safe harbor at 42 CFR   OIG is not adopting this suggestion.  A rebate is 
1001.952(h) to define rebate to include any  a type of discount, and a discount is a reduction 
service fee paid as a percentage of sales.  in price charged for an item or service.  A 
discount, including a rebate, does not include 
 
 
2 OIG, Medicare and State Health Care Programs: Fraud and Abuse; Revisions to Safe Harbors Under the Anti-Kickback Statute, and 
Civil Monetary Penalty Rules Regarding Beneficiary Inducements, 85 FR 77684, 77709 (Dec. 2, 2020).  Accessed at 
https://www.govinfo.gov/content/pkg/FR-2020-12-02/pdf/2020-26072.pdf on April 24, 2023. 
98 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
payment for a service.  In a final rule issued in 
1991, OIG stated that contracts for personal or 
management services do not fit within the 
statutory discount exception or the definition of 
discount in the regulatory safe harbor.3  We 
decline to revise the definition of rebate to 
include service fees paid as a percentage of 
sales. 
New safe harbor for manufacturer-sponsored  OIG is not adopting this suggestion.  We 
patient engagement and product support  continue to evaluate the ways in which 
programs, including therapy management and  pharmaceutical manufacturers may be able to 
medication adherence support to encourage  contribute to the delivery of quality care for 
patients to manage and follow their treatment  patients through programs such as medication 
plans.  adherence support, but we continue to have 
concerns about the offer of remuneration to 
patients through these programs, which raises 
many of the traditional fraud and abuse risks 
(e.g., patient steering).  We may consider this 
topic in future rulemaking. 
New safe harbor to protect internal cost sharing  OIG is not adopting the suggestion to create a 
(or gainsharing) payments or modification to the  new safe harbor or modify the personal services 
personal services and management contracts  and management contracts and outcomes-
and outcomes-based payment arrangements  based payment arrangements safe harbor.  We 
safe harbor, 42 CFR  1001.952(d), to expand the  continue to believe, as stated in the preamble to 
definition of "outcomes-based payment" to  the 2020 final rule, that payments for 
include internal cost sharing (or gainsharing)  arrangements that reduce internal costs may 
payments.  pose risks to patient care, among other 
concerns.4  At this time, we continue to believe 
that the risks outweigh any potential benefits of 
these arrangements such that safe harbor 
protection is not warranted.   
New safe harbor for payments from hospitals to  OIG is not adopting this suggestion.  We believe 
post-acute care providers to transition patients  that existing regulations, including new and 
to clinically appropriate, lower cost care settings.  modified safe harbors that were finalized in the 
2020 final rule, provide sufficient regulatory 
flexibility for financial arrangements between 
referral sources that balance the goals of care 
 
 
3 42 CFR  1001.952(h)(5)(vi); OIG, Medicare and State Health Care Programs: Fraud and Abuse; OIG Anti-Kickback Provisions, 56 FR 
35952 (July 29, 1991).  Accessed at https://oig.hhs.gov/documents/compliance/857/072991.htm on April 24, 2023. 
4 85 FR 77845. 
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  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2022, Through March 31, 2023 
coordination and delivery of value-based care 
with the need to protect both patients and 
Federal health care programs.  We may consider 
this topic in future rulemaking. 
A new safe harbor for the waiver or offset of  OIG has repeatedly expressed concerns 
cost-sharing obligations for items and services  regarding routine waivers of Medicare cost-
provided in connection with: (i) value-based  sharing amounts that do not meet an exception 
arrangements for care management or remote  to the CMP provision prohibiting inducements to 
patient monitoring, and (ii) the Acute Care  beneficiaries at section 1128A(i)(6)(A) of the 
Hospital at Home program and any follow-on  Social Security Act.  Accordingly, we decline to 
model that may be established by CMS following  adopt these suggestions. 
the expiration of the Section 1135 Public Health 
Emergency waiver. 
A new safe harbor that would protect  OIG is not adopting this suggestion.  We may 
remuneration between wholly owned  consider this topic in future rulemaking. 
subsidiaries and between a parent company and 
a subsidiary. 
 
 
 
 
 
 
 
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