U.S. Department of Justice U.S. Department of Health and Human Services
Office of the Attorney General Office of the Secretary
Annual Report of the
Departments of Health and
Human Services and Justice
Health Care Fraud and Abuse 
Control Program FY 2022 The Department of Health and Human Services 
and 
The Department of Justice 
Health Care Fraud and Abuse Control Program 
Annual Report for Fiscal Year 2022 
November 2023  TABLE OF CONTENTS 
EXECUTIVE SUMMARY ............................................................................................................ 1 
STATUTORY BACKGROUND ................................................................................................... 3 
PROGRAM RESULTS AND ACCOMPLISHMENTS ................................................................ 5 
Monetary Results ........................................................................................................................ 5 
Expenditures ............................................................................................................................... 7 
Overall Settlements, Judgments, and Recoveries ....................................................................... 7 
Strike Force................................................................................................................................. 8 
Opioid Fraud and Abuse Detection Unit .................................................................................. 11 
Health Care Fraud Prevention and Enforcement Action Team (HEAT) .................................. 12 
Healthcare Fraud Prevention Partnership (HFPP) .................................................................... 13 
COVID-19 Pandemic-Related Enforcement............................................................................. 13 
Highlights of Significant Criminal and Civil Investigations .................................................... 15 
DEPARTMENT OF HEALTH AND HUMAN SERVICES....................................................... 37 
Office of Inspector General ...................................................................................................... 37 
Centers for Medicare & Medicaid Services.............................................................................. 67 
Administration for Community Living..................................................................................... 91 
Office of the General Counsel .................................................................................................. 96 
Food and Drug Administration Pharmaceutical Fraud Program............................................. 101 
DEPARTMENT OF JUSTICE ................................................................................................... 105 
United States Attorneys .......................................................................................................... 105 
Civil Division.......................................................................................................................... 108 
Criminal Division.................................................................................................................... 113 
Civil Rights Division .............................................................................................................. 118 
Office of the Inspector General............................................................................................... 122 
APPENDIX................................................................................................................................. 125 
Federal Bureau of Investigation.............................................................................................. 125 
Return on Investment Calculation .......................................................................................... 132 
Total Health Care Fraud and Abuse Control Resources......................................................... 133 
Glossary of Common Terms....................................................................................................... 134  GENERAL NOTE 
All years are fiscal years unless otherwise 
stated in the text.  EXECUTIVE SUMMARY 
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) established a national 
Health Care Fraud and Abuse Control Program (HCFAC or the Program) under the joint 
direction of the Attorney General and the Secretary of the Department of Health and Human 
Services (HHS), 1 acting through the Inspector General, designed to coordinate Federal, state, and 
local law enforcement activities with respect to health care fraud and abuse.  In its 26th year of 
operation, the Programs continued success confirms the soundness of a collaborative approach 
to identifying and prosecuting the most egregious instances of health care fraud, preventing 
future fraud and abuse, and protecting program beneficiaries. 
During Fiscal Year (FY) 2022 civil health care fraud settlements and judgments under the False 
Claims Act exceeded $1.6 billion,2 in addition to other health care administrative impositions 
won or negotiated by the Federal Government. Because of these efforts, as well as those of 
preceding years, more than $1.7 billion was returned to the Federal Government or paid to 
private persons in FY 2022. Of this $1.7 billion, the Medicare Trust Funds 3 received transfers of 
more than $1.2 billion during this period, in addition to over $126.1 million in Federal Medicaid 
money that was transferred separately to the Centers for Medicare & Medicaid Services (CMS). 
Enforcement Actions 
In FY 2022, the Department of Justice (DOJ) opened more than 809 new criminal health care 
fraud investigations.  Federal prosecutors filed criminal charges in over 419 cases involving at 
least 680 defendants.  More than 477 defendants were convicted of health care fraud related 
crimes during the year.  Also, in FY 2022, DOJ opened more than 774 new civil health care 
fraud investigations and had over 1,288 civil health care fraud matters pending at the end of the 
fiscal year.  Federal Bureau of Investigation (FBI) investigative efforts resulted in over 499 
operational disruptions of criminal fraud organizations and the dismantlement of the criminal 
hierarchy of more than 132 health care fraud criminal enterprises. 
In FY 2022, investigations conducted by HHSs Office of Inspector General (HHS-OIG) resulted 
in 661 criminal actions against individuals or entities that engaged in crimes related to Medicare 
and Medicaid, and 726 civil actions, which include false claims, unjust-enrichment lawsuits filed 
in Federal district court, and civil monetary penalty (CMP) settlements.  HHS-OIG excluded 
2,332 individuals and entities from participation in Medicare, Medicaid, and other Federal health 
care programs.  Among these were exclusions based on criminal convictions for crimes related to 
Medicare and Medicaid (983) or to other health care programs (433), for beneficiary abuse or 
neglect (305), and as a result of state health care licensure revocations (372). 
1 Hereafter, referred to as the Secretary. 
2 The amount reported only reflects the Federal settlements and judgments and therefore does not reflect state 
Medicaid monies won or negotiated as part of any global Federal state settlements. As in prior years, the reported 
settlements and judgments include matters the United States pursued, as well as matters pursued by 
relators/whistleblowers under the qui tam provisions of the False Claims Act. 
3 The Medicare Trust Funds is the collective term for the Medicare Hospital Insurance (Part A) Trust Fund and the 
Supplemental Medical Insurance (Part B) Trust Fund. 
1  Sequestration Impact 
Sequestration of mandatory funding generally results in DOJ, FBI, HHS, and HHS-OIG having 
fewer resources to fight fraud and abuse of Medicare, Medicaid, and other health care programs.  
Due to partial sequester suspension in FY 2022, no funds were sequestered from the HCFAC 
program from October 1, 2021, to March 31, 2022.4   However, a combined total of $160.1 
million in mandatory funds have been sequestered in the past ten years.  Including funds 
sequestered from the FBI ($74.5 million in the past ten years), $234.6 million has been 
sequestered from mandatory HCFAC funds since FY 2013. 
4 Section 3709 of the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) (Public Law (P.L.) 116-
136) suspended Medicare sequestration from May 1, 2020, through December 31, 2020; the Consolidated 
Appropriations Act, 2021 (P.L. 116-260) extended this suspension to March 31, 2021; the Medicare sequester 
moratorium included in P.L. 117-7 extended the suspension again until December 31, 2021; and the Protecting 
Medicare and American Farmers from Sequester Cuts Act (P.L. 117-71) extended the suspension for the last time 
through March 31, 2022.   This sequester adjustment was meant to provide an economic boost to Medicare providers 
treating patients during the COVID-19 public health emergency and has resulted in additional funding for the 
HCFAC program. The four bills overlapped to cover the entirety of FY 2021 and half of FY 2022. 
2  STATUTORY BACKGROUND 
The Annual Report of the Attorney General and the Secretary detailing expenditures and 
revenues under the Health Care Fraud and Abuse Control Program for FY 2022 is provided as 
required by Section 1817(k)(5) of the Social Security Act. 
The Social Security Act Section 1128C(a), as established by HIPAA (Public Law (P.L.) 104-
191, or the Act), created the Health Care Fraud and Abuse Control Program, a far-reaching 
program to combat fraud and abuse in health care, including both public and private health plans.  
As was the case before HIPAA, amounts paid to Medicare in restitution or for compensatory 
damages must be deposited in the Medicare Trust Funds.  The Act requires that an amount 
equaling recoveries from health care investigationsincluding criminal fines, forfeitures, civil 
settlements and judgments, and administrative penaltiesalso be deposited in the Trust Funds.  
The Act appropriates monies from the Medicare Hospital Insurance Trust Fund to an expenditure 
account, called the Health Care Fraud and Abuse Control Account (the Account), in amounts that 
the Secretary and Attorney General jointly certify as necessary to finance anti-fraud activities.  
The maximum amounts available for certification are specified in the Act.  Certain portions of 
these sums are to be used only for activities of the HHS-OIG, with respect to the Medicare and 
Medicaid programs.  In FY 2006, the Tax Relief and Health Care Act (TRHCA) (P.L 109-432, 
303) amended the Act so that funds allotted from the Account are available until expended.
TRHCA also allowed for yearly increases to the Account based on the change in the consumer
price index for all urban consumers (all items, United States city average) (CPI-U) over the
previous fiscal year for fiscal years 2007 through 2010. 5  In FY 2010, the Patient Protection and
Affordable Care Act, as amended by the Health Care and Education Reconciliation Act,
collectively referred to as the Affordable Care Act (P.L. 111-148, ACA) extended permanently
the yearly increases to the Account based upon the change in the consumer price index for all
urban consumers, or CPI-U.
In FY 2022, the Secretary and the Attorney General certified $322.7 million in mandatory 
funding to the Account.  (This reflects sequester suspension per footnote four.)  Additionally, 
Congress appropriated $873.0 million in discretionary funding.  A detailed breakdown of the 
allocation of these funds is set forth later in this report.  HCFAC appropriations generally 
supplement the direct appropriations of HHS that are devoted to health care fraud enforcement 
and have supported over three-fourths of DOJs health care fraud funding and over three-fourths 
of HHS-OIGs appropriated budget in FY 2022.  (Separately, the FBI, which is discussed in the 
Appendix, received $152.9 million from HIPAA, including sequester suspension).  Under the 
joint direction of the Attorney General and the Secretary, the Programs goals are: 
5 The CPI-U adjustment in TRHCA did not apply to the Medicare Integrity Program (MIP).   Section 6402 of the 
ACA indexed Medicare Integrity Program funding to inflation starting in FY 2010. 
3  (1) To coordinate Federal, state, and local law enforcement efforts relating to health care 
fraud and abuse with respect to health plans; 
(2) To conduct investigations, audits, inspections, and evaluations relating to the delivery of 
and payment for health care in the United States; 
(3) To facilitate enforcement of all applicable remedies for such fraud; and 
(4) To provide education and guidance regarding complying with current health care law. 
Additionally, the Act requires the Attorney General and the Secretary to submit a joint annual 
report to the Congress that identifies both: 
(1) The amounts appropriated to the Trust Funds for the previous fiscal year under various 
categories and the source of such amounts; and 
(2) The amounts appropriated from the Trust Funds for such year for use by the Attorney 
General and the Secretary and the justification for the expenditure of such amounts. 
This annual report fulfills the above statutory requirements.  
Finally, this report fulfills the requirement in the annual discretionary HCFAC appropriation 
(P.L.117-103, Consolidated Appropriations Act, 2022) that this report include measures of the 
operational efficiency and impact on fraud, waste, and abuse in the Medicare, Medicaid, and 
CHIP programs for the funds provided by this appropriation. 
4  PROGRAM RESULTS AND ACCOMPLISHMENTS 
Monetary Results 
As required by the Act, HHS and DOJ must detail in this Annual Report the amounts deposited 
to the Medicare Trust Funds and the source of such deposits.  In FY 2022, more than $1.7 billion 
was deposited with the Department of the Treasury (Treasury) and CMS, transferred to other 
Federal agencies administering health care programs, or paid to private persons during the fiscal 
year.  Monetary results from these transfers and deposits are provided in the table below: 
Monetary Results:  Total Transfers / Deposits by Recipient FY 2022 
Department of the Treasury 
Deposits to the Medicare Trust Fund, as required by HIPAA: 
Gifts and Bequests  $33 
Amount Equal to Criminal Fines  8,551,075 
Civil Monetary Penalties  23,911,906 
Asset Forfeiture  138,948,411 
Penalties and Multiple Damages  432,136,798 
Subtotal  $603,548,221 
Centers for Medicare & Medicaid Services 
HHS/OIG Audit Disallowances:  RecoveredMedicare  230,981,050 
Restitution/Compensatory Damages*  399,662,832 
Subtotal  $1,234,192,102 
Total Transferred to the Medicare Trust Funds 
Restitution/Compensatory Damages to Federal Agencies 
TRICARE  $26,155,403 
HHS/CMS  20,643,435 
Department of Labor  11,695,536 
Department of Veterans Affairs  8,235,502 
U.S. Postal Service  7,511,402 
Other Agencies  27,135,093 
Subtotal  $101,376,370 
Centers for Medicare & Medicaid Services 
Federal Share of Medicaid  126,100,863 
HHS/OIG Audit Disallowances:  RecoveredMedicaid  92,842,480 
Subtotal  $218,943,343 
Total  $320,319,713 
Relators' Payments**  $170,457,876 
GRAND TOTAL MONETARY RESULTS***  $1,724,969,691 
*Restitution, compensatory damages, and recovered audit disallowances include returns to both the Medicare
Hospital Insurance (Part A) Trust Fund and the Supplemental Medical Insurance (Part B) Trust Fund.
**These are funds awarded to private persons who file suits on behalf of the Federal Government under the qui tam
(whistleblower) provisions of the False Claims Act, 31 U.S.C.  3730(b).
5  ***State funds are also collected on behalf of state Medicaid programs; only the Federal share of Medicaid funds 
transferred to CMS are represented here. 
The above transfers include certain collections, or amounts equal to certain collections, required 
by HIPAA to be deposited directly into the Medicare Trust Funds.  These amounts include: 
(1) Gifts and bequests made unconditionally to the Trust Funds, for the benefit of the 
Account or any activity financed through the Account; 
(2) Criminal fines recovered in cases involving a Federal health care offense, including 
collections under section 24(a) of Title 18, United States Code (relating to health care 
fraud); 
(3) Civil monetary penalties in cases involving a Federal health care offense; 
(4) Amounts resulting from the forfeiture of property by reason of a Federal health care 
offense, including collections under section 982(a)(7) of Title 18, United States Code; 
and 
(5) Penalties and damages obtained and otherwise creditable to miscellaneous receipts of the 
general fund of the Treasury obtained under sections 3729 through 3733 of Title 31, 
United States Code (known as the False Claims Act, or FCA), in cases involving claims 
related to the provision of health care items and services (other than funds awarded to a 
relator, for restitution, or otherwise authorized by law). 
6  Expenditures 
In the 26th year of operation, the Secretary and the Attorney General certified $322.7 million in 
mandatory funding as necessary for the Program, after accounting for mandatory sequester 
suspension as required by P.L. 116-136, P.L. 116-260, P.L. 117-7, and P.L. 117-71.  In addition, 
Congress appropriated $873.0 million in discretionary funding.  Allocation by recipient is below: 
FY 2022 ALLOCATION OF HCFAC APPROPRIATION 
Mandatory  Discretionary  Funds  Total 
Allocation6  Allocation  Sequestered7  Allocation 
Department of Health and 
Human Services 
Office of the Inspector General  $234,829,612  $102,145,000  ($6,314,180)  $330,660,432 
Office of the General Counsel  7,717,000  0  0  7,717,000 
Administration for Community  2,000,000  30,000,000  0  32,000,000 
Living 
Food and Drug Administration  11,855,000  0  0  11,855,000 
Centers for Medicare & Medicaid  0  628,648,000  0  628,648,000 
Services 
Assistant Secretary for Planning  5,000,000  0  0  5,000,000 
and Evaluation 
Unallocated Funding  1,801,595  0  (1,207,663)  593,932 
Subtotal  $263,203,207  $760,793,000  ($7,521,843)  $1,016,474,364 
Department of Justice 
United States Attorneys  $32,423,135  $40,762,075  $0  $73,185,210 
Civil Division  17,248,860  32,326,123  0  49,574,983 
Criminal Division  13,674,307  25,664,305  0  39,338,612 
Civil Rights Division  3,535,304  5,365,714  0  8,901,018 
Justice Management Division  132,000  0  0  132,000 
Federal Bureau of Investigation  0  7,144,840  0  7,144,840 
Office of the Inspector General  0  943,943  0  943,943 
Unallocated Funding  1,971,461  0  (1,971,461)  0 
Subtotal  $68,985,067  $112,207,000  (1,971,461)  $179,220,606 
TOTAL  $332,188,274  $873,000,000  ($9,493,304)  $1,195,694,970 
Overall Settlements, Judgments, and Recoveries 
During FY 2022, civil health care fraud settlements and judgments under the False Claims Act 
exceeded $1.6 billion, and the Federal Government attained additional administrative 
6 As of FY 2007, mandatory funds are available until expended. Discretionary funds are available for two years. 
7 The sequester amounts reflect P.L. 117-71 sequester suspension from October 1, 2021, to March 31, 2022. 
7  impositions in health care fraud cases and proceedings. 8  Because of these efforts, as well as 
those of preceding years, more than $1.7 billion was returned to the Federal Government or 
private persons.  Of this $1.7 billion, the Medicare Trust Funds received transfers of over $1.2 
billion during this period; approximately $126.1 million in Federal Medicaid money was 
transferred to the CMS separately. 9 
In addition to these enforcement actions, numerous audits, evaluations, and other coordinated 
efforts yielded recoveries of overpaid funds and prompted changes in Federal health care 
programs that reduce vulnerability to fraud. 
The return on investment (ROI) for the HCFAC program over the last three years (20202022) is 
$2.90 returned for every $1.00 expended.  The ROI has been adversely impacted by the COVID-
19 pandemic.  Unique factors associated with the pandemic, such as court closures, interrupted 
or slowed criminal and civil enforcement and other HCFAC activities.  Consequently, 
recoveries, disallowances, and restitutions covered by this reporting period are lower compared 
to recent years. Because the annual ROI can vary from year to year depending on the number 
and type of cases that are settled or adjudicated during that year, DOJ and HHS use a three-year 
rolling average ROI for results contained in the report.  Additional information on how the ROI 
is calculated may be found in the Appendix. 
It is important to note that the ROI does not capture the full impact of the results of the Program.  
Civil and criminal enforcement that stops ongoing fraud saves the Program from future losses.  
Even actions that do not result in recoveries, for example, a search warrant, an indictment, or an 
arrest, may prevent the defendant from continuing to defraud Federal health care programs.  
Therefore, this ROI calculation relies on actual recoveries and collections, and does not represent 
the effect of preventing future fraudulent payments.  Further, the threat of oversight alone can 
have a sentinel impact that deters future bad actors from defrauding Medicaid, Medicare, and 
other Federal health care benefit programs. 
Strike Force 
Health Care Fraud Strike Force Teams (Strike Force) harness data analytics and the combined 
resources of Federal, state, and local law enforcement entities to prosecute complex health care 
fraud matters and prescription opioid distribution and diversion schemes.  The Strike Force is 
comprised of inter-agency teams made up of investigators and prosecutors that focus on the 
worst offenders in regions with the highest known concentration of fraudulent activities.  The 
Strike Force uses advanced data analysis techniques to identify aberrant billing levels in health 
8 The amount reported only reflects the Federal settlements and judgments and therefore does not reflect state 
Medicaid monies won or negotiated as part of any global Federal-state settlement. As in prior years, the reported 
settlements and judgments include matters the United States pursued, as well as matters pursued by 
relators/whistleblowers under the qui tam provisions of the False Claims Act. 
9 Note that some of the judgments, settlements, and administrative actions that occurred in FY 2022 will result in 
transfers in future years, just as some of the transfers in FY 2022 are attributable to actions from prior years. 
8  care fraud hot spotscities with high levels of billing fraudand target suspicious billing 
patterns, as well as emerging schemes and schemes that migrate from one community to another.  
First established in March 2007, Strike Force teams currently operate in 27 districts across the 
United States, including, but not limited to:  Los Angeles, California; Miami and Tampa and 
Orlando, Florida; Chicago, Illinois; Ft. Mitchell, Kentucky; Baton Rouge and New Orleans, 
Louisiana; Detroit, Michigan; Concord, New Hampshire; Brooklyn, New York; Newark, New 
Jersey and Philadelphia, Pennsylvania; Nashville, Tennessee; and Houston, San Antonio, Dallas, 
and the Rio Grande Valley, Texas; along with the National Rapid Response Strike Force 
(NRRSF) located in Washington, D.C.    
The NRRSF was established in September 2020, as the nature and scope of health care fraud has 
evolved rapidly over the past few years with the advent of new technologies that have broadened 
the reach of health care and, consequently, health care fraud.  It is comprised of dedicated 
prosecutors who target large-scale and multi-jurisdictional schemes occurring across the country.  
Since its creation, the NRRSF has organized and led several of the Health Care Fraud Units 
(HCF Unit) nationwide initiatives involving billions of dollars of fraud and pressing national 
priorities, including leading the Departments nationwide enforcement actions involving 
telemedicine, sober homes, and COVID-19.  Examples of the types of cases prosecuted by 
NRRSF include the recent conviction at trial of the President of a Silicon Valley technology 
company who claimed to have invented revolutionary technology to detect allergies and COVID-
19 using a single drop of blood; trial conviction of two defendants in a $1.4 billion rural hospitals 
fraud matter in the Middle District of Florida (one of the largest health care fraud cases ever 
charged); convictions in three separate trials (between December 2021 and June 2022) of sober 
homes operators and doctors who were responsible for hundreds of millions in loss; the 
prosecution of telemedicine company executives and medical professionals in cases involving 
billions of dollars in alleged fraud loss; and prosecutions of those seeking to criminally exploit 
the COVID-19 pandemic through health care fraud and related financial fraud schemes.  
The NRRSF also has led the Departments efforts to combat health care fraud arising from the 
COVID-19 pandemic.  The NRRSF leads the COVID-19 Health Care Fraud Working Group, 
which is chaired by the Criminal Divisions Fraud Section, HCF Unit, and comprised of 
leadership from over 10 key government agencies, including Food and Drug Administration 
(FDA), HHS, CMS, the Small Business Administration (SBA), the Department of Veterans 
Affairs (VA), FBI, the Drug Enforcement Administration (DEA), and Homeland Security 
Investigations (HSI), among others.  The purpose of the Working Group is to identify, 
investigate, and prosecute COVID-19 health care fraud schemes, and enable coordination, 
deconfliction, and efficient staffing of COVID-19 health care fraud investigations.  Since the 
beginning of the pandemic, the Strike Force has charged 45 defendants with over $340.0 million 
in COVID-19 fraud.  This includes cases charged in two COVID-19 Health Care Fraud 
Enforcement Actions in 2021 and 2022. 
The NRRSF and its team members (prior to NRRSFs creation) also have led nationwide efforts 
to combat fraud committed using or exploiting telemedicine (the use of telecommunications 
technology to provide health care services remotely) and ensure that needed access to care 
supported by this technology is not compromised by wrongdoers.  In the past three and a half 
9  years, the HCF Unit has charged over $10.0 billion in fraud committed using or exploiting 
telemedicine, including the following major nationwide enforcement actions:  2019s Operation 
Brace Yourself, 2019s Operation Double Helix, 2020s Operation Rubber Stamp, the 
telemedicine component of the 2021 National Health Care Fraud Enforcement Action, and the 
2022 Telemedicine, Clinical Laboratories, and Durable Medical Equipment Enforcement Action.  
The deterrent impact of these actions has saved the pubic fisc substantial amounts of money.  
Specifically, the Operation Brace Yourself Telemedicine and Durable Medical Equipment 
Takedown alone resulted in a savings of more than $1.9 billion in the amount paid by Medicare 
for orthotic braces in the 20 months following that enforcement action. 
Each Strike Force team brings the investigative and analytic resources of the FBI, HHS-OIG, the 
CMS Center for Program Integrity (CMS-CPI), the Defense Criminal Investigative Service 
(DCIS), the Federal Deposit Insurance Corporation Office of the Inspector General (FDIC-OIG), 
the Internal Revenue Service (IRS), and other agencies, together with the prosecutorial resources 
of the Criminal Divisions Fraud Section and the U.S. Attorneys Offices (USAOs) to bring 
cases in Federal district court.  During FY 2022, Strike Force accomplishments in the areas noted 
above, as well as USAO accomplishments included: 10 
  Filing 266 indictments, criminal informations and complaints 11 involving charges against 
392 defendants who allegedly collectively billed Federal health care programs and 
private insurers approximately $2.2 billion 12 
  Obtaining 395 guilty pleas and litigating 42 jury trials, with guilty verdicts against 48 
defendants; and 
  Securing imprisonment for 323 defendants sentenced, with an average sentence of over 
53 months. 
Since its inception, Strike Force prosecutors and USAOs in Strike Force districts filed more than 
2,700 cases charging more than 5,400 defendants who collectively billed Federal health care 
programs and private insurers approximately $27.0 billion, more than 3,700 defendants pled 
guilty and over 460 others were convicted in jury trials, 13 and more than 3,300 defendants were 
sentenced to imprisonment for an average term of approximately 50 months.  Medicare payment 
trends demonstrate the positive impact of Strike Force enforcement and prevention efforts. 
During FY 2022, the Strike Force coordinated three separate enforcement actions, in 
collaboration with USAOs, HHS-OIG, FBI, the DEA, and other Federal and state partners.  On 
April 20, 2022, and on May 4, 2022, Assistant Attorney General Kenneth A. Polite Jr. 
announced the 2022 COVID-19 Health Care Fraud and Opioid Enforcement Actions, 
respectively.  In the 2022 COVID-19 Enforcement Action, criminal charges were brought 
10 The summary statistics in this document exclude sealed cases. 
11 This number does not include complaints filed by USAOs. 
12 This alleged loss amount figure only reflects the amounts of alleged loss in cases handled by the Criminal 
Division, Fraud Section. 
13 These numbers do not include guilty pleas and verdicts obtained by USAOs where the defendant had not been 
sentenced before the end of FY 2022. 
10  against 21 defendants, in nine Federal districts across the United States, for their alleged 
participation in various health care related fraud schemes that exploited the COVID-19 
pandemic.  These cases allegedly resulted in over $149.0 million in COVID-19-related false 
billings to Federal programs and theft from Federally funded pandemic assistance programs.  In 
connection with the enforcement action, the department seized over $8.0 million in cash and 
other fraud proceeds.  CMS-CPI separately took adverse administrative action against 28 
providers for their alleged involvement in fraud, waste, and abuse schemes related to the delivery 
of care for COVID-19, as well as schemes that capitalize upon the public health emergency.  In 
the 2022 Opioid Enforcement Action, criminal charges were brought against 14 defendants, 12 
of which were medical professionals, in eight Federal districts across the United States, for their 
alleged involvement in crimes related to the unlawful distribution of opioids.  Additionally, 
CMS-CPI took adverse administrative action against six providers for their alleged involvement 
in these offenses.  Finally, the Criminal Division announced the 2022 Telemedicine, Clinical 
Laboratory, and Durable Medical Enforcement Action on July 20, 2022, wherein criminal 
charges were brought against 36 defendants, in 13 Federal districts across the United States, for 
more than $1.2 billion in alleged schemes that involved fraud committed using or exploiting 
telemedicine, cardiovascular and cancer genetic testing, and durable medical equipment.  
Additionally, CMS-CPI took adverse administrative action against 52 providers involved in 
similar schemes.  In connection with the enforcement action, the department seized over $8.0 
million in cash, as well as luxury vehicles and other fraud proceeds. 
In October 2018, the Criminal Division announced the formation of the Appalachian Regional 
Prescription Opioid (ARPO) Strike Force, a joint effort between DOJ, FBI, HHS-OIG, DEA, and 
state and local law enforcement to combat health care fraud and the opioid epidemic in parts of 
the country that have been particularly harmed by addiction.  Since its inception, the ARPO 
Strike Forces (North and South) have charged 115 defendants with crimes related to the unlawful 
distribution of prescription opioids.  Together, these defendants issued prescriptions for over 115 
million controlled substance pills.  Sixteen defendants were charged in FY 2022, including 14 
medical professionals.  As of September 2022, 62 of the ARPO defendants have entered guilty 
pleas, with more pleas scheduled.  Eight additional defendants have been convicted at trial, 
including five trial convictions, and sixteen ARPO defendants were sentenced in FY 2022. 
Opioid Fraud and Abuse Detection Unit 
The Opioid Fraud and Abuse Detection Unit (OFAD) AUSA program focuses specifically on 
opioid-related health care fraud using data to identify and prosecute individuals that are 
contributing to the prescription opioid epidemic.  In FY 2022, OFAD AUSAs handled a variety 
of investigations and prosecutions involving medical professionals.  OFAD attorneys filed 42 
cases, against 72 defendants, alleging various charges including health care fraud, drug 
trafficking, and money laundering.  For example, on September 12, 2022, a Michigan doctor 
who attempted to flee to Mexico was sentenced to four years in prison for unlawfully selling 
12,500 opioid pills.  The doctor pleaded guilty to conspiring with patient recruiters and others to 
distribute prescription opioid pills in violation of his medical and DEA licenses.  He unlawfully 
prescribed 12,500 hydrocodone pills without regard to medical necessity and outside the course 
11  of professional medical practice.  In another matter, on January 21, 2022, a former Tennessee 
clinic owner was sentenced to 168 months in prison for unlawfully distributing opioids.  The 
clinic owner was found guilty of six counts of unlawfully distributing controlled substances and 
one count of maintaining a drug-involved premises.  Evidence presented at the trial showed that 
he unlawfully prescribed approximately 15,000 opioid pills to three women with whom he had 
sexual relationships.  He also prescribed pills to a male patient who later passed away. 14 
Health Care Fraud Prevention and Enforcement Action Team (HEAT) 
The Attorney General and the Secretary maintain regular consultation at both senior and staff 
levels to accomplish the goals of the HCFAC Program.  The DOJ and HHS-OIG established the 
Health Care Fraud Prevention and Enforcement Action Team (HEAT) in 2009 to build and 
strengthen existing programs combatting Medicare fraud, while investing new resources and 
technology to prevent and detect fraud and abuse.  HEAT expanded the DOJ-HHS Health Care 
Fraud Strike Force program noted above, which targets emerging or migrating fraud schemes, to 
include fraud by criminals masquerading as health care providers or suppliers.  The HEAT 
mission is: 
  To marshal significant resources across government to prevent waste, fraud and 
abuse in the Medicare and Medicaid programs and crack down on the fraud 
perpetrators who are abusing the system and costing the government billions of dollars. 
  To reduce health care costs and improve the quality of care by ridding the system of 
perpetrators who are preying on Medicare and Medicaid beneficiaries. 
  To target doctors and physicians who prescribe opioids outside the scope of 
legitimate medical practice and often charge Medicare and/or Medicaid for these visits 
and prescriptions.  
  To highlight best practices by providers and public sector employees who are 
dedicated to ending waste, fraud, and abuse in Medicare. 
  To build upon existing partnerships between DOJ and HHS, such as its Strike Force 
Teams, to reduce fraud and recover taxpayer dollars. 
Since its creation, HEAT has focused on key areas for coordination and improvement.  HEAT 
members are working to identify new enforcement initiatives and areas for increased oversight 
and prevention.  HEAT activities have also expanded to include significant involvement from 
Medicaid Fraud Control Units (MFCUs), which play a critical role in the many fraud cases 
involving both Medicare and Medicaid.  For example, MFCUs participated in 10 cases during 
the FY 2022 enforcement actions. 
14 This case was handled in conjunction with ARPO, led by the Department of Justices Criminal Division. 
12  The DOJ and HHS have expanded data-sharing and improved information-sharing procedures in 
order to get critical data and information into the hands of law enforcement to track patterns of 
fraud and abuse and increase efficiency in investigating and prosecuting complex health care 
fraud cases.  This expanded data sharing enables the DOJ and HHS to efficiently identify and 
target the worst actors in the system.  The Departments established a cross-government health 
care fraud data intelligence sharing workgroup to share fraud trends, new initiatives, ideas, and 
success stories to improve awareness across issues relating to health care fraud. 
Both Departments also have developed training programs to prevent honest mistakes and help 
stop potential fraud before it happens.  This includes CMS compliance training for providers, 
HHS-OIG compliance program guidance documents and trainings for providers, ongoing 
meetings at USAOs with the public and private sector, and increased efforts by HHS to educate 
specific groupsincluding communities of older adults and immigrant communitiesto help 
protect them.  Moreover, HHS-OIG offers a Compliance Resource Portal on its website, which 
includes special fraud alerts, videos, and other resources directed at various segments of the 
health care industry.  In addition, DOJ conducts, with the support of HHS, a Health Care Fraud 
training program designed to teach the Strike Force concept and case model to prosecutors, law 
enforcement agents, and administrative support teams.  
Healthcare Fraud Prevention Partnership (HFPP) 
The HFPP is a voluntary public-private partnership among the Federal Government, state 
agencies, law enforcement, private health insurance plans, employer organizations, and health 
care anti-fraud associations.  The purpose of the partnership is to exchange data and information 
between the partners to help improve capabilities to fight fraud, waste, and abuse in the health 
care industry.  The number of participants has increased to 267 public, private, and state partner 
organizations at the end of FY 2022.  Seventy-five of the current partners are actively submitting 
claim level data.  
The HFPP commenced or completed studies using multiple partners data to address fraud, 
waste, and abuse in FY 2022, providing partners with detailed results that can be used for 
corrective actions within their organizations.  The HFPP continued its efforts to foster 
collaboration among partners by hosting virtual information-sharing sessions (due to the Public 
Health Emergency).  These meetings are used to share fraud schemes and provider alerts, 
provide updates on law enforcement activities, and strategize on how to broaden the HFPPs 
impact in the private and public sectors.  In addition, the HFPP held focus groups to ascertain 
from Partners their thoughts on the strategic direction of the Partnership. See the CMS HFPP 
section for more information on HFPP activities. 
COVID-19 Pandemic-Related Enforcement 
Since the start of the COVID-19 Public Health Emergency (PHE) in March 2020, CMS has 
examined how the PHEand more specifically, the waivers and flexibilities offered by the 
13  Agencymay create new fraud risks in Federal health programs.  CMS has developed a robust 
fraud risk assessment process, using principles outlined in the Government Accountability Office 
(GAO) Fraud Risk Management Framework, to identify potential risks and vulnerabilities 
associated with PHE and potential unintended consequences of the waivers and flexibilities.  
Fraud, waste, and abuse mitigation strategies include data analyses and studies, targeted 
investigations, development of Fraud Prevention System (FPS) models and edits, and 
implementation of new policies.  CMS, DOJ, HHS-OIG, and other law enforcement agency 
partners are working together to investigate and prosecute frauds from identified risks and 
related schemes.  Examples of potential risks and vulnerabilities include: 
  Additional, unnecessary services:  Offering COVID-19 tests to Medicare beneficiaries in 
exchange for personal details, including Medicare information, when the services are 
unapproved and illegitimate.  Fraudsters are targeting beneficiaries in a number of ways, 
including telehealth for Evaluation and Management up-coding or services not rendered, 
telemarketing calls, text messages, social media platforms, and door-to-door visits.  
These scammers exploit the pandemic to benefit themselves, and beneficiaries face 
potential harms.  Fraudsters used telemedicine to facilitate fraud schemes for unnecessary 
items and services. The personal information collected can be used to fraudulently bill 
Federal health care programs and commit medical identity theft.  If Medicare or Medicaid 
denies the claim for an unapproved test, the beneficiary could be responsible for the cost. 
  Unnecessary laboratory testing:  Performing additional tests when conducting COVID-19 
tests, such as expensive tests or services that may or may not be related to COVID-
19.  For example, some laboratories are billing a COVID-19 test with other far more 
expensive tests, such as Respiratory Pathogen Panels (RPP), which test for a variety of 
respiratory infections along with COVID-19, and antibiotic resistance tests.  Other 
potentially unnecessary tests being billed along with COVID-19 tests include allergy, 
genetic and cardiac panel testing.  Some laboratories are also billing respiratory, 
gastrointestinal, genitourinary, and dermatologic pathogen code tests. 
  Health care technology schemes:  False and fraudulent representations about COVID-19 
testing, treatments, or cures that are used to defraud Federal health programs. 
  Fraudulently obtaining COVID-19 health care relief funds:  Filing false claims and 
applications for Federal relief funds, such as those provided under the Coronavirus Aid, 
Relief, and Economic Security (CARES) Acts Provider Relief Fund, the Paycheck 
Protection Program and Health Care Enhancement Act (PPP), or the Economic Impact 
Disaster Loan (EIDL) program. 
14  Highlights of Significant Criminal and Civil Investigations 
Our respective Departments successfully pursued criminal, including Strike Force, and civil 
investigations in a wide range of areas.  Cases are organized by type and presented in 
chronological order.  Strike Force cases are denoted by (SF) before the lead sentence. 
Clinics 
In February 2022, the owner of a South Florida medical clinic was sentenced to 10 years in 
prison for submitting over $40.0 million in false and fraudulent claims to United Healthcare.  In 
addition to the prison sentence, the defendant was ordered to forfeit to the United States property 
traceable to proceeds of his health care fraud scheme, including over $12.0 million and two 
Winnebago motor coaches, and to pay more than $12.0 million in restitution to United 
Healthcare.  The clinic owner pled guilty in 2021 to one count of conspiracy to commit health 
care fraud and one count of conspiracy to commit money laundering.  According to court 
documents, the defendants medical clinic purported to provide antigen therapy and other 
allergen immunotherapy services, such as allergy testing and allergy shots, to commercial 
insurance beneficiaries.  The defendant offered and paid kickbacks to co-conspirators to induce 
them to refer beneficiaries to his clinic, so that his clinic could bill the insurers for services that it 
never provided.  The defendant used the proceeds of his fraud to purchase a $3.0 million home in 
the Ocean Reef Club in Key Largo, Florida, two Winnebago motor coaches, and a 37-foot yacht. 
In August 2022, the owner of a Miami medical clinic was sentenced to five years in prison for 
submitting nearly $40.0 million in false and fraudulent claims to United Healthcare and Blue 
Cross Blue Shield.  In addition to the prison sentence, the defendant was ordered to forfeit to the 
United States property traceable to proceeds of his health care fraud scheme, including nearly 
$8.0 million, four real estate properties including a beachfront condominium unit in Pompano 
Beach, and numerous luxury vehicles.  According to court documents, the clinic owner 
submitted nearly $40.0 million in false and fraudulent claims for reimbursement for infusions of 
Infliximab, known by the brand name Remicade, a prescription immunosuppressive approved for 
the treatment of adult and pediatric Crohns disease, adult and pediatric ulcerative colitis, 
rheumatoid and psoriatic arthritis, ankylosing spondylitis, and plaque psoriasis.  Infliximab is 
one of the most expensive prescription drugs on the marketa single dose can have a retail price 
of nearly $10,000.  Despite claiming nearly $40.0 million in reimbursements for infusions of 
Infliximab purportedly provided to patients of the defendants clinic, the defendant admitted as 
part of his guilty plea to conspiracy to commit health care fraud that he never provided even a 
single infusion of the drug, nor did patients of the clinic require the medication. 
COVID-19 Related Enforcement 
In May 2022, a physician who attempted to profit from the pandemic by marketing what he 
described as a miracle cure for COVID-19, was sentenced to 30 days of custody and one year 
of home confinement for trying to smuggle hydroxychloroquine into the United States to sell in 
his coronavirus treatment kits.  The physician pleaded guilty to one count of importation 
contrary to law, admitting that he worked with a Chinese supplier to try to smuggle into the 
United States a barrel that he believed contained over 26 pounds of hydroxychloroquine powder 
15  by mislabeling it as yam extract.  The defendant admitted that he intended to sell the 
hydroxychloroquine powder in capsules as part of his business venture selling COVID-19 
treatment kits in March and April 2020, at the beginning of the global pandemic. 
In June 2022, MorseLife Health System Inc. (MorseLife), a Florida-entity that oversees a nursing 
home and assisted living facility on its campus, agreed to pay the United States $1.8 million to 
resolve allegations that in 2020 and 2021 it violated the civil FCA by facilitating COVID-19 
vaccinations under the Centers for Disease Control and Preventions (CDC) Pharmacy 
Partnership for Long-Term Care Program (LTC PPP) for hundreds of individuals ineligible to 
receive them, but who MorseLife targeted for donations.  The LTC PPP was specifically 
designed to vaccinate long-term care facility residents and staff when doses of COVID-19 
vaccine were in limited supply early in the pandemic.  MorseLife allegedly knew this but 
nevertheless invited and facilitated the vaccination of hundreds of ineligible persons at the clinic 
by falsely characterizing them as staff and volunteers, many of whom MorseLife targeted for 
donations.  Specifically, the United States alleged that MorseLife (1) characterized board 
members and their spouses, children, family members and friends as staff, (2) directed the 
organizations fundraising arm to invite donors and potential donors to the vaccination clinic, 
and (3) allowed the Vice Chairman of MorseLifes board and his brother to invite close to 300 
individuals who neither worked or lived on MorseLifes campus, and most of whom did not 
volunteer or have any other prior affiliation with MorseLife, to receive the vaccine.  A 
significant number of these invitees were members of the same country club as the Vice 
Chairman and his brother.  
Diagnostic Testing 
In December 2021, a former doctor and his company were found guilty after trial of scheming to 
defraud private insurance companies and the TRICARE health care program by fraudulently 
submitting an estimated $355.0 million in claims.  The company, Surgery Center Management 
LLC, focused on the promotion and performance of Lap-Band weight-loss surgeries.  At the 
direction of the defendants, employees pushed patients to undergo sleep studies regardless of 
medical necessity and falsified thousands of sleep study results to reflect that the patients had 
obstructive sleep apnea, which was a co-morbidity that would help convince insurance 
companies to cover a patients Lap-Band surgery.  The falsified sleep study reports were then 
submitted to insurers in support of pre-approval requests for Lap-Band surgeries, as well as 
claims for apnea machines, and for the sleep studies themselves, which were usually billed at 
exorbitant rates of $14,000 to $18,000 per study.  In total, defendants caused the submission of 
over $354.0 million in fraudulent claims for which insurers paid more than $71.0 million.  
In July 2022, Inform Diagnostics, Inc., (Inform), a clinical laboratory headquartered in Irving, 
Texas, agreed to pay $16.0 million to resolve civil FCA allegations that it submitted false claims 
for payment to Medicare and other Federal health care programs.  According to the settlement, 
Inform admitted that between 2013 and 2018 it routinely and automatically conducted additional 
tests on biopsy specimens prior to a pathologists review and without an individualized 
determination regarding whether additional tests were medically necessary.  Informs policy of 
conducting routine additional tests caused Inform to perform many tests that were medically 
16  unnecessary.  Inform submitted these medically unnecessary tests for payment, causing Federal 
health care programs to pay for false claims. 
(SF) In July 2022, the owner of a diagnostic laboratory was convicted of one count of conspiracy 
to pay and receive for his role in an illegal kickback scheme involving medically unnecessary 
genetic testing in which Medicare was billed at least $7.9 million and paid $4.7 million for 
kickback-tainted genetic testing.  The defendant awaits sentencing. 
Drug Companies 
In November 2021, kaleo Inc. (kaleo), a Virginia-based pharmaceutical manufacturer, agreed to 
pay the United States $12.7 million to resolve civil FCA allegations that it caused the submission 
of false claims to the Medicare program and other Federal health care programs for the drug 
Evzio, an injectable form of naloxone hydrochloride indicated for use to reverse opioid overdose.  
Evzio was the highest-priced naloxone hydrochloride product on the market, and insurers 
frequently required the submission of prior authorization requests before they would approve 
coverage for Evzio.  The United States alleged that, between March 14, 2017, and April 30, 
2020, kaleo directed prescribing doctors to send Evzio prescriptions to certain preferred 
pharmacies that in turn submitted false prior authorization requests to insurers.  The prior 
authorization requests allegedly misrepresented that the prescribing physicians submitted the 
request when the pharmacies did so and/or contained false or misleading assertions about the 
patients medical histories, such as false statements that patients had previously tried and failed 
less costly alternatives to Evzio.  The pharmacies also allegedly dispensed Evzio without 
collecting or attempting to collect required copayments from government beneficiaries.  The 
United States contends that kaleo knew of or deliberately ignored this pharmacy misconduct, but 
nevertheless kept directing business to these pharmacies.  The United States also alleged that 
kaleo provided illegal remuneration to prescribing physicians and their office staff in violation of 
the Anti-Kickback Statute (AKS) to induce and reward their prescribing of Evzio. 
In March 2022, pharmaceutical company Mallinckrodt ARD LLC, previously Questcor 
Pharmaceuticals Inc. (collectively, Mallinckrodt), agreed to pay $260.0 million to resolve 
separate allegations that it violated the civil FCA by knowingly (1) underpaying Medicaid 
rebates due for its drug H.P. Acthar Gel (Acthar), and (2) paying kickbacks in the form of copay 
subsidies for Acthar in violation of the AKS.  With respect to the former, the settlement resolved 
allegations that from 2013 until 2020 Mallinckrodt paid rebates for Acthar as if it was a new 
drug as of 2013, as opposed to a preexisting drug for which Mallinckrodt had significantly 
raised the price in years prior, from approximately $40 per vial to over $28,000 per vial by the 
end of 2013, and to approximately $40,000 per vial thereafter.  This practice allegedly resulted in 
significant Medicaid rebate underpayments for the amounts Mallinckrodt owed on account of 
these price increases but did not pay.  With respect to the latter, the settlement resolved 
allegations that, from 2010 through 2014, Mallinckrodt knowingly used a foundation as a 
conduit to pay illegal kickbacks in the form of copay subsidies for Acthar so it could market the 
drug as free to doctors and patients while increasing its price significantly. Under the 
settlement, Mallinckrodt admitted that Acthar was not a new drug as of 2013 and agreed to pay 
rebates on the pre-2013 price increases going forward.  Mallinckrodt also entered into a five-year 
CIA with HHS-OIG in connection with the settlement.  
17  In September 2022, Akorn Operating Company LLC (Akorn) agreed to pay the United States 
$7.9 million to resolve alleged civil FCA violations that it caused the submission of false claims 
to Medicare Part D for three generic drugs that were no longer eligible for Medicare coverage.  
FDA-approved prescription only (Rx-only) drugs may be dispensed only upon a prescription 
and are reimbursed by Medicare Part D, whereas over the counter (OTC) drugs may be 
purchased by retail customers without a prescription and are not reimbursed by Medicare Part D. 
Subject to FDA approval, companies may seek to fully convert a brand-name Rx-only drug to an 
OTC drug.  After FDAs approval of a drugs full conversion to OTC status, the drug is no 
longer considered an Rx-only product and makers of generic equivalents are then required either 
to seek FDA approval for their own OTC switch or to seek withdrawal of their generics Rx-only 
approval and cease marketing it.  As part of the settlement, Akorn admitted to the following 
facts:  Akorn continued to sell three generic drugs under obsolete Rx-only labeling after the 
brand name equivalents of these generic drugs had already been approved for OTC status by the 
FDA.  In particular, Akorn delayed seeking the required OTC conversions for the generics 
because it believed that continuing to sell them as Rx-only would have been more profitable.  
Accordingly, Akorn continued to sell newly manufactured units of the generics under obsolete 
Rx-only labeling, rather than beginning the process of converting them to OTC or withdrawing 
their approval and ceasing their distribution.  In connection with the settlement, Akorn was 
credited under the Department of Justices guidelines for taking disclosure, cooperation, and 
remediation into account in FCA cases, Justice Manual 4-4.112.  
Durable Medical Equipment (DME) 
(SF) In November 2021, the owner and operator of durable medical equipment brace suppliers 
and purported marketing companies, was convicted of one count of conspiracy to commit health 
care fraud for his role in paying and receiving health care kickbacks and bribes for doctors 
orders of medically unnecessary orthotic braces.  To conceal the kickbacks and bribes, the 
defendant and others concealed the scheme by entering into sham marketing and business 
process outsourcing contracts and by creating sham invoices.  The defendant and others caused 
Federal health care programs to pay more than $33.0 million for medically unnecessary orthotic 
braces.  In May 2022, the defendant was sentenced to 120 months imprisonment. 
In November 2021, two business owners were sentenced for their roles in a conspiracy to 
defraud Federal health benefit programs, including Medicare and the Civilian Health and 
Medical Program of the Department of Veterans Affairs (CHAMPVA). The first business owner 
was sentenced to 78 months in Federal prison and the second business owner was sentenced to 
63 months in Federal prison.  As part of their sentences, the court also entered a monetary 
judgment against the defendants in the amount of $2.1 million and $3.0 million, respectively, 
which were proceeds of the conspiracy.  The business owners were also ordered to pay 
restitution, jointly and severally with each other and other conspirators, in the amount of 
$29,020,304. According to court documents, from around October 2016 through around April 
2019, the business owners ran a telemarketing company in Tampa that targeted older adults to 
generate thousands of medically unnecessary physicians orders for durable medical equipment 
(DME) and cancer genetic testing (CGx).  The business owners also created and operated a 
telemedicine company through which they illegally bribed physicians to sign the orders 
regardless of medical necessity.  The business owners then illegally sold the signed physicians 
18  orders to client-conspirators for use as support for false and fraudulent claims submitted to 
Medicare and CHAMPVA.  The conspiracy resulted in the submission of at least $134.0 million 
in fraudulent claims to the Federal health benefit programs, resulting in approximately $29.0 
million in payments. 
(SF) In December 2021, two owners of two of DME supply companies were each sentenced to 
151 months imprisonment stemming from a June 2021 conviction following a jury trial resulting 
from their involvement in a scheme to defraud Medicare.  According to court documents, the 
defendants paid kickbacks and bribes in exchange for signed doctors orders for orthotic braces 
that were not medically necessary.  To conceal the kickbacks and bribes, the defendants and their 
co-conspirators executed sham contracts and created fake invoices appearing to be for legitimate 
marketing or business process outsourcing services.  The defendants DME companies 
collectively billed Medicare Parts B and C over $59.0 million. 
In December 2021, a business owner was sentenced to 78 months in prison for health care fraud 
and conspiracy to commit health care fraud.  The court also ordered the business owner to forfeit 
$7.1 million and to repay more than $16.1 million in restitution.  According to documents filed 
by the government, on October 17, 2016, the business owner signed a written agreement in 
which he agreed to be excluded from the Medicare Program for 10 years.  The exclusion 
agreement provided that Medicare would not pay claims submitted by anyone who employed the 
business owner in a management or administrative role.  Nevertheless, from 2016 until 2021, the 
business owner committed health care fraud by continuing to manage and control pharmacies 
that submitted claims for payment to Medicare.  In order to avoid detection, the business owner 
ensured that those submitting Medicare enrollment/revalidation paperwork for these pharmacies 
would not disclose the business owners ownership interest or managerial role in these 
pharmacies.  From October 17, 2016, to August 16, 2021, Medicare paid over $16 million to the 
pharmacies in which the business owner had an ownership interest or managerial role. 
In April 2022, a Florida DME company owner was sentenced in Boston to 96 months in prison 
and required to pay $35.6 million in forfeiture and $30 million in restitution.  The defendant 
pleaded guilty in October 2020 to one count of health care fraud and one count of payment of 
kickbacks in connection with the submission of more than $109.0 million in false and fraudulent 
claims for DME.  The defendant instructed his employees to establish shell companies in more 
than a dozen different states, listing his mother, wife and yacht captain as corporate directors and 
using fictitious names to register the shell companies as DME providers.  The defendant 
purchased Medicare patient data from foreign and domestic call centers that targeted older 
patients and instructed call centers to contact the Medicare beneficiaries with an offer of ankle, 
arm, back, knee, and/or shoulder braces at little to no cost.  He then submitted Medicare claims 
for those patients without obtaining a prescribers order to ensure that the braces were medically 
necessary.  The defendant submitted blatantly fraudulent claims, including claims for deceased 
patients and repeat claims for the same patient and the same DME.  The defendant failed to 
provide any DME for more than $7.5 million in claims.  When the defendant did provide DME 
to patients, he typically billed insurance policies more than 12 times the average price of the 
DME that he provided to the patient.  Six other individuals who played a role in the defendants 
19  fraudulent scheme also pled guilty and were ordered to pay a combined total of over $30.0 
million in restitution. 
In May 2022, a Florida man was sentenced in Newark, New Jersey, to 120 months in prison for 
his role in a health care fraud and kickback scheme.  The defendant and co-conspirators had 
financial interests in multiple DME companies.  The DME companies paid kickbacks to 
suppliers of DME orders, including the defendant, in exchange for DME orders, which the DME 
companies subsequently fraudulently billed to Medicare, TRICARE, CHAMPVA, and other 
health care benefit programs.  Defendants and co-conspirators owned and operated multiple call 
centers through which they obtained DME orders for beneficiaries of Medicare and other Federal 
health care programs.  The call centers paid illegal kickbacks and bribes to telemedicine 
companies to obtain DME orders for these beneficiaries.  The telemedicine companies then paid 
physicians to write medically unnecessary DME orders.  The DME orders were provided to 
DME supply companies owned by defendant and others in exchange for bribes.  The DME 
supply companies in turn provided the braces to beneficiaries and fraudulently billed the health 
care programs.  The defendant and co-conspirators caused losses to Medicare, TRICARE, and 
CHAMPVA of approximately $50.0 million.  In addition to the prison term, the defendant was 
ordered to pay restitution of $33,777,799.67 and forfeit $9,477,925. 
(SF) In May 2022, a jury convicted the owners and operators of four orthotic brace suppliers in 
Texas and Arkansas for a $6.5 million illegal kickback scheme.  The evidence presented at trial 
showed that the defendants concealed the scheme by entering into sham agreements with 
purported marketing companies that characterized the illegal payments for doctors orders as 
marketing expenses.  The defendants await sentencing. 
In August 2022, Philips RS North America, LLC, formerly Respironics, Inc., a durable medical 
equipment (DME) manufacturer based in Pittsburgh, Pennsylvania, agreed to pay $24.8 million 
to resolve civil FCA allegations that it knowingly provided unlawful kickbacks to DME 
suppliers to induce them to select Respironics' respiratory equipment.  Specifically, the 
settlement resolves allegations that from November 2014 through April 2020 Respironics caused 
DME suppliers to submit claims for ventilators, oxygen concentrators, CPAP and BiPAP 
machines, and other respiratory-related medical equipment that were false because Respironics 
provided inducements to them.  The inducements allegedly came in the form of prescribing data 
that Respironics provided free of charge yet knew was valuable in assisting DME suppliers 
marketing efforts to physicians.  In connection with the settlement, Respironics entered into a 
five-year CIA with HHS-OIG. 
In August 2022, Vision Quest Industries, Incorporated (VQ) agreed to pay the United States $2.3 
to resolve civil FCA allegations that VQ, a DME manufacturer, caused Osteo Relief Institutes 
(ORI) to bill Medicare for knee braces that were tainted by illegal kickbacks.  VQ also entered 
into a five-year Corporate Integrity Agreement. The case involved allegations that between 2011 
and 2018, VQ paid kickbacks to an independent VQ sales representative and his company, 
Results Laboratories, LLC, in the form of commission payments that ranged from 2035 percent 
of VQs net revenue on each knee brace ordered by the ORI Clinics.  The government alleged 
20  that VQ understood that the sales representative was in a position to tell the ORIs which braces 
to order and that this arrangement locked in millions of dollars in annual brace sales for VQ. 
Genetic Testing/RPP Testing 
(SF) In November 2021, a purported marketer was convicted of one count of conspiracy to 
commit health care fraud for his role in an illegal scheme to obtain doctors orders for medically 
unnecessary genetic tests in exchange for the payment of millions of dollars in kickbacks.  The 
defendant arranged for the doctors orders to be sold to laboratories in Louisiana, which 
submitted over $132.0 million in fraudulent claims to Medicare.  The defendant is awaiting 
sentencing. 
Home Health Providers 
(SF) In September 2021, the managing employee of a Pakistan-based home health care 
consulting company was convicted of one count of health care fraud and one count of 
conspiracy to commit money laundering for his role in a home health care scheme in which 
Medicare paid more than $40.0 million for home health care services that were not provided. 
The defendant then laundered the proceeds of this fraud scheme by causing the transmittal of 
payments from the home health care agencies within the United States to bank accounts in 
Pakistan for his benefit and the benefit of other scheme participants.  In February 2022, the 
defendant was sentenced to 12 years imprisonment. 
In November 2021, an employee of a home health care company was sentenced to 56 months in 
prison and ordered to pay $6.3 million in restitution for her participation in a conspiracy to 
commit health care and wire fraud.  According to court documents and the evidence presented at 
trial, the employee worked at a home health care company owned by a husband and wife.  The 
husband and wife were previously sentenced to 84 months and 60 months in prison, respectively, 
for their role in the conspiracy.  Between 2011 and 2017, the home health care company 
fraudulently billed Medicare at least $6.3 million. At trial, the government demonstrated that 
around 90 percent of the home health care companys patients were not homebound and did not 
qualify for the types of care that the company had billed to Medicare.  Further, many patients 
received cash bribes to receive home health visits, some of which were performed in the 
visiting nurses car. The employee facilitated the conspiracy by falsifying patient visit records 
that were used to support claims billed to Medicare.  She was convicted by a Federal jury on 
February 14, 2020. 
In March 2022, two Brooklyn based home care services agencies, All American Homecare 
Agency (All American) and Crown of Life Care NY LLC (Crown of Life), paid over $5.4 
million to the United States and New York State to resolve False Claims Act liability arising 
from their falsely claiming that they paid their health care aides minimum wages required by 
law.  The agencies had received millions of dollars in funding from Medicaid and much of that 
money was meant to pay the wages and benefits of their aides.  Home health aides perform all 
aspects of personal care for sick or homebound patients and frequently work long shifts lasting 
up to 24 hours.  The tasks performed in caring for patients are demanding and can consist of 
assisting or lifting patients out of bed and bathing, dressing, grooming, preparing meals and, in 
some instances, feeding them.  Importantly, in addition to paying multiple damages to the 
21  government, All American and Crown of Life are now paying their aides the wages and benefits 
they were required to pay under New York States Wage Parity Law.  Under the terms of 
settlement, American and Crown expressly accepted responsibility for their conduct. 
In May 2022, Signature Home Health Services of Florida LLC and its related entities 
(collectively, Signature) paid $2.1 million to the United States government to resolve civil FCA 
allegations that Signature improperly billed the Medicare Program for home health services 
provided to beneficiaries living in Florida. Signature, whose corporate headquarters is located in 
Louisville, Kentucky, operated home health care services in Florida.  The government alleged 
that between 2013 and 2017 Signature knowingly submitted false or fraudulent claims seeking 
payment from the Medicare Program for home health services to Medicare beneficiaries who: 
(1) were not homebound. (2) did not require certain skilled care, (3) did not have a valid or 
otherwise appropriate plans of care in place, and/or (4) did not have appropriate face-to-face 
encounters needed in order to be appropriately certified to receive home health services. 
Hospice Care 
In October 2021, Geisinger Community Health Services (GCHS) agreed to pay $18.5 million to 
resolve allegations of common law civil liability for submitting claims to Medicare for hospice 
and home health services that violated Medicare rules and regulations.  GCHS voluntarily 
disclosed the violations.  According to the voluntary disclosures, between January 2012 and 
December 2017, GCHS submitted claims, through several affiliated entities, to Medicare for 
hospice and home health services that violated Medicare rules and regulations regarding 
physician certifications of terminal illness, patient elections of hospice care, and physician face-
to-face encounters with home health patients.  
In November 2021, Carrefour Associates LLC and its related companies, which operate under 
the name Crossroads Hospice in multiple states including Ohio and Tennessee (Crossroads 
Hospice), agreed to pay $5.5 million to resolve civil FCA allegations by submitting claims to 
Medicare for non-covered hospice services.  The settlement resolved allegations that Crossroads 
Hospice knowingly submitted false claims to Medicare for hospice services for patients who 
were not terminally ill.  The United States alleged that from January 1, 2012, to December 31, 
2014, Crossroads Hospice billed Medicare for hospice care for certain patients with a diagnosis 
of dementia or Alzheimers disease at its Ohio and Tennessee locations who were not terminally 
ill for at least a portion of the more than three years that the patients received care at these 
locations. 
In August 2022, 13 defendants were sentenced to a combined 84 years in Federal prison for their 
roles in causing $27.0 million in fraudulent hospice services claims to be paid by Medicare and 
Medicaid between July 2012 to May 2016.  The defendants included the CEO of Novus Health 
Services, a Dallas-based hospice agency, as well as other company officers, nurses and 
physicians serving as medical directors.  As a part of the scheme, defendants submitted false 
claims for hospice services, submitted false claims for continuous care hospice services, 
recruited ineligible hospice beneficiaries by providing kickbacks to referring physicians and 
health care facilities, violated HIPAA to recruit potential hospice patients, dispensed Schedule II 
controlled substances to patients without the oversight of medical professionals, and used a new 
company to bill Medicare in order to avoid a Medicare suspension. 
22  Hospitals and Health Systems 
In November 2021, Flower Mound Hospital Partners LLC (Flower Mound Hospital), a partially 
physician-owned hospital in Flower Mound, Texas, agreed to pay $18.2 million to resolve 
allegations that, between July 2019 and June 2021, it violated the civil FCA by knowingly 
submitting claims to the Medicare, Medicaid, and TRICARE programs that resulted from 
violations of the Physician Self-Referral Law (the Stark Law) and the AKS.  The settlement 
resolves allegations that Flower Mound Hospital violated the Stark Law and the AKS when it 
repurchased shares from physician-owners aged 63 or older and then resold those shares to 
younger physicians.  The United States alleges that Flower Mound Hospital impermissibly 
considered the volume or value of certain physicians referrals when it (1) selected the 
physicians to whom the shares would be resold and (2) determined the number of shares each 
physician would receive.  In connection with the settlement, Flower Mound entered into a five-
year CIA with HHS-OIG. 
In March 2022, Providence Health & Services Washington (Providence), a large health care and 
hospital system operating in seven western U.S. states, agreed to pay $22.7 million to resolve 
civil FCA allegations that it fraudulently billed Medicare, Medicaid, and other Federal health 
care programs for medically unnecessary neurosurgery procedures.  The settlement resolved 
allegations that between 2013 and 2018 Providence St. Marys Medical Center in Walla Walla, 
Washington, employed certain neurosurgeons and paid them based on a productivity metric that 
provided them a financial incentive to perform more surgical procedures of greater complexity. 
The government alleged that Providence falsely billed Medicare, Washington State Medicaid, 
and other Federal health care programs for deficient and medically unnecessary neurosurgery 
procedures performed by these neurosurgeons.  In connection with the settlement, Providence 
entered into a five-year CIA with HHS-OIG.  
In April 2022, BayCare Health System Inc. and entities that operate four affiliated Florida 
hospitals (collectively, BayCare) agreed to pay $20.0 million to resolve civil FCA allegations 
that BayCare improperly funded the states share of Medicaid payments to BayCare through 
donations to the Juvenile Welfare Board of Pinellas County (JWB).  Under Federal law, 
Floridas share of Medicaid payments must consist of state or local government funds, and not 
non-bona fide donations from private health care providers, such as hospitals.  The settlement 
resolved allegations that, between October 2013 and September 2015, BayCare made improper, 
non-bona fide cash donations to JWB knowing that JWB would and then did transfer a portion of 
the cash donations to the State of Floridas Agency for Health Care Administration for Floridas 
Medicaid Program.  The government alleged that funds transferred by JWB to the state were 
matched by the Federal Government before being returned to the BayCare hospitals as 
Medicaid payments, and BayCare was thus able to recoup its original donations to JWB and also 
receive Federal matching funds, in violation of the Federal prohibition on non-bona fide 
donations.  Accordingly, BayCares donations to JWB allegedly violated the civil FCA by 
increasing Medicaid payments received by BayCare without any actual expenditure of state or 
local funds. 
Laboratory Testing 
In October 2021, Nevada-based MD Spine Solutions LLC d/b/a MD Labs Inc. (MD Labs) and 
23  two of its owners agreed to pay up to $16.0 million to resolve civil FCA allegations that MD 
Labs submitted false claims for Medicare and other Federal health care programs for medically 
unnecessary urine drug testing (UDT).  In particular, under the settlement, MD Labs and the 
owners admitted that between 2015 and 2019, MD Labs regularly billed Federal health care 
programs for medically unnecessary UDT.  MD Labs performed two types of UDT 
presumptive testing, a relatively inexpensive test that quickly provides qualitative results, and 
confirmatory testing, an expensive test that is designed to confirm quantitatively the results of 
presumptive UDTat approximately the same time and then simultaneously submitted the 
results to health care providers.  MD Labs and the owners knew that doctors would not review 
presumptive UDT results when they already had the more precise confirmatory UDT results.  
MD Labs and the owners also knew that, absent a presumptive UDT result, there was often 
nothing to confirm, and so there was no basis to bill for a confirmatory UDT result.  Under the 
terms of the settlement agreement, MD Labs and the owners will pay the government and 
various states no less than $11.6 million and up to $16.0 million, depending on MD Labs 
financial circumstances over time. 
(SF) In February 2022, a Detroit man was convicted of one count of health care fraud for 
operating a kickback scheme for a clinical laboratory, in which he paid marketers to solicit urine 
samples from physicians for comprehensive urine drug testing. The fraudulent conduct resulted 
in $28.2 million worth of improper claims submitted to Medicare, for which Medicare paid the 
laboratory $2.1 million during the fraud period.  The defendant is awaiting sentencing. 
In March 2022, Radeas LLC, a North Carolina-based clinical laboratory, agreed to pay $11.6 
million to resolve civil FCA allegations that it submitted false claims for payment to Medicare 
for medically unnecessary UDT.  Radeas admitted that between January 2016 and September 
2021, it performed on the same samples, at or near the same time, both presumptive UDT and 
definitive or confirmatory UDT.  Radeas then reported both the presumptive and definitive UDT 
results back to health care providers at the same time for the same or similar substances, often 
providing overlapping information for presumptive and definitive UDT.  Radeas also admitted to 
compensating sales organizations on a commission basis for their referrals of UDT to the 
company, from May 10, 2013, through April 30, 2021.  
In May 2022, the CEO of Northwest Physicians Laboratory was sentenced to serve 24 months in 
prison and ordered to pay $7.6 million in restitution for conspiracy to solicit kickbacks from 
medical testing labs in exchange for referring government testing business to the labs.  The CEO 
helped the laboratory obtain more than $3.7 million in kickback payments by steering urine drug 
test specimens to two labs that billed the government for testing, resulting in government 
payments to those two labs of more than $6.5 million.  According to records filed in the case, 
between January 2013 and July 2015, those two labs, which were not physician owned, made 
payments to the Laboratory in exchange for referrals of Medicare and TRICARE program 
business, in violation of the AKS. Paying remuneration to medical providers or provider-owned 
laboratories in exchange for referrals encourages providers to order medically unnecessary 
services.  The AKS functions, in part, to discourage such behavior.  The Laboratory was 
physician-owned, and for that reason could not test urine samples for patients covered by 
government health programs such as Medicare, Medicaid, and TRICARE.  In order to conceal 
24  the payment of the kickbacks, the CEO and other co-conspirators described the fees as being for 
marketing services; however, no marketing services were performed.  To date, the labs and 
individuals involved in this investigation have agreed to pay more than $14.0 million to settle 
related civil allegations. 
In July 2022, Metric Lab Services LLC and Metric Management Services LLC (collectively, 
Metric), Spectrum Diagnostic Labs LLC (Spectrum), clinical laboratories in Mississippi and 
Texas, respectively, and two of their owners and operators agreed to pay $5.7 million to resolve 
allegations that they caused the submission of false claims to Medicare by paying kickbacks in 
return for genetic testing samples.  The United States alleged that the defendants participated in a 
genetic testing fraud scheme with various marketers that solicited genetic testing samples from 
Medicare beneficiaries.  The marketers arranged to have a physician fraudulently attest that the 
genetic testing was medically necessary, and Metric and Spectrum would process the tests, 
receive reimbursement from Medicare and pay a portion of that reimbursement to the marketers.  
The individual defendants each previously pleaded guilty to one count of conspiracy to defraud 
the United States in connection with this scheme and are awaiting sentencing. 
In July 2022, an owner and operator of a youth mentoring program known as Do-It-4-The Hood 
Corporation (D4H) was sentenced to 70 months in prison and two years of supervised release 
and ordered to pay restitution for his part in defrauding Medicaid programs in North Carolina, 
South Carolina, and Georgia of more than $5 million.  From January 2016 through November 
2018, D4H paid students from Historically Black Colleges to recruit at-risk youths, in particular 
children who were Medicaid eligible in North Carolina and Georgia, for its program.  Once 
enrolled, children were required to submit urine specimens for drug testing.  The defendant then 
conspired with certain laboratories in Georgia, North Carolina, and Virginia to perform 
medically unnecessary drug testing on the enrolled childrens urine specimens and received 
kickbacks once the laboratories were reimbursed by the state Medicaid programs.  The South 
Carolina scheme preceded the North Carolina and Georgia urine testing scheme.  The defendant 
and co-conspirators became owners of a Wrights Care Services LLC (Wrights Care) franchise in 
Columbia.  Starting in or around 2014 and continuing until January 2016, the defendant and his 
conspirators defrauded the South Carolina Medicaid program by filing fraudulent claims for 
mental health counseling or other services that were either not provided, partially provided, or 
did not qualify for Medicaid reimbursement.  They submitted falsified patient billing records and 
fake medical notes to support their fraudulent reimbursement claims.  Over the course of the 
scheme, the defendant and his co-conspirators submitted thousands of fraudulent claims to 
Medicaid programs in the three states totaling over $17.0 million and received over $5.0 million 
in fraudulent reimbursements.  In addition, they received $1.8 million in kickbacks from the 
laboratories that participated in the conspiracy. 
Managed Care 
In August 2022, Ventura County Medi-Cal Managed Care Commission d/b/a Gold Coast Health 
Plan (Gold Coast), a county organized health system, Ventura County, California, Dignity 
Health, and Clinicas del Camino Real Inc., agreed to pay a total of $70.7 million to the 
government and California pursuant to three separate civil settlements.  These settlements 
resolved allegations that the entities violated the civil FCA and state analogue by knowingly 
25  submitting or causing the submission of false claims to Californias Medicaid Program (Medi-
Cal) for Additional Services provided to Adult Expansion Medi-Cal members, stemming from 
the Medicaid Adult Expansion under the Patient Protection and Affordable Care Act (ACA) 
between January 1, 2014, and May 31, 2015.  The United States and California alleged that the 
payments were not allowed medical expenses under Gold Coasts contract with the state, were 
pre-determined amounts that did not reflect the fair market value of any Additional Services 
provided. and/or the Additional Services were duplicative of services already required to be 
rendered.  In connection with the settlement, Gold Coast and Ventura County entered into five-
year CIAs with HHS-OIG.  This is the first resolution of its kind involving Medicaid Adult 
Expansion fraud.  
Medical Devices 
In November 2021, Arthex, Inc. (Arthex), a Florida-based medical device company, agreed to 
pay $16.0 million to resolve civil FCA allegations that from August 2010 through March 5, 
2021, it paid kickbacks that caused the submission of false claims to the Medicare program. 
According to the settlement, Arthex, which specializes in orthopedic products, allegedly paid 
kickbacks to a Colorado-based orthopedic surgeon.  The settlement resolves allegations that the 
medical device company agreed to provide remuneration to the surgeon in the form of royalty 
payments purportedly for the surgeons contributions to Arthexs SutureBridge and SpeedBridge 
products when the remuneration was in fact intended to induce the surgeons use and 
recommendation of Arthexs products.  The United States contended that the medical device 
companys participation in this arrangement violated the Federal AKS and, in turn, the civil 
FCA, by causing the submission of false or fraudulent Medicare claims.  In connection with the 
settlement, the medical device company entered into a five-year corporate integrity agreement 
with HHS-OIG. 
In December 2021, the CEO of a North Georgia medical group and Entellus Medical, a medical 
device manufacturer, resolved criminal and civil allegations that they entered into unlawful 
kickback arrangements.  The unlawful remuneration included cash payments and all-expense 
paid trips in return for the CEO's agreement to require the practice group physicians to 
exclusively use the medical device company's sinuplasty medical devices, increase the number of 
sinuplasty procedures conducted on the practice group's patients and order medically 
unnecessary lab tests.  The civil case was settled for $4.2 million.  The CEO was sentenced to 
three years in prison followed by three years of supervised release.  
In April 2022, Eargo Inc. (Eargo), a company headquartered in California that sells and 
dispenses hearing aid devices to customers nationwide, agreed to pay $34.4 million to resolve 
civil FCA and common law allegations that from January 1, 2017, until September 22, 2021, it 
submitted or caused to be submitted claims containing unsupported diagnosis codes to the 
Federal Employees Health Benefits Program (FEHBP) for the reimbursement of its hearing aid 
devices.  In particular, the government alleged that these claims lacked support for patients 
diagnoses of hearing loss, which is required by FEHBP health insurance plans to trigger hearing 
aid device reimbursement.  
In June 2022, Oregon-based medical device manufacturer Biotronik, Inc. (Biotronik) agreed to 
26  pay $13.0 million to resolve civil FCA allegations that, from January 1, 2013, through October 1, 
2013, it caused the submission of false claims to Medicare and Medicaid by paying kickbacks to 
physicians to induce and reward their use of Biotroniks implantable cardiac devices, including 
pacemakers and defibrillators.  In particular, the United States alleged that Biotronik abused a 
new employee training program by paying physicians for an excessive number of trainings and, 
in some cases, for training events that either never occurred or were of little or no value to 
trainees.  The United States further alleged that Biotronik made these payments despite concerns 
raised by its own compliance department, which warned that salespeople had too much influence 
in selecting physicians to conduct new employee training and that the training payments were 
being over-utilized.  The settlement also resolved allegations that Biotronik violated the AKS 
when it paid for physicians holiday parties, winery tours, lavish meals with no legitimate 
business purpose, and international business class airfare and honoraria in exchange for making 
brief appearances at international conferences. 
In August 2022, Essilor International, Essilor of America Inc., Essilor Laboratories of America 
Inc., and Essilor Instruments USA (collectively, Essilor), headquartered in Dallas, agreed to pay 
$22.0 million to resolve civil FCA allegations that the company caused claims to be submitted to 
Medicare and Medicaid that resulted from violations of the AKS.  The United States alleged that 
between January 1, 2011, and December 31, 2016, Essilor, which manufactures, markets, and 
distributes optical lenses and equipment used to produce optical lenses, knowingly and willfully 
offered or paid remuneration to eye care providers, such as optometrists and ophthalmologists, to 
induce those providers to order and purchase Essilor products for their patients, including 
Medicare and Medicaid beneficiaries, in violation of the AKS.  In connection with the 
settlement, Essilor entered into a five-year CIA with HHS-OIG.  
Nursing Homes and Facilities 
In June 2022, TCPRNC, LLC d/b/a Plaza Rehab and Nursing Center (Plaza Rehab Center) and 
Citadel Consulting Group LLC d/b/a Citadel Care Centers LLC (Citadel) agreed to pay the 
United States $7.9 million to resolve civil FCA allegations that Plaza Rehab Center, acting at the 
direction of Citadel, fraudulently switched the type of Medicare coverage in which older 
residents were enrolled in order to maximize the Medicare payments that the skilled nursing 
facility would receive.  The Government specifically alleged that Plaza Rehab Center staff 
disenrolled many residents from their self-selected Medicare Advantage Plans and enrolled them 
in Original Medicare (e.g., fee-for-service Medicare) without obtaining the consent of the 
residents or their authorized representatives.  This change had the potential to impact the 
residents out-of-pocket payments, the scope of the services and care covered, and their drug 
coverage plan.  As part of the settlement, Citadel agreed to take steps to ensure that all skilled 
nursing facilities that are Citadel Care Centers comply with applicable guidance on Medicare 
health plan disenrollments and enrollments.  Plaza Rehab Center and Citadel also entered into a 
CIA with HHS-OIG. 
Pharmacies 
In December 2021, an executive who owned and operated two compounding pharmacies was 
sentenced to three years in Federal prison and ordered to pay more than $3.0 million in 
restitution to the IRS for evading the payment of approximately $5.5 million in personal income 
27  taxes and submitting false reimbursement claims to CVS Caremark, a national pharmacy benefit 
manager. According to court documents, HHS OIG, the Oregon Department of Justices 
Medicaid Fraud Unit, and other agencies pursued a multi-year investigation into alleged illegal 
kickback arrangements at compounding pharmacies owned by the executive and members of his 
family in several states.  Two such pharmacies were located in Southeast Portland.  The 
investigation ultimately revealed that the executive had devised various indirect means of 
incentivizing health care providers to write prescriptions for compounded drugscustom-mixed 
medications that generate outsized reimbursement from Medicare, Medicaid, and other health 
care-benefit programsand to direct those prescriptions to his pharmacies for dispensing.  These 
arrangements proved enormously profitable for the executives pharmacies. 
In January 2022, a Milwaukee-based pharmacy chain and its two owners agreed to pay $2.0 
million to resolve allegations that it violated the civil FCA by submitting false claims to 
Medicare and Medicaid for prescription medications in 2019.  The United States alleged that the 
pharmacy submitted false claims to Medicare and Medicaid for two prescription medications, a 
topical cream consisting of iodoquinol, hydrocortisone, and aloe, and a multivitamin with the 
trade name Azesco.  During the relevant time period, Medicaid paid thousands of dollars per 
prescription for the iodoquinol-hydrocortisone-aloe cream, and Medicare paid hundreds of 
dollars per prescription for Azesco.  The United States alleged that the pharmacy switched 
Medicaid and Medicare patients from lower cost medications to the iodoquinol-hydrocortisone-
aloe cream and Azesco without any medical need and/or without a valid prescription.  In addition 
to paying over $2.0 million to resolve the allegations concerning these false claims, the 
pharmacy agreed to conduct annual training concerning waste, fraud and abuse, and compliance 
with rules concerning medication switches. 
In April 2022, a business owner was sentenced to 77 months in prison for carrying out multiple 
schemes to defraud health care programs, including obtaining more than $6.5 million from 
Medicare Part D plans and Medicaid drug plans.  According to court documents, the individual 
was the owner and operator of five pharmacies.  Between 2015 and 2020, the owner utilized 
these pharmacies to engage in schemes that defrauded health care programs, including Medicare 
and Medicaid, by submitting claims for prescription drugs that were not dispensed, not 
prescribed as claimed, not medically necessary, or dispensed during a time when the pharmacy 
was no longer registered with the State of New York.  The fraudulent claims included claims for 
expensive prescription drugs for the treatment of the human immunodeficiency virus (HIV).  The 
owner and her family used proceeds of the scheme to purchase luxury items such as a Cadillac 
Escalade SUV, a Mercedes Benz sedan, a Porsche Turbo coupe, as well as jewelry and real 
property in Queens and Pocono Pines, Pennsylvania. 
In August 2022, Dunn Meadow LLC, a New Jersey licensed retail pharmacy that sent controlled 
substances and other prescription medications to patients via mail throughout the United States, 
pleaded guilty to its role in a conspiracy to illegally distribute prescription opioids, including 
highly addictive and dangerous transmucosal immediate release fentanyl (TIRF) medications, 
and to give kickbacks to health care providers.  Dunn Meadow had contracts with and received 
payments from pharmaceutical companies that marketed and sold TIRF medications, including 
INSYS Pharma Inc.  From 2015 through 2019, Dunn Meadow knowingly filled prescriptions for 
28  controlled substances, including TIRF medications, for patients exhibiting suspicious and drug-
seeking behavior, including patients that repeatedly requested early refills, paid thousands of 
dollars in cash for their prescriptions, or requested that prescriptions be sent to suspicious or 
inappropriate locations including hotels, casinos, and elementary schools.  Dunn Meadow also 
admitted that it conspired to offer kickbacks to health care providers and pharmaceutical 
company sales representatives in violation of the Federal AKS, in the form of lunches, dinners, 
and happy hours to induce them to send TIRF prescriptions to Dunn Meadow, causing a loss to 
Federally funded health care programs of over $4.5 million.  In addition, Dunn Meadow and its 
parent company, Allegheny Pharma LLC entered a civil settlement with the United States to 
resolve Dunn Meadows civil liability for violations of the False Claims Act and the Controlled 
Substances Act.  Dunn Meadows criminal restitution payment will be applied to the civil 
resolution.  Dunn Meadow has agreed to pay up to $50.0 million dollars over the next five years 
to resolve its civil liability if it generates future revenue. 
Physical Therapy 
In May 2022, the co-owners of a South Florida physical therapy clinic were each sentenced to 
135 months in prison for using their clinic as a vehicle for both health care fraud and CARES 
Act fraud.  In addition to the prison sentence, the clinic owners were ordered to pay over $3.0 
million in restitution to a health insurance company and over $1.0 million in restitution to the 
U.S. Small Business Administration (SBA), as well as to forfeit to the United States property 
traceable to proceeds of the health care and wire fraud schemes.  The clinic owners were 
convicted at trial on all charged crimes (one count of conspiracy to commit health care fraud and 
wire fraud, seven counts of health care fraud, and two counts of wire fraud).  In addition, an 
office manager and two patient recruiters pled guilty to conspiracy to commit health care fraud 
and received both prison sentences and orders to pay restitution.  According to evidence 
introduced in court, the billing fraud conspiracy resulted in more than $8.0 million in false 
claims submissions.  Most of the claims were for unneeded or never-provided physical therapy 
treatments, such as electrical stimulation, ultrasound therapy, and therapeutic exercise, as well as 
for durable medical equipment.  Additionally, the evidence showed that in 2021, the clinic 
owners fraudulently applied for a $607,585 PPP loan as well as a $500,000 EIDL from the SBA.  
As a result of this fraud, the clinic owners received over $1.0 million through these COVID-19 
relief programs, stealing money that was meant for legitimate small businesses suffering from 
the devastating effects of the COVID-19 pandemic. 
(SF) In August 2022, a jury convicted an office manager/recruiter for participating in a scheme 
to defraud several private health insurers of millions of dollars.  The defendant paid kickbacks 
and bribes to patient recruiters and patients with private insurance in exchange for allowing four 
Miami physical therapy clinics to bill for medical services that were never actually provided to 
those patients.  The defendant and co-conspirators falsified medical records to give the 
impression that the physical therapy services were medically necessary, prescribed by a doctor, 
and actually rendered.  In truth and fact, virtually none of the purported services had been 
provided.  The defendant and co-conspirators submitted approximately $34.6 million in false and 
fraudulent claims to several private insurers for those nonexistent physical therapy services, of 
which the insurers paid approximately $7.7 million.  The defendant awaits sentencing. 
29  Physician and Other Practitioners 
In November 2021, 24 individuals and entities agreed to pay more than $28.0 million to resolve 
civil FCA allegations that the subjectswhich included anesthesia providers and outpatient 
surgery centersentered into a series of kickback arrangements in which the anesthesia 
providers paid for medications, supplies, and labor expenses incurred by the outpatient surgery 
centers in exchange for the centers' referral of their patients to the anesthesia providers.  The 
Government alleged that between 2005 and 2015, Ambulatory Anesthesia of Atlanta, LLC 
(AAA) and Northside Anesthesiology Consultants, LLC (NAC) made payments for drugs, 
supplies, equipment, and labor, and provided free staffing to a number of Georgia outpatient 
surgery centers in order to induce the centers to select AAA and NAC as their exclusive 
anesthesia providers. The Government alleged that these arrangements violated the AKS and 
caused the submission of false claims in violation of the civil FCA.  
In December 2021, a Montana vascular surgeon and his business, Bellamah Vein & Surgery, 
PLLC, doing business as Bellamah Vein Center, agreed to pay the government $3.7 million to 
resolve civil FCA allegations that he knowingly performed unnecessary vein ablation surgeries 
on many Medicare, Medicaid, Department of Veteran's Affairs, and TRICARE beneficiaries. 
The Government alleged that the defendant used improper techniques to conduct and analyze 
ultrasounds and used false ultrasound findings to conduct and bill for medically unreasonable 
and unnecessary services related to the diagnosis and treatment of venous reflux disease and 
varicose veins. 
In March 2022, Physician Partners of America LLC (PPOA), headquartered in Tampa, Florida, 
its founder, and its former chief medical officer, agreed to pay $24.5 million to resolve civil FCA 
allegations that (1) between October 1, 2015 and November 8, 2021 they billed Federal health 
care programs for unnecessary medical testing and services and paid unlawful remuneration to 
its physician employees, and (2) on April 10, 2020, made a false statement in connection with a 
loan obtained through the SBAs PPP.  In particular, the United States alleged that PPOA caused 
the submission of claims for medically unnecessary UDT by requiring its physician employees to 
order multiple tests at the same time without determining whether any testing was reasonable and 
necessary, or even reviewing the results of initial testing (presumptive UDT) to determine 
whether additional testing (definitive UDT) was warranted.  The United States further alleged 
that PPOAs affiliated toxicology lab billed for the highest-level UDT and that PPOA 
incentivized physicians to order UDT by paying them 40 percent of the profits of testing, in 
violation of the Stark law.  PPOA allegedly also required patients to submit to genetic and 
psychological testing before patients were seen by physicians, without a medical determination 
as to the medical necessity of such tests.  PPOA also required its physician-employees to 
schedule unnecessary telehealth evaluation and management appointments.  In connection with 
the settlement, PPOA entered into a five-year CIA with HHS-OIG.  
(SF) In April 2022, a physician was sentenced to 93 months of imprisonment for defrauding 
Medicare, re-packaging single-use catheters for re-use on patients, and submitting false 
declarations in a bankruptcy proceeding.  According to court documents, from August 2012 to 
August 2015, the defendant billed Medicare $12.4 million for medically unnecessary vein 
ablation procedures and was paid $4.5 million.  The defendant recruited Medicare beneficiaries 
30  to his clinics, falsely diagnosed the beneficiaries, and provided them with the medically 
unnecessary procedures, while also billing the procedures using an inappropriate code in order to 
obtain a higher reimbursement, a practice known as upcoding.  In addition, the defendant re-
packaged used, contaminated catheters for re-use on patients.  These catheters had been cleared 
by the Food and Drug Administration for marketing as single-use only and the re-use of these 
devices put patients at risk of infection and other bodily injury. 
In July 2022, a dentist practicing in a rural community outside Milwaukee, Wisconsin, was 
sentenced to 54 months in prison for health care fraud.  Following trial in March 2022, a jury 
convicted the dentist of five counts of health care fraud and two counts of making false 
statements in connection with health care matters arising out of a years long scheme in which 
the dentist convinced patients that they needed crown procedures that, in fact, they did not need.  
Insurance typically covers a crown procedure only if the patients tooth is so damaged by decay 
or fracture that it cannot be repaired with a filling.  In order to obtain insurance coverage for the 
unnecessary crowns, once the dentist convinced a patient to receive a crown, he used his dental 
drill to break off a portion of the patients tooth, then stopped to take an x-ray or photo of the 
damage he caused, and ultimately submitted that image of the now-damaged tooth to insurance 
in order to get paid for the procedure.  In addition to the prison sentence, the dentist was ordered 
to pay $1,043,229 in forfeiture to the United States to account for the proceeds of the fraudulent 
scheme.  The dentist will also pay restitution to insurance companies and patients in an amount 
to be determined by the court, but which will likely exceed $400,000. 
In May 2022, a physician was sentenced to 20 years in prison followed by five years of 
supervised release, and was ordered to pay a $40,000 fine and almost $4.0 million in restitution 
for running a prescription pill mill from 2015 to 2018 from his Philadelphia medical practice. 
In January 2020, the physician pleaded guilty to 19 counts of health care fraud and 23 counts of 
distributing oxycodone outside the course of professional practice and without a legitimate 
medical purpose. The defendant fraudulently billed insurers for medically unnecessary physical 
therapy, acupuncture, chiropractic adjustments, and prescription drugs, and also fraudulently 
billed for treatments that were not provided at all.  Regardless of their medical complaint, at 
every visit, patients received a goodie bag filled with prescription drugs for which the 
physician submitted pharmacy claims through his company.  The goodie bags typically included 
a combination of drugs such as topical analgesics Relyyt and/or Lidocaine, muscle relaxers such 
as Chloroxazon and/or Cyclobenzaprine, anti-inflammatories such as Celecoxib and/or Nalfon. 
Schedule IV controlled substances such as Tramadol for pain, and/or Eszopiclone and Quazepam 
for insomnia and anxiety.  The defendant obtained payments from insurers of more than $4,000 
for each bag by falsely asserting that the drugs were for the benefit of the patient.  As part of the 
fraud scheme, the physician also prescribed oxycodone to pill-seeking patients in exchange for 
their tacit approval that he would submit excessive claims to the patients insurer for the goodie 
bag and other medically unnecessary services.  The defendant is also subject to a civil judgment 
under which he is obligated to pay approximately $1.8 million as a result of civil FCA liability 
for false claims submitted to Medicare, and is subject to a permanent prohibition on prescribing, 
distributing, or dispensing controlled substances. 
31  In July 2022, the operator of medical billing companies was convicted after a six-week trial of 
eight counts related to perpetrating an over $600.0 million health care fraud scheme, which also 
included wire fraud and aggravated identity theft charges.  The defendant operated medical 
billing companies to provide billing services for physicians (primarily plastic surgeons) 
throughout the United States, and used his companies to carry out a massive scheme to defraud 
insurance companies.  As a third-party medical biller, the defendant submitted claims to 
insurance companies and when necessary, requested reconsideration or appeals of denied claims.  
He billed for procedures that were either more serious or entirely different than those his doctor-
clients performed.  For example, the defendant impersonated the National Football Leagues 
general counsel and a professional basketball player for the Boston Celtics of the National 
Basketball Association in calls the defendant made to insurance companies in which he 
exaggerated medical procedures.  The defendant made thousands of impersonation calls resulting 
in over tens of millions of dollars in additional reimbursement to his doctor-clients and from 
which he received a percentage of the fraudulent proceeds.  The defendant also directed his 
doctor-clients to schedule elective surgeries through the emergency room so that insurance 
companies would reimburse at substantially higher rates.  When insurance companies denied the 
inflated claims, the defendant impersonated patients to demand that the insurance companies pay 
the outstanding balances of tens or hundreds of thousands of dollars. 
Prescription Drugs and Opioids 
(SF) In September 2021, a dentist was convicted of one count of unlawful distribution of 
controlled substances and one count of conspiracy to unlawfully distribute controlled substances 
based on the dentists involvement in a conspiracy to illegally generate prescriptions for opioids 
and benzodiazepines in the names of co-conspirator dental assistants, their family members, and 
an unwitting office staff member using the dentists DEA registration.  These prescriptions were 
issued outside the usual course of professional practice and without a legitimate medical purpose, 
as the defendant and co-conspirators split the prescription drugs for personal use.  In February 
2022, the dentist was sentenced to 60 months of imprisonment. 
(SF) In November 2021, the owner of a pain management clinic in Miami was convicted for his 
role orchestrating a pill mill conspiracy that resulted in the illegal distribution of more than 3 
million pills of oxycodone and generated more than $9.0 million in drug proceeds.  In April 
2022, the defendant was sentenced to more than 16 years in prison. 
In February 2022, a physician was sentenced to 24 months in Federal prison, to be followed by 
three years of supervised release for conspiring to violate the AKS in connection with a scheme 
to take bribes and kickbacks from a pharmaceutical company in exchange for prescribing a 
powerful fentanyl spray to his chronic pain patients.  According to the plea agreement, beginning 
in late 2012 and continuing through November 2015, the defendant conspired with 
pharmaceutical company employees to take approximately $344,000 in bribes and kickbacks 
from the manufacturer of Subsys, a powerful sublingual fentanyl spray approved by the FDA in 
2012 to treat breakthrough pain in cancer patients.  The bribes were disguised as payments or 
honoraria for purportedly delivering educational speaker programs to the defendants medical 
peers.  In fact, the defendant often delivered no programs at allat one point taking payments of 
over $40,000 from the manufacturer for 17 programs he allegedly delivered to his own staff at 
32  his medical clinic.  As part of the plea agreement, the defendant admitted that he entered into a 
quid pro quo relationship with the manufacturer, and that the payments affected his prescribing 
decisions.  He abused his position of trust vis-a-vis his patients and the Federal health care 
programs in which he was enrolled, becoming one of the manufacturers top revenue-generating 
prescribers. Prescriptions for Subsys typically cost thousands of dollars each month, and 
Medicare and Medicaid paid millions of dollars to cover Subsys prescriptions written by the 
physician. Fentanyl is at least 50 times more powerful than morphine, and to ensure patient 
safety, the FDA requires Subsys prescribers, patients, and pharmacies to enroll in and comply 
with the TIRF Risk Evaluation and Mitigation Strategy (TIRF REMS) program.  The defendant 
disregarded the rules imposed by this program, failing to notify his patients of the risks posed by 
the Schedule II controlled substance. 
(SF) In March 2022, a Delaware physician was sentenced to 240 months of imprisonment 
stemming from his July 2021 trial conviction of thirteen counts of unlawfully prescribing 
controlled substances, outside the usual course of professional practice and without a legitimate 
medical purpose, and maintaining a drug involved premises.  In just over a year, he 
distributed/dispensed over one million pills, mostly oxycodone products, and mostly for cash. 
(SF) In March 2022, the owner of a Houston cash-only, pill-mill was convicted at trial of one 
count of conspiracy to unlawfully distribute and dispense controlled substances, four counts of 
unlawfully distributing and dispensing controlled substances, one count of conspiracy to launder 
monetary instruments, and two counts of engaging in monetary transactions in property derived 
from specified unlawful activity.  Throughout the duration of the conspiracy, approximately 
739,000 hydrocodone pills and 344,000 oxycodone pills, almost all in their maximum strength, 
were distributed and dispensed not for a legitimate medical purpose.  On June 24, 2022, the 
defendant was sentenced to 240 months of imprisonment. 
In March 2022, a former doctor, was sentenced to 20 years in prison for unlawful drug 
distribution and maintaining a drug-involved premises.  According to court documents and 
evidence presented at trial, the former doctor unlawfully distributed or dispensed a variety of 
powerful opioidsincluding fentanyl, morphine, methadone, OxyContin and oxycodone 
outside the usual scope of professional practice and for illegitimate medical purposes.  The 
former doctor operated an internal medicine practice where he frequently prescribed these 
dangerous controlled substances in high dosages, sometimes in combination with each other or in 
other dangerous combinations, mostly in exchange for cash.  Evidence at trial showed that the 
former doctor distributed over 1 million opioid pills.  Although these Schedule II drugs are 
approved for pain management treatment, the former doctor provided no meaningful medical 
care and instead prescribed these controlled substances to patients he knew were suffering from 
substance use disorder and/or who demonstrated clear signs that the prescribed drugs were being 
abused, diverted or sold on the street. 
In September 2022, a former Hawaii pain doctor was sentenced to seven and a half years in 
prison.  He had been found guilty in April 2022 of all 38 counts of an indictment charging him 
with conspiracy to distribute oxycodone and fentanyl and distribution of oxycodone and fentanyl 
outside the course of professional practice and without a legitimate medical purpose.  
33  Immediately following the Federal jurys verdict, the defendant was remanded into custody.  
Following a three-week trial, the jury deliberated for less than one day and convicted him of 
distributing substantial quantities of oxycodone, a Schedule II controlled substance, to his close 
friends to sell to pay for tuition at one of the most expensive private schools in the State of 
Hawaii and to purchase cocaine. 
In June 2022, an Arkansas physician was convicted on 22 of 22 counts including conspiracy, 
wire fraud, mail fraud, violating the AKS, lying to the FBI, falsifying records, and aggravated 
identity theft.  This represented the tenth and final conviction in a massive compounded drug 
scheme.  Recruiters bribed TRICARE beneficiaries to receive free compounded drugs and 
bribed health care providers, including the defendant, to rubber stamp the necessary prescriptions 
without ever consulting the patient or determining whether the drugs were even medically 
necessary.  In less than one year, the scheme generated hundreds of bogus prescriptions in the 
names of TRICARE beneficiaries from coast to coast for which TRICARE paid over $12.0 
million.  When the FBI and HHS-OIG began investigating, the defendant and his co-conspirators 
responded by lying to the authorities, altering existing business records to conceal the link 
between recruiters and prescribers, and fabricating medical records to make it seem as if 
recipients of prescriptions were bona fide patients who had been consulted by their doctor.  Co-
conspirators sentenced thus far have received prison terms of 51 months, 48 months, and 15 
months, respectively. 
In August 2022, a former Registered Nurse was sentenced to 18 months in prison for tampering 
with opioid medications and placing her patients in danger.  Between 2019 and 2020, while 
employed as an RN at a hospital in Moses Lake, Washington, the defendant used a syringe to 
remove morphine from vials in the hospitals controlled substance area, which she then used 
while on the job.  The defendant replaced the morphine in the vials with saline solution and 
glued the caps back onto the vials to conceal her theft and tampering, which resulted in patients 
who required and were prescribed morphine instead receiving saline solution.  This conduct 
resulted in at least one patient being admitted to the emergency room because he did not 
experience any pain relief from being administered what medical staff believed to be morphine 
but which was, instead, saline.  The court specifically found that the defendants conduct placed 
her patients at risk and caused serious harm.  
Psychiatric and Psychological Testing and Services 
In March 2022, a Licensed Professional Counselor was sentenced to 57 months of imprisonment 
for fraudulently billing the Connecticut Medicaid program for over $1.3 million of 
psychotherapy services that he never provided.  The defendant operated group homes in 
Connecticut for victims of domestic violence, including women and their children.  The 
defendant required the tenants to provide copies of the Medicaid cards for themselves and their 
children, and then used this information to bill Medicaid for over $500,000 in fraudulent 
services.  The defendant also worked as a guidance counselor at the New Haven Adult and 
Continuing Education Center, where he improperly accessed a database of personal identifying 
information for students and former students, which he used to determine whether the students 
34  were Medicaid members.  He then used this information to fraudulently bill Medicaid for nearly 
$600,000 for psychotherapy services that were not provided.  
(SF) In April 2022, a jury convicted a Texas husband and wife for a $1.0 million Medicare fraud 
scheme. According to court documents and evidence presented at trial, the defendants were 
patient recruiters who owned and operated group homes in which Medicare beneficiaries 
lived.  In exchange for sending their group home residents to a community mental health center 
(CMHC) that purported to provide partial hospitalization services, the CMHC paid the 
defendants and other patient recruiters kickbacks often concealed as payment for 
transportation or other sham services.  The defendants await sentencing. 
In August 2022, the former chief operating officer of a Federally qualified health center based in 
Louisiana was convicted of one count of conspiracy to commit health care fraud for her role in a 
scheme to defraud Medicaid by providing educational services in school classrooms, but then 
billing Medicaid approximately $1.8 million for having falsely provided group psychotherapy 
services.  After learning that a mental health diagnosis was required for reimbursement, the 
defendant and others directed the clinics staff to assign false mental health diagnoses to the 
students to further the fraudulent scheme.  The defendant is awaiting sentencing. 
Substance Use Treatment Centers 
(SF) In November 2021 and in March 2022, the two owners and the medical director of two 
South Florida addiction treatment facilities were convicted at separate trials for engaging in a 
scheme that fraudulently billed approximately $112 million for substance abuse services that 
were never provided or were medically unnecessary.  The two owners obtained patients through 
patient recruiters who offered illegal kickbacks to patients, including free airline tickets, illegal 
drugs, and cash payments.  The medical director, a medical doctor, and others admitted patients 
for medically unnecessary detox services, the most expensive kind of treatment the facilities 
offered.  The defendants submitted and caused the submission of false and fraudulent claims for 
excessive, medically unnecessary urinalysis drug tests that were never used in treatment.  The 
defendants shuffled a core group of patients between the two treatment facilities in a cycle of 
admissions and re-admissions to fraudulently bill for as much as possible.  Patients were given a 
so-called Comfort Drink to sedate them, and to keep them coming back.  Patients were also 
given large and potentially harmful amounts of controlled substances, in addition to the 
Comfort Drink, to keep them compliant and docile, and to ensure they stayed at the facility.  In 
March 2022, the owners were sentenced to 188 months and 97 months in prison, respectively, 
and in July 2022, the medical director was sentenced to 54 months in prison. 
In March 2022, the owner of several substance abuse treatment clinics and a toxicology lab in 
Eastern Kentucky was sentenced to more than 10 years in prison for schemes in which he tricked 
opioid-addicted patients into paying millions of dollars for services already covered by their 
Medicaid insurance and billed unnecessary urine drug testing services to the Medicare and 
Medicaid programs.  As Kentucky Medicaid-enrolled providers, the defendant's clinics were 
required by Kentucky law to bill that insurance program for services rendered to Medicaid 
patients.  The defendant deceived indigent, opioid-addicted patients into paying $200-$300 per 
month in cash for treatment at his clinics, despite having Medicaid insurance, by falsely claiming 
35  his clinics were not eligible to bill Medicaid for counseling and related services.  Cash payments 
from Medicaid patients totaled around $3.8 million between May 2016 and October 2019 for 
services that should have been free to these Medicaid beneficiaries.  At the same time, the 
defendant caused his clinics to bill Medicaid for addiction treatment services, receiving millions 
in reimbursements from that program as well.  In addition to the cash-for-services scheme, the 
defendant, who was not a doctor or medical professional, caused his laboratory to bill for 
medically unnecessary urine drug testing of samples collected from patients at his clinics.  None 
of the unnecessary testing was ordered by a physician and was done solely at the defendant's 
direction.  As well as his 125-month prison sentence, the defendant was ordered to pay $5.7 
million in restitution. 
Telemedicine Exploitation and Fraud 
In November 2021, a business owner was sentenced to 82 months in Federal prison and ordered 
to pay over $61.0 million in restitution for his role in a $73.0 million conspiracy to defraud 
Medicare by paying kickbacks to a telemedicine company to arrange for doctors to authorize 
medically unnecessary genetic testing.  The scheme exploited temporary amendments to 
telehealth restrictions enacted during the COVID-19 pandemic that were intended to ensure 
access to care for Medicare beneficiaries.  According to court documents, the business owner 
admitted that he conspired with other co-owners to pay kickbacks in exchange for his work 
arranging for telemedicine providers to authorize genetic testing orders for the laboratories.  The 
owners entered into a sham contract for purported IT and consultation services to disguise the 
true purpose of these payments.  They then exploited the temporary telehealth restriction 
amendments by offering telehealth providers access to Medicare beneficiaries, for whom they 
could bill Medicare for consultations.  In exchange, these providers agreed to refer beneficiaries 
to the laboratories for expensive and medically unnecessary cancer genetic testing. 
In June 2022, a business owner was sentenced to 14 years in prison for health care and wire 
fraud resulting in a loss of more than $20.0 million to Medicare, and for evading taxes. 
According to court documents, the individual owned and operated several telemarketing and 
telemedicine companies to market medically unnecessary genetic tests to Medicare beneficiaries, 
and to sell prescriptions (i.e., doctors orders) for medically unnecessary genetic tests to 
laboratories in exchange for kickbacks and bribes.  The business owner knew these laboratories 
would use these doctors orders to bill Medicare for medically unnecessary goods and services. 
Through nominee owners, the business owner also operated and controlled other companies to 
market compounded prescription creams to customers with certain health conditions. 
Pharmacies and laboratories associated with this company filled the prescriptions, billed the 
customers insurance companies, and paid the business owner kickbacks.  The business owner 
used these company accounts to purchase luxury items such as high-end watches and diamond 
jewelry, classic and exotic cars, two yachts, and other items.  The business owner also evaded 
paying over $2.5 million in personal income taxes for years dating back to 2000.  When the IRS 
attempted to collect back taxes from the business owner, he tried to conceal assets by transferring 
property to trusts and individuals and by repeatedly opening and closing companies, among other 
things. In addition to the prison term and Medicare restitution, the business owner was ordered to 
pay more than $4.0 million in restitution to the IRS. 
36  DEPARTMENT OF HEALTH AND HUMAN SERVICES 
Office of Inspector General 
The HHS-OIG mission is to protect the integrity of HHS programs and the health and welfare of 
the people they serve.  As established by the Inspector General Act of 1978, HHS-OIG is an 
independent and objective organization that fights fraud, waste, and abuse and promotes 
efficiency, economy, and effectiveness in HHS programs and operations. 
HHS-OIGs vision is to drive positive change in HHS programs and in the lives of the people 
they serve.  HHS-OIG pursues this vision through independent oversight of HHS programs and 
operations and by providing HHS and Congress with objective, reliable information for use in 
policymaking.  HHS-OIG assesses the Departments performance, administrative operations, and 
financial stewardship.  HHS-OIG also evaluates risks to HHS programs and recommends 
recovery of misspent funds and program improvements.  HHS-OIGs law enforcement 
component investigates fraud and abuse of HHS programs and holds wrongdoers accountable for 
their actions.  In addition to safeguarding Federal funds, HHS-OIG takes oversight and 
enforcement action to promote the safety and quality of services delivered by HHS programs.  
As the leading oversight agency specializing in health care fraud, HHS-OIG employs a multi-
disciplinary approach and uses data-driven decision-making to produce outcome-focused results.  
HHS-OIG strives to be a flexible and efficient organization that adapts to the needs of the times.  
HHS-OIG deploys resources as optimally as possible to keep pace with the fast-changing nature 
of health care programs and the corresponding changes in fraud, waste, and abuse.  To do so, 
HHS-OIG leverages sophisticated data analysis to identify and target potential fraud schemes 
and areas of program waste and abuse and to provide quality, timely, and actionable data to 
frontline staff, as well as to its Government and, as appropriate, private sector partners.  HHS-
OIG combines data analysis, field intelligence, and state-of-the-art investigative techniques to 
combat fraud and abuse.  HHS-OIG also continues to modernize its infrastructure capacity to 
deliver high-quality, timely, actionable data to produce these results.  HHS-OIG is focused on 
developing data-driven, key performance indicators and has helped achieve results in priority 
areas and measures that further the goals of HHS-OIGs work. 
With respect to HCFAC funds, HHS-OIG focuses on combating Medicare and Medicaid fraud, 
waste, and abuse, including in priority areas such as protecting beneficiaries from prescription 
drug abuse, including opioid abuse; enhancing program integrity in noninstitutional care settings, 
such as home health and hospice care; and strengthening Medicaid program integrity, including 
working with state partners to enhance the effectiveness of the MFCUs.  HHS-OIG is also 
strengthening oversight of nursing homes, Medicare Advantage (MA) managed care plans, 
Medicaid managed care programs, value-based models, Medicare hospital payments efficiency, 
telehealth and other remote care expansion, and cybersecurity.  
37  A certain portion of the funds appropriated under HIPAA are, by law, set aside for the Medicare 
and Medicaid activities of HHS-OIG.  In FY 2022, the Secretary and the Attorney General 
jointly allotted $214.6 million to HHS-OIG.  HHS-OIG was allocated an additional $13.9 million 
in HCFAC mandatory funds from the Secretary.  Additionally, Congress appropriated 
$102.1 million in discretionary funding for HHS-OIG HCFAC activities. 
Emergency Preparedness, Response, and Recovery 
OIG has repeatedly identified strengthening emergency preparedness and response capabilities as 
a top management challenge for HHS.  During the COVID-19 pandemic, OIG acted swiftly to 
protect people from harm and to protect the millions of dollars flowing to or through HHS 
programssuch as the Provider Relief Fund and the Uninsured Fundby preventing, detecting, 
and combating fraud.  It will be critical to understand the efficacy of pandemic response efforts 
over time and the lessons learned for responding to future pandemics and broader emergency 
preparedness.  HHS-OIG is using risk assessment and data analytics to identify, monitor, and 
target potential fraud, waste, and abuse affecting HHS programs and beneficiaries and to 
promote the effectiveness of HHSs emergency response and recovery programs, including 
Medicare and Medicaid programs and beneficiaries.  Oversight efforts include close coordination 
with key government partners, including the Pandemic Response Accountability Committee. 
Additional information about the HHS-OIG COVID-19 Response Strategic Plan, fraud alert, and 
work related to COVID-19 is available online on the COVID-19 Portal.  
HHS-OIG Priority Outcomes 
HHS-OIG identifies priority outcomes to achieve the greatest impact across HHSs many 
programs.  The priority outcomes are selected based on findings from past and ongoing 
HHS-OIG work, top challenges facing HHS as identified annually by HHS-OIG, availability of 
data, and the ability to influence outcomes.  For each priority outcome, HHS-OIG develops 
strategies, drives action, unleashes organizational creativity, and measures impact to provide 
solutions and improve outcomes for HHS programs and the people they serve.    
38  Results 
HHS-OIG delivers financial savings to taxpayers while protecting the health and welfare of 
beneficiaries and safeguarding programs from mismanagement and fraud.  
In FY 2022, HHS-OIG investigations resulted in 661 criminal actions against individuals or 
entities that engaged in crimes related to Medicare and Medicaid, as well as 726 civil actions that 
included false claims and unjust-enrichment lawsuits filed in Federal district court, CMP 
settlements, and administrative recoveries related to provider self-disclosure matters.  In 
addition, during FY 2022 HHS-OIG excluded a total of 2,332 individuals and entities, the details 
of which appear below. 
HHS-OIGs investigations, audits, and evaluations frequently reveal vulnerabilities, misspent 
funds, or incentives for questionable or fraudulent practices in agency programs or 
administrative processes.  HHS-OIG makes recommendations to agency managers to address 
these vulnerabilities as required by the Inspector General Act.  In turn, agency managers may 
recommend legislative proposals or other corrective actions that, when enacted or implemented, 
close loopholes and reduce improper payments or conduct.  The savings from these efforts can 
be substantial.  For FY 2022, potential savings from legislative and administrative actions that 
were supported by HHS-OIG recommendations were estimated by third parties, such as the 
Congressional Budget Office or actuaries within HHS, to be $2.9 billionof which $ 2.4 billion 
was in Medicare savings and $514.0 million was in savings to the Federal share of Medicaid.  
HHS-OIGs expected recoveries from its involvement in health care audits and investigations 
totaled more than $3.9 billion, which resulted in an ROI of about $11.00 to $1.00 15 
Additional information about savings achieved through such policy and procedural changes may 
be found in the HHS-OIG fall Semiannual Report to Congress that appears online at 
https://oig.hhs.gov.  
Enforcement 
HHS-OIG works with its law enforcement partners to conduct criminal and civil investigations 
involving the Medicare and Medicaid programs and participates in settlements of False Claims 
Act cases, including settlements reached through negotiations of Corporate Integrity Agreements 
(CIAs).  HHS-OIG works with MFCUs to address fraud and abuse in the Medicaid program.  In 
addition to investigating criminal and civil matters, HHS-OIG imposes CMPs for a variety of 
health care-related offenses. 
15This ROI uses a three-year average of expected recoveries, fines, penalties, and stolen and misspent funds relating 
to HHS-OIGs health care oversight that is compared to HHS-OIGs annual obligations. This ROI differs from the 
HCFAC ROI, which uses actual dollars returned to the Government. HHS-OIG expects the ROI to fluctuate over 
time due to factors including the types and sizes of settlements and identified disallowances, complexity of schemes 
that are subject to HHS-OIG scrutiny in a given year, and heightened focus on high-value but low-dollar work 
addressing patient safety and quality of care. 
39  Strike Force Operations 
In FY 2022, HHS-OIG continued to staff and support Strike Force operations working in 
conjunction with the DOJ Criminal Divisions Fraud Section, local USAOs, the FBI, and State 
and local law enforcement agencies.  HHS-OIG has assigned agents to Strike Forces in Miami 
and Tampa, 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 and Philadelphia, Pennsylvania; along with the NRRSF in Washington, D.C.  HHS-
OIG supports Strike Force operations by providing investigative, analytic, and forensic 
resources.  
In addition to fighting other fraudulent conduct, the Strike Forces have effectively investigated 
and prosecuted individuals and entities that do not provide legitimate health care services but 
exist solely for the purpose of defrauding Medicare and other Government health care programs.  
For example, in July 2022, a nationwide enforcement action resulted in criminal charges against 
36 defendants in 13 Federal districts across the United States for more than $1.2 billion in 
alleged fraudulent telemedicine, cardiovascular and cancer genetic testing, and DME schemes.  
HHS-OIG works alongside Strike Force partners to disrupt fraud schemes that use the guise of 
telehealth to expand the reach of kickback schemes designed to cheat Federally funded health 
care programs.  The continued support of Strike Force operations is a top priority for HHS-OIG. 
Combating the Opioid Epidemic 
Fighting the opioid crisis and protecting beneficiaries from prescription drug abuse are among 
HHS-OIGs top priorities.  Opioid-related matters comprise a substantial portion of HHS-OIGs 
investigations.  In addition to the opioid-related nationwide enforcement actions, in FY 2022 
HHS-OIG excluded 446 providers based on conduct related to opioid diversion and abuse. 
Program Exclusions 
One important mechanism that HHS-OIG uses to safeguard program beneficiaries and help 
ensure the quality of care provided to them is excluding providers and suppliers who have 
engaged in crimes related to Medicare or Medicaid, patient abuse or neglect, financial 
misconduct, or controlled substances, or who have had their licenses to provide health care 
revoked. This list of conduct is not exhaustive but identifies the most prevalent cases underlying 
HHS-OIGs exclusions of individuals or entities.  The effect of an HHS-OIG exclusion is that no 
Federal health care program payment may be made for any items or services furnished:  (1) by 
an excluded person or (2) at the medical direction or on the prescription of an excluded 
person. HHS-OIG completed the deployment of a new service for MFCUs to report convictions 
through a central, web-based portal for exclusion.  HHS-OIG is also responsible for reinstating 
providers who apply and have met the requirements of their exclusions. 
In FY 2022, HHS-OIG excluded a total of 2,332 individuals and entities.  In addition to those 
mentioned in the Enforcement Actions section above, exclusion actions by HHS-OIG included: 
  Louisiana: On February 20, 2022, HHS-OIG excluded seven nursing homes in the State 
of Louisiana for an indefinite period of time based on the States actions to revoke their 
40  licenses to operate as nursing homes.  Based on those exclusion actions, HHS-OIG 
excluded the owner of the nursing homes on May 22, 2022, under its authority to exclude 
owners of sanctioned entities.  As background, the nursing homes lost their operating 
licenses following a series of documented violations identified in the aftermath of 
Hurricane Ida.  Specifically, the nursing homes evacuated more than 800 residents of the 
facilities to a single warehouse where state inspectors observed residents living in 
inhumane conditions (e.g., residents were sleeping on mattresses near standing water, 
some were undressed or naked, and others were calling for help but had been left alone 
with full diapers).  During these onsite visits, the owner attempted to threaten, intimidate 
and interfere with the assessment of the site, where seven residents eventually died. 
  Texas:  On February 20, 2022, HHS-OIG excluded a medical doctor who owned and 
operated several clinics in Texas for a minimum period of 35 years based on convictions 
related to operating a pill mill scheme that dispensed and distributed controlled 
substances for nine years.  The court sentenced this physician to 240 months of 
incarceration, and the Texas Medical Board revoked his license to practice. 
  Virginia:  On March 30, 2022, HHS-OIG excluded a nurse for a minimum period of 25 
years based on his conviction for sexual assaults of a 72-year-old bedridden patient over 
several months.  The court sentenced this individual to serve eight years of incarceration, 
and the Virginia Department of Health Professions suspended this individuals license to 
practice.  
  Mississippi:  On April 20, 2022, HHS-OIG excluded a private business owner for a 
minimum period of 80 years based on a health care fraud conviction for defrauding 
TRICARE by causing fraudulent claims for compound medications to be submitted for 
high-dollar reimbursements without regard for patient need.  The court sentenced this 
individual to 156 months of incarceration and ordered payment of approximately 
$184,407,600 in restitution. 
  North Carolina:  On May 19, 2022, HHS-OIG excluded the owner and operator of a 
billing agency for a minimum period of 30 years based on a conviction for health care 
fraud conspiracy.  Specifically, the individual engaged in a scheme to defraud Medicaid 
by submitting claims that were false and fraudulent.  The court ordered payment of 
approximately $6,121,600 in restitution, and the individual was sentenced to 84 months 
of incarceration.     
  Georgia:  On May 19, 2022, a dietary supplements company and its owner were 
excluded for a minimum period of three years based on their convictions for introducing 
a misbranded drug into interstate commerce in violation of the Federal Food, Drug, and 
Cosmetic Act.  Specifically, the individual and company pleaded guilty to selling and 
distributing a Vitamin D product with false and misleading marketing claims, namely 
that it would lower consumer risk of contracting COVID-19. 
41    Washington:  On July 20, 2022, a medical doctor in Seattle was excluded for a minimum 
period of 18 years based on a conviction by jury on multiple counts of wire fraud, bank 
fraud, and money laundering.  Specifically, the physician submitted false and misleading 
loan applications as part of a fraud scheme to obtain funding from the Paycheck 
Protection Program and EIDL Program, which were authorized by the CARES Act to 
offset economic hardships caused by the COVID-19 pandemic.  In addition, the court 
ordered payment of $1,438,000 in restitution and sentenced the doctor to 48 months of 
incarceration.  The Washington Department of Health Medical Commission also 
suspended the doctors license to practice. 
  Texas:  On August 18, 2022, HHS-OIG excluded a medical doctor for a minimum period 
of 25 years based on convictions for conspiracy to distribute a controlled substance and 
commit mail fraud.  In addition to illegally dispensing controlled substances (e.g., 
hydrocodone), this physician conspired with others to unlawfully enrich themselves by 
submitting fraudulent claims to workers compensation programs as well as other health 
insurers for medical services that were not rendered.  The court ordered the medical 
doctor to pay approximately $376,300 in restitution and serve 144 months of 
incarceration. 
  Maine:  On September 20, 2022, HHS-OIG excluded a physicians assistant for a 
minimum period of 23 years based on a conviction of unlawful sexual contact with a 
minor patient.  The court also sentenced the physicians assistant to seven years of 
incarceration, and the Maine State Board of Medical Licensure revoked the physicians 
license. 
Civil Monetary Penalties Law 
HHS-OIG has the authority to seek CMPs, assessments, and exclusions under the Civil Monetary 
Penalties Law (CMPL) against an individual or entity based on a wide variety of prohibited 
conduct.  HHS-OIG brings CMP cases to emphasize HHS-OIG guidance, enhance HHS-OIG 
work such as audits and evaluations, fill enforcement gaps, and level the playing field for 
compliant providers.  HHS-OIG uses its CMP authorities in three common ways:  (1) false 
claims and kickback affirmative enforcement, (2) Emergency Medical Treatment and Labor Act 
(EMTALA) enforcement, and (3) the Self-Disclosure Protocol.  In FY 2022, HHS-OIG 
concluded cases involving more than $65.1 million in CMPs and assessments. 
Affirmative Litigation and Exclusion 
HHS-OIG may seek a CMP or exclusion against an individual or entity that presents claims to 
Federal health care programs that the individual or entity knows or should know are for items or 
services that were not provided as claimed or were false or fraudulent.  HHS-OIG may also seek 
a CMP or exclusion against an individual or entity that knowingly and willfully violates the AKS 
by:  (1) offering or paying remuneration, directly or indirectly, to induce referrals of Federal 
health care program business; or (2) soliciting and receiving remuneration, directly or indirectly, 
in return for referrals of Federal health care program business.  In FY 2022, HHS-OIG recovered 
more than $15.2 million in false claims and kickback affirmative enforcement actions.  HHS-
42  OIG also excluded 45 individuals and entities from participation in Federal health care programs 
based on allegations of false claims and kickbacks.  Affirmative litigation examples include: 
  In July 2022, a physician and the physicians practice entered into a $409,809 settlement 
agreement with HHS-OIG.  The settlement agreement resolved allegations that the 
physician and practice submitted claims to Medicare for facet joint injections and 
denervations that exceeded the allowable number of sessions in a rolling 12-month 
period. 
  In July 2022, an ambulance company entered into a $1,578,412 settlement agreement 
with HHS-OIG.  The settlement agreement resolved allegations that the company 
presented claims to Medicare Part B for ambulance transportation to and from skilled 
nursing facilities (SNFs) where such transportation was already covered by the SNF 
consolidated billing payment under Medicare Part A. 
Patient Dumping 
HHS-OIG may also seek a CMP against any hospital that negligently violates its obligations 
under EMTALA, known as the patient dumping statute, which requires a hospital to stabilize 
and treat, or appropriately transfer if the hospital lacks the specialized capabilities necessary to 
stabilize the person, anyone who presents to an emergency department with an emergency 
medical condition.  In FY 2022, HHS-OIG recovered more than $1.4 million in cases under the 
EMTALA statute.  A patient dumping example follows: 
  In December 2021, HHS-OIG entered into a settlement agreement for $725,000 with a 
741-bed acute care hospital.  HHS-OIG identified 29 incidents in which the hospital 
violated EMTALA.  In each of these incidents, a patient presented to the hospitals 
Emergency Department (ED) with an unstable psychiatric emergency medical condition. 
In each incident, the hospital failed to providewith the staff and facilities available at 
the hospitalfurther medical examination and treatment required to stabilize the 
patients emergency medical condition.  In two of these incidents, rather than admitting 
the patient to the hospitals inpatient psychiatric unit, which had the capability and 
capacity to treat the patient, the hospital discharged the patient home with an unstable 
emergency medical condition.  For other presentments the hospital, rather than admitting 
the patient to the inpatient psychiatric unit, held the patient inappropriately in its ED for 
more than 24 hours before transferring the patient to other surrounding facilities.  The 
decision to transfer the patient, and where to transfer the patient, was made by the 
hospital and was based, in part, on the patients insurance status. 
Self-Disclosure Protocol 
HHS-OIG maintains the Self-Disclosure Protocol (the Protocol) whereby providers may 
voluntarily identify, disclose, and resolve instances of potential fraud involving Federal health 
care programs for resolution under the CMPL.  The Protocol incentivizes persons to detect and 
prevent fraud internally and to bring potential fraud to HHS-OIGs attention.  Under the 
Protocol, HHS-OIG provides these persons with speedy resolutions, reduced CMPs, and other 
benefits compared to affirmative cases brought by HHS-OIG or DOJ for similar conduct.  HHS-
43  OIG collected $46.0 million under the Protocol in FY 2022.  Self-disclosure examples include: 
  In May 2022, an Illinois hospital network self-disclosed conduct to HHS-OIG and paid 
$6,232,195.50 for allegedly violating the Civil Monetary Penalties Law.  HHS-OIG 
alleged that the hospital network knowingly submitted claims to Medicare Part A for 
inpatient psychiatric admissions that were not medically necessary. 
  In May 2022, a Maryland based anesthesia medical group self-disclosed conduct to HHS-
OIG and paid $1,117,684.50 for allegedly violating the Civil Monetary Penalties Law. 
HHS-OIG alleged that the group knowingly submitted claims to Federal health care 
programs for services provided by certified registered nurse anesthetists (CRNAs) who 
were not authorized to bill for their services on behalf of the group.  Therefore, the group 
billed for these services under the name of another CRNA who was authorized to bill on 
behalf of the group. 
  In February 2022, a Florida hospital self-disclosed conduct to HHS-OIG and paid 
$12,721,885.58 for knowingly submitting claims to the Medicare, Medicaid, and 
TRICARE programs for professional and technical fees for certain pain management 
procedures and evaluation and management services performed by two independent 
contractor-physicians at the hospitals facilities that did not meet Federal health care 
program coverage criteria.  The specific procedures that were improperly billed by the 
hospital include epidurals, paravertebral facet joint blocks, implantable infusion pumps 
for treatment of intractable pain, sacroiliac joint injections, injection of trigger points, 
destruction of paravertebral facet joint nerves, and radiology services. 
Corporate Integrity Agreements (CIAs) and Enforcement 
Many health care providers elect to settle their cases before litigation.  HHS-OIG provides 
information on its website that identifies how it evaluates future risk to Federal health care 
programs from providers who settle health care fraud cases (called the Fraud Risk Indicator).   
As part of the settlements, providers often agree to enter into CIAs with HHS-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 Federal health care program rules.  The 
compliance programs are designed, in part, to prevent future fraud.  HHS-OIG monitors 
providers compliance with these agreements.  Parties to CIAs are required to disclose certain 
reportable events which may implicate HHS-OIGs CMP authorities.  HHS-OIG may impose 
penalties on entities that fail to comply with the requirements of their CIAs.  HHS-OIG collected 
more than $2.4 million through reportable events under CIAs in FY 2022.  Examples include: 
  In June 2022, after it disclosed conduct to HHS-OIG pursuant to its CIA, a Michigan 
hospital agreed to pay $1,732,548 for allegedly violating the CMP by paying kickbacks. 
HHS-OIG alleged that the hospital:  (1) paid remuneration to cardiologists in the form of 
excess compensation, and (2) paid remuneration to a medical practice in the form of free 
use of medical equipment and personnel. 
44    In December 2021, a large, nationwide pharmacy chain under a CIA agreed to pay 
$512,923 to resolve allegations that it reported under its CIA.  The pharmacy reported 
that it paid improper remuneration to induce referrals in violation of the AKS and the 
Physician Self-Referral Law.  From 2013 to 2019, the pharmacy paid remuneration in the 
form of discounts on retail product purchases at its locations in Puerto Rico to 1,719 
health care professionals who wrote prescriptions for items that were paid for by a 
Federal health care program. 
Audits and Evaluations 
HHS-OIG promotes the economy, effectiveness, and efficiency of HHS programs through audits 
and evaluations.  HHS-OIG uses a dynamic, data-driven work planning process and makes 
adjustments throughout any one year to meet evolving priorities and to anticipate and respond to 
emerging issues with the resources available.  HHS-OIGs work is informed by mandatory 
requirements set forth in laws, regulations, or other directives; requests made or concerns raised 
by Congress, HHS management, or the Office of Management and Budget; or alignments with 
strategic goals, etc.  With respect to Medicare and Medicaid, HHS-OIG uses a risk assessment 
approach to focus oversight on protecting programs and patients from fraud and ensuring sound 
program management, payment accuracy, patient safety, and quality of care. 
In FY 2022, HHS-OIG issued 114 audit reports and 43 evaluations, resulting in 445 new 
recommendations issued to HHS operating divisions, HHS grantees, and other entities.  During 
this same time period, 431 HHS-OIG recommendations were implemented.   
Select examples of HHS-OIGs audit and evaluation findings in FY 2022 are listed below and 
organized by reports that:  (1) minimize risks to beneficiaries, and (2) safeguard programs from 
improper payments and fraud. 
Minimize Risks to Beneficiaries 
Adverse Events in Hospitals:  A Quarter of Medicare Patients Experienced Harm in October 
2018. One in four Medicare patients experienced patient harm events during their hospital stays 
in October 2018.  Patient harm events indicate that a patients care resulted in an undesirable 
clinical outcome not caused by underlying disease.  Forty-three percent of these harm events 
could have been prevented.  Our findings can help the CMS and the Agency for Health care 
Research and Quality (AHRQ) track and reduce patient harm in hospitals and improve patient 
safety.  CMS and AHRQ concurred with some but not all of our seven recommendations.  We 
recommended that CMS:  (1) update and broaden its hospital-acquired condition lists to capture 
common, preventable, and high-cost harm events;  (2) explore expanding the use of patient 
safety metrics in pilots and demonstrations for health care payment and service delivery as 
appropriate; and (3) as the HHS-OIG previously recommended, develop and release interpretive 
guidance to surveyors for assessing hospital compliance with requirements to track and monitor 
patient harm.  In addition, this report included four recommendations to AHRQ:  (1) with 
support from HHS leadership, reassess patient safety efforts across the Department by ensuring 
that agencies update quality strategic plans, identify weaknesses, and address gaps in these 
efforts; (2) complete development and deployment of its new surveillance system to effectively 
45  track and monitor patient harm events; (3) develop an effective model to disseminate information 
on national clinical practice guidelines or best practices to improve patient safety; and (4) 
continue efforts to identify and develop new strategies to prevent common patient harm events in 
hospitals.  (OEI-06-18-00400) 
Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise 
Concerns About Beneficiary Access to Medically Necessary Care.  Medicare Advantage 
Organizations (MAOs) sometimes denied prior authorization and payment requests that met 
Medicare coverage rules; we found that 13 percent of prior authorization requests that MAOs 
denied, and 18 percent of payment requests that MAOs denied, met Medicare coverage rules 
and/or MAO billing rules.  When MAOs deny requests for Medicare-covered services, they may 
prevent or delay beneficiaries from accessing needed care and create administrative burden for 
both beneficiaries and providers.  CMS concurred with our recommendations to:  (1) issue new 
guidance on the appropriate use of MAO clinical criteria in medical necessity reviews; (2) update 
its audit protocols to address the issues identified in this report, such as MAO use of clinical 
criteria and/or examining particular service types; and (3) direct MAOs to take additional steps to 
identify and address vulnerabilities that can lead to manual review errors and system errors.  
(OEI-09-18-00260) 
Most Medicare Beneficiaries Received Telehealth Services Only From Providers With Whom 
They Had an Established Relationship.  From March 2020 through December 2020, most 
beneficiaries received telehealth services from providers with whom they had an established 
relationship.  These beneficiaries tended to see their providers in person about four months prior 
to their first telehealth service, on average.  Beneficiaries enrolled in traditional Medicare were 
more likely to receive services from providers with whom they had an established relationship, 
compared to beneficiaries in Medicare Advantage.  This data snapshot provides information to 
policymakers and other stakeholders about the relationship between beneficiaries and providers 
of telehealth services.  These data are critical to informing decisions about how to structure 
telehealth services in Medicare on a more permanent basis.  (OEI-02-20-00521) 
More Than One-Third of Medicaid-Enrolled Children in Five States Did Not Receive Required 
Blood Lead Screening Tests.  In 5 States, we found that more than 380,000 Medicaid-enrolled 
children did not receive a blood lead screening test at 12 months or 24 months of age, as required 
by Medicaids schedule.  Prevention is key to avoiding the permanent developmental effects of 
lead exposure in children.  Scheduled blood lead screening tests can help support early detection 
of elevated lead levels, timely follow-up, and improved outcomes.  CMS concurred with all of 
our recommendations, which were:  (1) monitor national Early and Periodic Screening, 
Diagnostic, and Treatment program performance data for blood lead screening tests and target 
efforts toward low-performing states to develop action plans for increasing the provision of 
blood lead screening tests, according to Medicaids schedule; (2) ensure consistency across CMS 
guidance related to actionable blood lead reference values (i.e., the blood lead level at which 
public health actions should be initiated) and blood lead screening test definitions; and (3) 
coordinate with partners to develop and disseminate to state Medicaid agencies educational 
resources that reaffirm requirements and schedules for blood lead screening tests.  (OEI-07-18-
00371) 
46  Many Medicare Beneficiaries Are Not Receiving Medication to Treat Their Opioid Use 
Disorder. About 1 million Medicare beneficiaries were diagnosed with opioid use disorder in 
2020, yet less than 16 percent of these beneficiaries received medication to treat their opioid use 
disorder and even fewer received both medication and behavioral therapy.  These findings show 
a need to increase the number of Medicare beneficiaries receiving treatment for opioid use 
disorder.  CMS concurred with the following recommendations:  (1) conduct additional outreach 
to beneficiaries to increase awareness about Medicare coverage for the treatment of opioid use 
disorder, (2) take steps to increase the number of providers and opioid treatment programs for 
Medicare beneficiaries with opioid use disorder, (3) create an action plan and take steps to 
address disparities in the treatment of opioid use disorder, and (4) collect data on the use of 
telehealth in opioid treatment programs.  CMS did not explicitly indicate whether it concurred or 
nonconcurred with two recommendations:  (1) assist the Substance Abuse and Mental Health 
Services Administration by providing data about the number of Medicare beneficiaries receiving 
buprenorphine in office-based settings and the geographic areas where Medicare beneficiaries 
remain underserved, and (2) take steps to increase the utilization of behavioral therapy among 
beneficiaries receiving medication to treat opioid use disorder.  (OEI-02-20-00390) 
Certain Medicare Beneficiaries, Such as Urban and Hispanic Beneficiaries, Were More Likely 
Than Others to Use Telehealth During the First Year of the COVID-19 Pandemic.  Beneficiaries 
in urban areas were more likely than those in rural areas to use telehealth during the first year of 
the pandemic.  Beneficiaries in Massachusetts, Delaware, and California were more likely than 
beneficiaries in some other states to use telehealth.  Dually eligible beneficiaries (i.e., those 
eligible for both Medicare and Medicaid), Hispanic beneficiaries, younger beneficiaries, and 
female beneficiaries were also more likely than others to use telehealth.  In addition, 
beneficiaries almost always used telehealth from home or other non-health-care settings. 
Furthermore, almost one-fifth of beneficiaries used certain audio-only telehealth services, with 
the vast majority of these beneficiaries using these audio-only services exclusively.  Older 
beneficiaries were more likely to use these audio-only services, as were dually eligible and 
Hispanic beneficiaries.  As CMS, HHS, Congress, and other stakeholders consider permanent 
changes to Medicare telehealth services, it is important that they balance concerns about issues 
such as access, quality of care, health equity, and program integrity.  CMS did not explicitly 
indicate whether it concurred with our four recommendations.  Our recommendations were for 
CMS to: (1) take appropriate steps to enable a successful transition from current pandemic-
related flexibilities to well-considered long-term policies for the use of telehealth for 
beneficiaries in urban areas and from the beneficiarys home; (2) temporarily extend the use of 
audio-only telehealth services and evaluate their impact; (3) require a modifier to identify all 
audio-only telehealth services provided in Medicare; and (4) use telehealth to advance health 
care equity.  (OEI-02-20-00522) 
Opioid Overdoses and the Limited Treatment of Opioid Use Disorder Continue To Be Concerns 
for Medicare Beneficiaries.  About 50,400 Medicare Part D beneficiaries experienced an opioid 
overdose in 2021.  Also, almost a quarter of Part D beneficiaries received opioids during 
2021. In addition, more than 1 million Medicare beneficiaries had a diagnosis of opioid use 
disorder in 2021, yet fewer than one in five received medication to treat their opioid use 
47  disorder. At the same time, the number of beneficiaries receiving prescriptions for naloxonea 
drug that reverses opioid overdosesthrough Part D grew.  Monitoring opioid use and access to 
medications for the treatment of opioid use disorder as well as to naloxone are critical to 
addressing the opioid crisis.  A December 2021 HHS-OIG report recommended that the CMS 
take steps to improve access to medications for the treatment of opioid use disorder and other 
support services.  We continue to call attention to the importance of implementing these 
recommendations and to ensuring access to treatment for opioid use disorder.  (OEI-02-22-
00390) 
Six of Eight Home Health Agency Providers Had Infection Control Policies and Procedures That 
Complied With CMS Requirements and Followed CMS COVID-19 Guidance To Safeguard 
Medicare Beneficiaries, Caregivers, and Staff During the COVID-19 Pandemic.  Six of the eight 
selected Home Health Agency (HHA) providers had infection control policies and procedures 
that complied with CMS requirements and followed CMS guidance to safeguard HHA staff, 
Medicare beneficiaries, and caregivers during the COVID-19 pandemic.  However, one HHA 
provider did not comply with CMS requirements or follow CMS COVID-19 guidance.  
Specifically, this HHA providers infection control policies and procedures did not:  (1) require 
staff to follow one of the standard precautions to prevent the transmission of infections and 
communicable diseases, (2) include documentation of surveillance methods used for identifying 
and tracking infections and improvement activities to prevent infection, (3) include COVID-19 
screening protocols for staff in accordance with CMS guidance, and (4) include information 
about how to care for patients with known or suspected COVID-19 in accordance with CMS 
guidance.  In addition, this provider and another HHA provider's COVID-19 screening protocols 
for patients were not consistent with CMS guidance.  As a result, the patients and staff at these 
two HHA providers were at an increased risk of infection.  (A-01-20-00508) 
Inaccuracies in Medicares Race and Ethnicity Data Hinder the Ability to Assess Health 
Disparities.  We found that Medicares enrollment race and ethnicity data are less accurate for 
some groups, particularly for beneficiaries identified as American Indian/Alaska Native, 
Asian/Pacific Islander, and Hispanic.  Data that are not accurate limit the ability to assess health 
disparities.  Limited race and ethnicity categories and missing information contribute to 
inaccuracies in the enrollment data.  Although the use of an algorithm improves the existing data 
to some extent, it falls short of self-reported data.  Finally, Medicares enrollment data on race 
and ethnicity, primarily sourced from the Social Security Administration (as the entity 
responsible for enrolling Medicare-eligible individuals into Medicare), are inconsistent with 
Federal data collection standards, which inhibits the work of identifying and improving health 
disparities within the Medicare population.  Advancing health equity is a priority for CMS and 
the Department.  Race and ethnicity data are foundational to identifying and understanding 
health disparities among Medicare beneficiaries and to assessing the effectiveness of efforts to 
reduce such disparities.  It is critical that these data are accurate, complete, and comprehensive.  
Therefore, CMS must improve the accuracy of its race and ethnicity data collection;  though a 
significant undertaking, the need for better data is pressing.  Accordingly, we recommend that 
CMS: (1) develop its own source of race and ethnicity data, (2) use self-reported race and 
ethnicity information to improve data for current beneficiaries, (3) develop a process to ensure 
that the data are as standardized as possible, and 4) educate beneficiaries about CMSs efforts to 
48  improve the race and ethnicity information.  CMS did not explicitly concur with the first 
recommendation and concurred with the other three recommendations.  (OEI-02-21-00100) 
Audits of Nursing Home Life Safety and Emergency Preparedness in Eight States Identified 
Noncompliance With Federal Requirements and Opportunities for the Centers for Medicare & 
Medicaid Services to Improve Resident, Visitor, and Staff Safety.  We identified a total of 2,233 
areas of noncompliance with life safety and emergency preparedness requirements at 150 of the 
154 nursing homes we visited.  Specifically, we identified 1,094 areas of noncompliance with 
life safety requirements and 1,139 areas of noncompliance with emergency preparedness 
requirements.  These deficiencies occurred because of several factors, including inadequate 
oversight by management, staff turnover, inadequate oversight by state survey agencies, and a 
lack of any requirement for mandatory participation in standardized life safety training programs. 
As a result, residents, visitors, and staff at the nursing homes were at increased risk of injury or 
death during a fire or other emergency.  CMS subsequently followed up with state survey 
agencies to determine whether they had addressed the recommendations included in our prior 
audits and, according to CMS, the States had already taken acceptable actions to address our 
recommendations.  We identified several opportunities for CMS to expand on its life safety 
requirements for nursing homes to improve the safety of residents, visitors, and staff.  Among 
other findings, CMS could propose regulations requiring nursing homes to install carbon 
monoxide detectors according to national standards.  We also noted areas in which CMS could 
improve its support for state survey operations and nursing home training.  CMS could work 
with state survey agencies to address issues preventing more frequent surveys of high-risk 
facilities and require mandatory participation in standardized nursing home staff training.  (A-02-
21-01010) 
An Estimated 91 Percent of Nursing Home Staff Nationwide Received the Required COVID-19 
Vaccine Doses, and an Estimated 56 Percent of Staff Nationwide Received a Booster Dose.  As 
of the week ended March 27, 2022, we determined for the 1,000 nursing home staff members in 
our sample that 884 had received the required vaccine doses (506 of these staff members had 
also received a booster dose); 78 had been granted an exemption from receiving the vaccine 
based on a sincerely held religious belief, practice, or observance (religious exemption); 12 were 
partially vaccinated; 3 had been granted an exemption from receiving the vaccine based on a 
medical condition (medical exemption); and 3 had applied for an exemption that was being 
reviewed by a nursing home.  For the remaining 20 staff members in our sample, the nursing 
homes did not provide us with documentation related to the staff members vaccination status, or 
the documentation provided did not clearly identify the staff members vaccination status.  As a 
result, we were not able to determine the vaccination status of these staff members.  On the basis 
of our sample results, we estimated that 91 percent of staff nationwide had received the required 
vaccine doses, 56 percent of staff nationwide had received a booster dose, and 6 percent of staff 
nationwide had been granted a religious exemption.  We did not estimate the percentages among 
the small number of staff members (i.e., 38) in our nationwide sample results who were partially 
vaccinated, who were granted a medical exemption, who applied for an exemption that was 
being reviewed, or for whom the vaccination status could not be determined.  In addition, the 
estimated percentages of staff who received the required vaccine doses, staff who received a 
booster dose, and staff who were granted a religious exemption varied depending on the location 
49  (i.e., the HHS region) of the nursing homes in which they worked.  (A-09-22-02003) 
Arkansas Did Not Fully Comply With Federal and State Requirements for Reporting and 
Monitoring Critical Incidents Involving Medicaid Beneficiaries With Developmental Disabilities. 
Arkansas did not fully comply with Federal Medicaid waiver and State requirements for 
reporting and monitoring critical incidents involving Medicaid beneficiaries with developmental 
disabilities who resided in community-based settings.  Specifically, Arkansas did not:  (1) ensure 
that community-based providers properly reported all incidents of suspected adult or child abuse 
to the appropriate hotline, (2) provide evidence of review and follow-up action on all incidents of 
adult or child abuse, and (3) review all deaths of beneficiaries receiving waiver services.  These 
issues occurred because Arkansas did not have controls in place to ensure that incidents of abuse, 
neglect, or death were reviewed and reported to the appropriate authority.  Additionally, 
Arkansas did not ensure that all incidents involving Medicaid beneficiaries, including incidents 
of death, were reported because its waiver did not clearly require that incidents that occurred 
outside of State custody or State facilities be reported.  Also, Arkansas did not have adequate 
internal controls in place to detect unreported incidents.  (A-06-17-01003) 
Massachusetts Implemented Our Prior Audit Recommendations and Generally Complied With 
Federal and State Requirements for Reporting and Monitoring Critical Incidents.  Massachusetts 
implemented the five recommendations from our prior audit and generally complied with Federal 
and state requirements for reporting and monitoring critical incidents involving Medicaid 
beneficiaries with developmental disabilities residing in group homes.  However, the corrective 
actions for one recommendation in our prior audit were not effective in addressing one of our 
previous findings.  Specifically, Massachusetts did not ensure all reasonable suspicions of abuse 
or neglect were reported to the Disabled Persons Protection Commission.  One possible reason 
that this issue occurred is because the Massachusetts Department of Developmental Services and 
group home staff were only required to take mandated reporter training on reporting reasonable 
suspicions of abuse and neglect (a corrective action) once rather than periodically.  Because 
Massachusetts did not ensure that all reasonable suspicions of abuse or neglect were reported, it 
did not fulfill all of the participant safeguard assurances it provided to CMS in the Medicaid 
Home and Community-Based Services Intensive Supports waiver along with the State 
requirements incorporated under the waiver.  (A-01-20-00003) 
Certain Nursing Homes May Not Have Complied With Federal Requirements for Infection 
Prevention and Control and Emergency Preparedness.  Selected nursing homes may not have 
complied with Federal requirements for infection prevention and control and emergency 
preparedness.  Specifically, 28 of the 39 nursing homes had possible deficiencies.  We found 48 
instances at 25 nursing homes of possible noncompliance with infection prevention and control 
requirements and 18 instances at 18 nursing homes of possible noncompliance with emergency 
preparedness requirements related to all-hazards risk assessments and strategies to address 
emerging infectious diseases.  The nursing homes attributed the possible noncompliance to:  (1) 
nursing home inadequate internal controls, (2) nursing home inadequate management oversight, 
(3) nursing home administrative and leadership changes, (4) inadequate communication and 
training from the CMS, and (5) inconsistent and confusing regulations.  (A-01-20-00005) 
50  CMS Should Take Further Action To Address States With Poor Performance in Conducting 
Nursing Home Surveys.  Slightly more than half of State survey agencies (states) repeatedly 
failed to meet requirements for conducting nursing home surveys during FYs 2015-2018, yet 
CMS rarely imposed higher-level sanctions in contrast to the more frequently used remedies and 
alternative sanctions, such as training or improvement plans.  Without effective oversight of 
nursing homes by the States, residents may be at increased risk for harm and poor care.  CMS 
concurred with the following recommendations:  (1) actively monitor the use and effectiveness 
of States corrective action plans and other remedies, with a focus on making the remedies 
specific and outcome-oriented; (2) establish guidelines for progressive enforcement actions, 
including the use of sanctions, when persistent or egregious performance problems emerge; 
(3) engage with senior State officials earlier and more frequently to address State performance 
problems; and (4) revise the State Operations Manual to reflect current CMS practices in 
overseeing State survey performance.  CMS did not concur or nonconcur with the remaining 
recommendation to disseminate results of State performance reviews more widely to ensure 
stakeholders become aware of problems.  (OEI-06-19-00460) 
Maine Implemented Our Prior Audit Recommendations and Generally Complied With Federal 
and State Requirements for Reporting and Monitoring Critical Incidents.  Maine implemented 
the seven recommendations from our prior audit and generally complied with Federal and State 
requirements for reporting and monitoring critical incidents involving Medicaid beneficiaries 
with developmental disabilities.  In addition, the corrective actions implemented in response to 
five of the seven recommendations were effective in addressing the related findings.  However, 
Maines corrective actions for two recommendations were not fully implemented by the 
conclusion of our current audit period and, therefore, were only partially effective in addressing 
two of our previous findings.  We concluded that the corrective actions were not fully effective 
in addressing these findings because Maine did not ensure that all follow-up reports were 
completed by community-based providers within 30 days of each incident and that the Mortality 
Review Committee conducted a trend analysis based on completed Mortality Review Form 
aggregate data. As a result, Maine did not fulfill all of the participant safeguard assurances it 
provided to CMS in the Medicaid Home and Community-Based Services Waiver along with the 
state requirements incorporated under the waiver.  (A-01-20-00007) 
Certain Life Care Nursing Homes May Not Have Complied With Federal Requirements for 
Infection Prevention and Control and Emergency Preparedness.  Selected Life Care nursing 
homes may not have complied with Federal requirements for infection prevention and control 
and emergency preparedness.  Specifically, 23 of the 24 nursing homes selected had possible 
deficiencies.  Actual deficiencies can only be determined following a thorough investigation by 
trained surveyors. At 22 nursing homes, we found 35 instances of possible noncompliance with 
infection prevention and control requirements related to annual reviews of the Infection 
Prevention and Control Program, training, designation of a qualified infection preventionist, and 
Quality Assessment and Assurance Committee meetings.  We also found at 16 nursing homes 20 
instances of possible noncompliance with emergency preparedness requirements related to the 
annual review of emergency preparedness plans and annual emergency preparedness risk 
assessments.  Life Care officials attributed the possible noncompliance to:  (1) leadership 
turnover, (2) staff turnover. (3) documentation issues (i.e., information was not documented or 
51  documentation was either lost or misplaced), (4) staff members who were unfamiliar with 
requirements (i.e., requirements stipulating that there is no grace period for infection 
preventionists to complete specialized training and that emergency preparedness plans needed to 
be reviewed annually), (5) qualified personnel shortage, and (6) challenges related to the 
COVID-19 public health emergency.  We also believe that many of the conditions noted in our 
report occurred because CMS did not provide nursing homes with communication and training 
for complying with the new, phase 3 infection control requirements, or clarification about the 
essential components to be integrated in the nursing homes emergency plans.  (A-01-20-00004) 
Selected Dialysis Companies Implemented Additional Infection Control Policies and Procedures 
To Protect Beneficiaries and Employees During the COVID-19 Pandemic.  The nine selected 
dialysis companies surveyed (representing 83 percent of the end-stage renal disease (ESRD) 
facilities that had a Medicare or Medicaid certification at any point during 2020) implemented 
additional infection control policies and procedures in accordance with CMS and CDC 
recommendations to protect high-risk ESRD beneficiaries and employees during the COVID-19 
pandemic.  We found all nine companies had infection control policies and procedures in place 
to protect beneficiaries and employees, and when recommended by CMS and CDC, the 
companies implemented additional policies and procedures.  However, while two companies 
provided education about the importance of hand hygiene, they did not emphasize the 
importance of hand hygiene immediately before and after any contact with a facemask or cloth 
face covering, as recommended by CDC.  (A-05-20-00052) 
End-Stage Renal Disease Network Organizations Reported Actions Taken in Response to the 
COVID-19 Pandemic.  The 18 ESRD Network Organizations that we surveyed provided 
information about the actions they took to aid dialysis clinics and patients and keep CMS 
informed about quality-of-care issues that arose during the COVID-19 pandemic.  Network 
Organizations also reported to us challenges they encountered in taking those actions during the 
pandemic.  Despite the unprecedented challenges faced by the Network Organizations during the 
pandemic, they took actions to ensure continuity of services in a safe manner for high-risk ESRD 
beneficiaries.  Network Organizations served a key role in addressing the additional demands on 
dialysis clinics during the pandemic through actions such as:  (1) disseminating changing 
guidance, (2) aiding dialysis clinics to address the increased concerns and grievances related to 
the pandemic, and (3) promoting safe alternative treatment options.  Network Organizations also 
kept CMS informed of quality-of-care issues by communicating through established 
communication processes and processes modified for better use during the pandemic.  (A-05-20-
00051) 
Safeguard Programs From Improper Payments and Fraud 
Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks. 
We identified 1,714 providers whose billing for telehealth services during the first year of the 
pandemic poses a high risk to Medicare.  Each of these 1,714 providers had concerning billing 
on at least one of seven measures we developed that may indicate fraud, waste, or abuse of 
telehealth services.  In addition, more than half of the high-risk providers we identified are a part 
of a medical practice with at least one other provider whose billing poses a high risk to Medicare.  
Furthermore, 41 providers whose billing poses a high risk appear to be associated with telehealth 
52  companies.  Although these high-risk providers represent a small proportion of all providers who 
billed for a telehealth service, these findings demonstrate the importance of strong, targeted 
oversight of telehealth services.  CMS concurred with our recommendation to follow up on the 
providers identified in this report, but CMS did not explicitly indicate whether it concurred with 
the other four recommendations.  Our recommendations were for CMS to:  (1) strengthen 
monitoring and targeted oversight of telehealth services, (2) provide additional education to 
providers on appropriate billing for telehealth services, (3) improve the transparency of incident-
to-services when clinical staff primarily delivered the telehealth service, (4) identify telehealth 
companies that bill Medicare, and (5) follow up on the providers identified in this report.  (OEI-
02-20-00720) 
Medicare and Beneficiaries Pay More for Preadmission Services at Affiliated Hospitals Than at 
Wholly Owned Settings.  Because the DRG window policy does not cover affiliated hospitals, 
Medicare and beneficiaries paid $168.0 million and $77.0 million, respectively, in 2019 for 
admission-related outpatient services thatif provided at wholly owned hospitalswould not 
have required separate outpatient payments.  (The policy states that if a beneficiary is furnished 
outpatient hospital services and is admitted to the hospital shortly afterward for the same 
condition, the outpatient services are considered part of the admission and are included in the 
pre-set inpatient payment amount, rather than resulting in separate payments for the outpatient 
services).  These findings indicate that Medicare and beneficiaries may be overpaying for these 
services, as affiliated settings are similar to wholly owned settings in key ways.  CMS neither 
concurred nor nonconcurred with our recommendation, which was for it to evaluate the potential 
impacts of updating the DRG window policy to include affiliated hospitals and seek the 
necessary legislative authority to update the policy as appropriate.  (OEI-05-19-00380) 
Facility-Initiated Discharges in Nursing Homes Require Further Attention.  Our findings raise 
concerns about weaknesses in the safeguards to protect nursing home residents from harm that 
may result from inappropriate facility-initiated discharges.  Our findings can help ACL assist 
Ombudsmen with responding to potentially inappropriate facility-initiated discharges.  Our 
findings can also help CMS improve its oversight of inappropriate facility-initiated discharge in 
nursing homes.  CMS concurred with our recommendations to: (1) provide training for nursing 
homes on Federal requirements for facility-initiated discharge notices, (2) assess the 
effectiveness of its enforcement of inappropriate facility-initiated discharges, and (3) implement 
its deferred initiatives to address inappropriate facility-initiated discharges.  ACL concurred with 
our recommendations to:  (1) assist State ombudsman programs in establishing a data-collection 
system for facility-initiated discharge notices, and (2) establish guidance for analysis and 
reporting of data collected by state ombudsman programs from facility-initiated discharge 
notices.  ACL and CMS did not explicitly state whether they concurred with our joint 
recommendation to coordinate to strengthen safeguards to protect nursing home residents from 
inappropriate facility-initiated discharges.  ACL and CMS concurred with our joint 
recommendation to ensure all State ombudsmen, state agencies, and CMS regional offices have 
an ongoing venue to share information about facility-initiated discharges and potentially other 
systemic problems in nursing homes.  (OEI-01-18-00250) 
53  COVID-19 Tests Drove an Increase in Total Medicare Part B Spending on Lab Tests in 2020, 
While Use of Non-COVID-19 Tests Decreased Significantly.  Medicare Part B spent $1.5 billion 
on COVID-19 tests in 2020, while at the same time, spending on non-COVID-19 tests declined 
by $1.2 billion.  The result was a net spending increase of four percent, but the decrease in 
utilization of non-COVID-19 tests raises questions about the potential impact on beneficiary 
health.  Our data brief contained no recommendations.  (OEI-09-21-00240) 
Medicare Part D and Beneficiaries Would Realize Significant Spending Reductions With 
Increased Biosimilar Use.  Biosimilarslower cost, highly similar alternatives to existing 
biologic drugs approved by FDAhave the potential to significantly reduce costs for Medicare 
Part D and beneficiaries if their use becomes more widespread.  Yet biosimilars are used far less 
frequently than their higher cost biologic alternatives, and a lack of biosimilar coverage on Part 
D formularies could limit wider utilization.  Our findings can help CMS and beneficiaries 
capitalize on potential savings associated with the increased use of biosimilars instead of existing 
biologics.  CMS concurred with our first recommendation and neither concurred nor 
nonconcurred with our second recommendation.  Our recommendations were for CMS to 
encourage Part D plans to increase access to and use of biosimilars and monitor Part D plans 
submitted formularies to determine whether they discourage beneficiaries from using 
biosimilars.  (OEI-05-20-00480) 
Part D Plan Preference for Higher-Cost Hepatitis C Drugs Led to Higher Medicare and 
Beneficiary Spending.  Medicare Part D beneficiaries are much less likely than Medicaid 
beneficiaries to receive lower-cost versions of the same drugs (i.e., authorized generics)as well 
as other widely used, lower-cost brand name drugsto treat hepatitis C.  Part Ds programmatic 
structure may lead plan sponsors to prefer higher-cost versions of hepatitis C drugs, which 
resulted in beneficiaries paying thousands more out-of-pocket and nearly double Medicare 
reinsurance in 2020.  Increasing the use of lower-cost hepatitis C drugs could generate 
significant savings for Medicare and its beneficiaries.  CMS concurred with HHS-OIGs 
recommendations that CMS:  (1) encourage Part D plans to increase access to and use of the 
authorized generic versions of Epclusa and Harvoni, within the authorities granted under statute; 
and (2) pursue additional strategiessuch as educating providers and pharmaciesto increase 
access to and use of lower-cost hepatitis C drugs in Part D.  (OEI-BL-21-00200) 
Medicare Part B Drug Payments: Impact of Price Substitutions Based on 2020 Average Sales 
Prices.  Because CMS did not implement all eligible drug price reductions based on 2020 
average sales prices (ASPs) for Part B drugs, savings that should have totaled $2.8 million over 
one year amounted to only $8,158.  (Generally, Part B-covered drugs are those that are injected 
or infused in physicians offices or outpatient settings.) ASPs generally serve as the basis for 
reimbursement for Part B drugs.  CMS has a price-substitution policy under which HHS-OIGs 
comparisons of ASPs with average manufacturer prices (AMPs) candepending on the 
differenceresult in the substitution of a lower calculated rate.  The use of this policy serves as 
a mechanism for monitoring market prices and limiting potentially excessive payment 
amounts.) Although the $8,158 amount is small, Medicare and its beneficiaries have saved 
$73.1 million for Part B-covered drugs since the price-substitution policy went into effect in 
2013. These total savings highlight the impact of HHS-OIGs mandated quarterly ASP-AMP 
54  comparisons and the implementation of CMSs current price-substitution policy. This data 
snapshot contains no recommendations.  However, HHS-OIG continues to support a previous 
recommendation that CMS expand the price-substitution criteria.  (OEI-03-22-00170) 
Reducing Medicares Payment Rates for Intermittent Urinary Catheters Can Save the Program 
and Beneficiaries Millions of Dollars Each Year.  In Medicare Part B, suppliers of intermittent 
urinary catheters received $407.0 million in fiscal year 2020, more than three times the suppliers 
estimated acquisition costs of $121.0 million.  Our findings demonstrate that Medicare and its 
beneficiaries have the opportunity to achieve substantial savings while allowing suppliers 
adequate payments for the items and services they provide.  CMS did not explicitly indicate 
whether it concurred with our recommendation; instead, CMS stated that it will take our 
recommendation under consideration as it determines appropriate next steps.  Our 
recommendation was for CMS to lower Medicares payment rates for intermittent urinary 
catheters. (OEI-04-20-00620) 
CMS Has Opportunities To Strengthen States Oversight of Medicaid Managed Care Plans 
Reporting of Medical Loss Ratios.  States oversight of Medicaid managed care plans annual 
reporting of medical loss ratios (MLRs) is critical to improve fiscal transparency, monitor costs, 
and promote high-quality care in Medicaid managed care.  (The Federal MLR is the percentage 
of premium revenue that a managed care plan spent on covered health care services and quality-
improvement activities in a 12-month period.) Although states reported that most of their plans 
submitted MLR reports, we found that nearly half of plans MLR reports were incomplete.  The 
data element for non-claims costs, generally defined as plans expenses for administrative 
services, accounted for the majority of incomplete MLR reports.  In addition, some states did not 
review selected MLR data elements for accuracy.  We made four recommendations to strengthen 
states oversight of MLR reporting and better ensure that plans are using Federal dollars for 
patient care.  CMS concurred with all four recommendations, which were for it to:  (1) design an 
annual MLR reporting template for states to provide to their Medicaid managed care plans, (2) 
clarify that States should verify the completeness of their plans MLR reports, (3) clarify that 
states should review their plans MLR reports to verify the accuracy of reported data elements, 
and (4) provide additional guidance to states regarding plans reporting of non-claims costs in 
MLR reports.  (OEI-03-20-00231) 
Medicaid Fraud Control Units Fiscal Year 2021 Annual Report.  This annual report provides 
statistics that highlight the accomplishments of the 53 MFCUs during FY 2021.  MFCUs 
reported 1,105 convictions in FY 2021.  Fraud cases accounted for about 70 percent of the 
MFCU convictions, while about 30 percent involved patient abuse or neglect.  Approximately 42 
percent of the 780 MFCU fraud convictions involved personal care services attendants and 
agencies.  MFCUs were responsible for 716 civil settlements and judgments, 36 percent of which 
involved pharmaceutical manufacturers.  MFCUs reported approximately $1.7 billion in criminal 
and civil recoveries.  Although MFCUs reported continuing operational challenges attributable to 
the COVID-19 pandemic, they also mentioned that those challenges had begun to subside.  In an 
appendix to the report, HHS-OIG summarizes beneficial practices identified by HHS-OIG in its 
reviews or inspections that may be useful to other MFCUs.  (OEI-09-22-00020) 
55  Medicare Overpaid $636 Million for Neurostimulator Implantation Surgeries.  More than 
40 percent of the health care providers covered by our audit did not comply with Medicare 
requirements when they billed for neurostimulator implantation surgeries.  On the basis of our 
sample results, we estimated that during calendar years (CYs) 2016 and 2017 providers received 
$636.0 million in unallowable Medicare payments associated with neurostimulator implantation 
surgeries, and beneficiaries paid $54.0 million in related unnecessary copays and deductibles.  
These unallowable payments occurred because providers did not include sufficient 
documentation in the medical records to support that Medicare coverage requirements were met.  
(A-01-18-00500) 
Medicare Improperly Paid Suppliers an Estimated $117 Million Over 4 Years for Durable 
Medical Equipment, Prosthetics, Orthotics, and Supplies Provided to Hospice Beneficiaries.  For 
121 of 200 sampled durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) 
items, Medicare improperly paid suppliers for DMEPOS items they provided to hospice 
beneficiaries.  These items should have been provided directly by the hospices or under 
arrangements between the hospices and the suppliers.  The improper payments occurred because: 
(1) the majority of the suppliers were unaware that they had provided DMEPOS items to hospice 
beneficiaries, (2) the system edit processes that should have prevented the improper payments 
were not effective or did not exist, and (3) the suppliers inappropriately used the GW modifier. 
On the basis of our sample results, we estimated that Medicare could have saved $116.9 million 
in payments during our audit period, and beneficiaries could have saved $29.8 million in 
deductibles and coinsurance that may have been incorrectly collected from them or from 
someone on their behalf.  (A-09-20-03026) 
Medicare Could Have Saved Approximately $993 Million in 2017 and 2018 If It Had 
Implemented an Inpatient Rehabilitation Facility (IRF) Transfer Payment Policy for Early 
Discharges to Home Health Agencies.  Medicare could have saved approximately $993.0 million 
in CYs 2017 and 2018 if CMS had expanded its IRF transfer payment policy to apply to early 
discharges to home health care.  We determined that this payment policy would generally result 
in payments to IRFs that would cover their costs to provide care.  When CMS announced its 
proposed IRF transfer payment policy in 2001, it stated that it would analyze claim data to 
compare billing patterns prior to and after its implementation and refine IRF payments in the 
future, if warranted.  For this audit, CMS officials did not explain why CMS has not expanded 
the IRF transfer payment policy to cover discharges to home health care.  CMS also did not 
analyze claims data to compare billing patterns prior to and after the implementation of the 
prospective payment system  for IRFs in January 2002, which could have provided information 
in support of expanding the IRF transfer payment policy to include early discharges to home 
health care.  (A-01-20-00501) 
Hospitals Did Not Always Meet Differing Medicare Contractor Specifications for Bariatric 
Surgery.  Not all hospitals inpatient claims for bariatric surgeries met Medicare national 
requirements or Medicare contractors eligibility specifications.  Differing eligibility 
specifications for bariatric surgery contributed to differences in the number of claims that did not 
meet the specifications among Medicare contractor jurisdiction groups.  Jurisdiction groups with 
more restrictive specifications had more claims that did not meet the eligibility specifications and 
56  more specifications that were not met.  The Medicare contractors may have issued differing 
eligibility specifications because CMSs national coverage determination requirements were not 
specific.  On the basis of our sample results, we estimated that Medicare could have saved 
$47.8 million during our audit period if Medicare contractors had disallowed claims that did not 
meet Medicare national requirements or Medicare contractor specifications for bariatric surgery.  
(A-09-20-03007) 
Medicare Payments of $6.6 Billion to Nonhospice Providers Over 10 Years for Items and 
Services Provided to Hospice Beneficiaries Suggest the Need for Increased Oversight.  Our 
analysis of trends and patterns in payments for items and services provided to Medicare 
beneficiaries outside the Medicare hospice benefit during a hospice period of care (which we 
refer to as nonhospice payments) demonstrate an increase in Medicare nonhospice payments for 
beneficiaries.  Nonhospice payments for Medicare Part A services and Part B items and services 
totaled $6.6 billion from 2010 through 2019.  If providers bill Medicare for nonhospice items 
and services that potentially should be covered by hospices, Medicare could pay for the same 
items or services twice.  Our prior work on Medicare Part D drugs and DMEPOS provided to 
hospice beneficiaries demonstrated that these duplicate payments are, in fact, occurring.  In three 
prior reports, we made several recommendations to CMS to establish oversight and scrutiny of 
Medicare nonhospice payments.  Implementing the recommendations from those reports and 
considering the information in this data brief may help CMS further evaluate the need to 
potentially restructure the hospice payment system to reduce duplicate payments for items and 
services that should be included in the hospice per diem payment.  The information in this data 
brief may also help CMS determine whether the hospice benefit is operating consistent with its 
longstanding position that services unrelated to a hospice beneficiarys terminal illness and 
related conditions should be exceptional, unusual, and rare given the comprehensive nature of 
the services covered under the Medicare hospice benefit.  (A-09-20-03015) 
CMSs System Edits Significantly Reduced Improper Payments to Acute-Care Hospitals After 
May 2019 for Outpatient Services Provided to Beneficiaries Who Were Inpatients of Other 
Facilities.  Medicare inappropriately paid acute-care hospitals $39.3 million for outpatient 
services they provided to beneficiaries who were inpatients of other facilities (i.e., long-term care 
hospitals, IRFs, inpatient psychiatric facilities, and critical-access hospitals).  None of the $39.3 
million should have been paid because the inpatient facilities were responsible for payment.  
Each type of inpatient facility covered by our audit must:  (1) provide directly all services 
furnished during an inpatient stay, or (2) arrange for services to be provided on an outpatient 
basis by an acute-care hospital and include those outpatient services on its inpatient claims 
submitted to Medicare.  Before May 2019, the system edits were not working properly.  
However, after CMS modified the edits in May 2019, only $3.4 million (less than 9 percent of 
the $39.3 million in improper payments for the entire audit period) was inappropriately paid to 
acute-care hospitals from June 2019 through December 2021.  (A-09-22-03007) 
Medicare Advantage Compliance Audit of Diagnosis Codes That SCAN Health Plan (Contract 
H5425) Submitted to CMS.  HHS-OIG found that SCAN did not submit some diagnosis codes to 
CMS for use in the risk adjustment program in accordance with Federal requirements.  HHS-
OIG identified some diagnosis codes that SCAN submitted to CMS but that were not supported 
57  in the medical records.  HHS-OIG also identified diagnosis codes that were supported in the 
medical records that SCAN should have submitted to CMS but did not.  As a result, we 
estimated that SCAN received at least $54.3 million in net overpayments for 2015.  (A-07-17-
01169) 
Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Cariten Health Plan, 
Inc., (Contract H4461) Submitted to CMS.  HHS-OIG found that Cariten, with respect to nine 
groups of diagnosis codes that were at high risk for being miscoded, did not submit most 
diagnosis codes to CMS for use in the risk adjustment program in accordance with Federal 
requirements.  HHS-OIG identified, for 206 of the sampled 270 enrollee-years, diagnosis codes 
that Cariten submitted to CMS but were not supported in the medical records.  As a result, we 
estimated that Cariten received at least $9.2 million in net overpayments for 2016 and 2017.  (A-
02-20-01009) 
California Improperly Claimed at Least $23 Million of $260 Million in Total Medicaid 
Reimbursement for Opioid Treatment Program (OTP) Services.  California claimed Medicaid 
reimbursement for some OTP services that did not meet Federal and State requirements. Of the 
130 sample items, 88 had services that were all allowable, but 42 had services that were 
unallowable.  On the basis of our sampled results, we estimated that California claimed at least 
$23.1 million in unallowable Federal Medicaid reimbursement for OTP services during our audit 
period.  In addition, we identified deficiencies in three areas that did not result in unallowable 
services but could impact the quality of care provided to beneficiaries receiving OTP services. 
(A-09-20-02009) 
Tennessee Medicaid Claimed Hundreds of Millions of Federal Funds for Certified Public 
Expenditures That Were Not in Compliance With Federal Requirements.  Tennessee did not 
comply with Federal requirements for claiming certified public expenditures (CPEs) for public 
hospital unreimbursed costs.  Of the $2 billion in CPEs that Tennessee claimed during our audit 
period, $909.4 million was allowable and supported.  However, the remaining $1.1 billion 
($767.5 million Federal share) exceeded the amount allowed.  This amount included $482.1 
million ($337.5 million Federal share) of excess CPEs that Tennessee claimed but did not return 
after calculating actual CPEs.  In addition, the actual CPEs that Tennessee calculated included 
another $609.4 million ($430 million Federal share) that exceeded the allowable amount.  It was 
composed of $522.3 million ($370.1 million Federal share) of unsupported net costs of caring for 
institutions for mental diseases (IMD) uninsured patients, $53.6 million ($37.9 million Federal 
share) of unallowable net costs of caring for TennCare IMD patients between the ages of 21 and 
64, and $33.5 million ($22.0 million Federal share) of overstated costs because of incorrect 
calculations.  (A-04-19-04070) 
New Mexico Did Not Claim $12.4 Million of $222.6 Million in Medicaid Payments for Services 
Provided by Indian Health Service Facilities in Accordance With Federal and State 
Requirements.  New Mexico claimed $12.4 million in IHS expenditures that did not meet Federal 
and State requirements.  Specifically, New Mexico claimed:  (1) $6.2 million in unsupported 
expenditures under its older waivers, which New Mexico did not identify because it did not 
reconcile initial expenditures with IHS encounter data; (2) $3.6 million in unsupported 
58  expenditures under its current waiver because its reconciliations did not account for encounter 
data adjustments; and (3) $2.6 million in expenditures for encounter data MCOs submitted 
beyond the two-year limit outlined in the MCO contracts.  Additionally, New Mexico may have 
claimed $750,811 for inpatient encounter data with dates-of-service spans that did not support 
the number of paid inpatient days.  (A-06-19-09005) 
Prior Audits of Medicaid Eligibility Determinations in Four States Identified Millions of 
Beneficiaries Who Did Not or May Not Have Met Eligibility Requirements.  Our previous audits 
of four states Medicaid eligibility determinations found that during 2014 and 2015 Medicaid 
payments were made on behalf of 109 of 460 sampled newly eligible beneficiaries and 98 of 515 
sampled non-newly eligible beneficiaries who did not meet or may not have met Medicaid 
eligibility requirements.  We determined that both human and system errors, as well as a lack of 
policies and procedures, contributed to these improper or potentially improper payments. 
Although the states concurred with all 31 recommendations from our prior audits to address 
these deficiencies, 15 of these recommendations remain unimplemented.  On the basis of our 
sample results, we estimated that the four states made Federal Medicaid payments on behalf of 
newly eligible beneficiaries totaling almost $1.4 billion for more than 700,000 ineligible or 
potentially ineligible beneficiaries.  We also estimated that the four States made Federal 
Medicaid payments on behalf of non-newly eligible totaling more than $5.0 billion for almost 
five million ineligible or potentially ineligible beneficiaries.  (A-02-20-01018) 
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. 
New Hampshire claimed Medicaid reimbursement for OTP services that did not comply with 
Federal and state requirements.  Of the 100 OTP services we sampled, six complied with Federal 
and State requirements, but 94 did not meet applicable Federal and State requirements.  These 
deficiencies occurred because New Hampshire did not have the resources to oversee providers 
and enforce the OTP requirements.  Providers said high personnel turnover, difficulty attracting 
and retaining personnel, and difficulty keeping patients engaged in counseling services 
contributed to the lack of adherence to state requirements.  Furthermore, New Hampshire did not 
always provide guidance regarding State OTP requirements.  On the basis of our sample results, 
we estimated that New Hampshire improperly claimed at least $7.9 million in Federal Medicaid 
reimbursement for OTP services during our audit period.  (A-01-20-00006) 
Texas Did Not Report and Return All Medicaid Overpayments for the States Medicaid Fraud 
Control Unit Cases.  Texas did not correctly report and return the Federal share of all MFCU-
determined Medicaid overpayments identified for the period October 1, 2016, through 
September 30, 2018. Texas should have reported MFCU-determined Medicaid overpayments 
totaling $24.3 million (at least $13.9 million Federal share) for the 65 cases with Medicaid 
restitution during the period that we reviewed.  Texas correctly reported $46,369 ($26,982 
Federal share) in MFCU-determined Medicaid overpayments for two of the 65 cases and did not 
correctly report the remaining 63 cases.  For the 63 cases, Texas did not report and return 
overpayments totaling $19.0 million ($11.1 million Federal share) for 26 cases for our audit 
period. As a result of our audit, Texas later returned the Federal share on the FY 2020 and FY 
2021 Form CMS-64s.  In addition, Texas did not report $5.2 million (at least $2.7 million 
59  Federal share) for 37 cases within the required timeframe.  These issues occurred because Texas 
did not have adequate internal controls to ensure that it always reported MFCU-determined 
Medicaid overpayments in accordance with Federal requirements.  (A-06-20-04004) 
New Jerseys Medicaid School-Based Cost Settlement Process Could Result in Claims That Do 
Not Meet Federal Requirements.  New Jerseys methodology for claiming Medicaid school-
based costs, as described in the Process Guide, does not comply with Federal requirements. 
Specifically, the Process Guides methodology for conducting random moment time studies 
(RMTSs):  (1) does not meet Federal requirements for statistical sampling, (2) defines one 
Medicaid administrative activity code as including activities not necessary for the administration 
of the Medicaid State plan, and (3) does not ensure that RMTS responses and Medicaid cost 
allocation ratios are supported.  In designing its Process Guide, New Jersey did not address 
deficiencies identified during our prior audit of its school-based program, follow CMS guidance, 
and ensure that its Medicaid cost allocation ratios could be supported.  Therefore, if CMS does 
not work with New Jersey to address the deficiencies identified in this report, Medicaid claims 
submitted for reimbursement by New Jersey school districts will not meet Federal requirements 
and the risk of improper payments could increase by tens of millions of dollars per year.  (A-02-
20-01012) 
The Centers for Medicare & Medicaid Services Eligibility Review Contractor Adequately 
Determined Medicaid Eligibility for Selected States Under the Payment Error Rate Measurement 
(PERM) Program.  We determined that CMSs eligibility review contractor correctly determined 
Medicaid eligibility for the beneficiaries associated with all 100 sampled claims.  Based on our 
sample results, we concluded that CMSs eligibility review contractor adequately determined 
Medicaid eligibility for three States (Connecticut, Pennsylvania, and Virginia) under CMSs 
PERM program in accordance with Federal and State requirements.  (A-02-20-01006) 
Montana Claimed Federal Medicaid Reimbursement for More Than $5 Million in Targeted Case 
Management (TCM) Services That Did Not Comply With Federal and State Requirements. 
Montana did not always claim Federal Medicaid reimbursement for TCM services during 
FYs 2018 through 2020 in accordance with Federal and State requirements.  Of the 150 
randomly sampled grouped line items, 43 sample items were at least partially unallowable 
because they had at least 1 error related to case managers lacking required experience or 
qualifications, unsupported services, unallowable services, or an ineligible recipient.  Montana 
had policies and procedures in place for the administration of TCM services that, if followed, 
would have ensured compliance with Federal and State requirements.  Based on our sample 
results, we estimated that Montana claimed at least $7.7 million (more than $5.0 million Federal 
share) in unallowable Medicaid reimbursement for these services.  (A-07-21-03246) 
Nearly All States Made Capitation Payments for Beneficiaries Who Were Concurrently Enrolled 
in a Medicaid Managed Care Program in Two States.  All 47 States reviewed made capitation 
payments on behalf of Medicaid beneficiaries who were concurrently enrolled in two States. 
Specifically, capitation payments were made on behalf of 208,254 concurrently enrolled 
beneficiaries in August 2019 and 327,497 concurrently enrolled beneficiaries in August 2020. 
The Medicaid program incurred costs of approximately $72.9 million in August 2019 and 
60  $117.1 million in August 2020 for capitation payments associated with beneficiaries in one of 
the two concurrently enrolled States. The significant increase in these payments from August 
2019 to August 2020 coincided with an overall increase in Medicaid enrollment during that time, 
and new Federal requirements and flexibilities that were available to states during the COVID-19 
public health emergency.  CMS does not actively monitor beneficiaries concurrent Medicaid 
managed care enrollments; instead, it relies on the States to identify concurrent enrollments and 
potential erroneous payments.  CMS does not provide States with Transformed Medicaid 
Statistical Information System (T-MSIS) national enrollment data that would assist them in 
identifying beneficiaries who were concurrently enrolled in a Medicaid managed care program in 
two States. Two States often made capitation payments for the same Medicaid beneficiary in 
part because states did not have full access to data they needed to identify beneficiaries who were 
concurrently enrolled in another State. Therefore, CMS does not take all available steps, either 
directly or through the States, to identify and prevent state capitation payments for non-resident 
beneficiaries.  CMS did not concur with our recommendations. (A-05-20-00025) 
New York Generally Determined Eligibility for Its Basic Health Program (BHP) Enrollees in 
Accordance With Program Requirements. New York generally determined eligibility for its BHP 
enrollees in accordance with Federal and State requirements.  Specifically, for 145 of 150 
sampled policies, New York correctly determined that the associated enrollees were eligible for 
the program.  However, for five sampled policies, New York enrolled individuals who were 
ineligible or potentially ineligible for the program and received improper monthly payments 
totaling $8,615.  Specifically, for three sampled policies, New York enrolled individuals who 
were eligible for Medicaid.  For one sampled policy, New York did not properly verify income. 
For the remaining sampled policy, New York received BHP payments from the CMS on behalf 
of a disenrolled deceased enrollee.  According to New York, system defects prevented controls 
that were in place from working as intended.  On the basis of our sample results, we estimated 
that the financial impact of the incorrect or potentially incorrect eligibility determinations made 
by New York for its BHP during the audit period totaled $69.9 million.  (A-02-20-01028) 
Texas Claimed or May Have Claimed More Than $30 Million of $9.89 Billion in Federal Funds 
for Medicaid Uncompensated Care (UC) Payments That Did Not Meet Federal and State 
Requirements.  Texas claimed $16.9 billion ($9.9 billion Federal share) in UC payments in 
accordance with applicable Federal and State requirements.  However, Texas incorrectly claimed 
$18.9 million ($11.0 million Federal share). Specifically, Texas claimed:  (1) $12.9 million 
($7.5 million Federal share) because it did not refund the full Federal share of overpayments, and 
(2) $6.0 million ($3.5 million Federal share) because it did not collect overpayments it identified. 
Additionally, the State agency may have incorrectly claimed $33.8 million ($19.7 million 
Federal share) because it did not reduce hospitals actual UC costs by Medicare payments the 
hospitals received.  (A-06-19-09002) 
New York Claimed $196.0 Million, Over 72 Percent of the Audited Amount, in Federal 
Reimbursement for NEMT Payments to New York City Transportation Providers That Did Not 
Meet or May Not Have Met Medicaid Requirements. Seventeen of the 100 sampled payments 
complied with Federal and State requirements.  However, for 41 sampled payments, non-
emergency medical transportation (NEMT) payments did not comply with Federal and State 
61  requirements and were therefore unallowable.  For the remaining 42 sampled payments, we 
could not determine whether the services complied with Federal and State requirements.  On the 
basis of our sample results, we estimated that New York improperly claimed at least $84.3 
million in Federal Medicaid reimbursement for payments to NEMT providers that did not 
comply with certain Federal and State requirements.  In addition, we estimated that New York 
claimed $112.0 million in Federal Medicaid reimbursement for payments to NEMT providers 
that may not have complied with certain Federal and State requirements.  (A-02-21-01001) 
Medicare Improperly Paid Physicians for Spinal Facet-Joint Denervation Sessions.  Medicare 
did not pay physicians for selected facet-joint denervation sessions in accordance with Medicare 
requirements.  In total, Medicare improperly paid physicians $9.5 million.  CMS plans to recover 
these overpayments for claims.  CMS established oversight mechanisms to prevent or detect 
improper payments to physicians for more than:  (1) two facet-joint denervation sessions related 
to the lumbar spine or cervical/thoracic spine per beneficiary during a rolling year, and (2) the 
allowed number of facet joints per denervation session.  These mechanisms, include 
implementing system edits and a fraud prevention system model to prevent or detect improper 
payments for facet-joint denervation sessions.  In addition, CMS plans to direct its Supplemental 
Medical Review Contractor to review a small sample of claims to determine whether Medicare 
appropriately paid for denervation sessions with dates of service after our audit period that were 
before the implementation of the oversight mechanisms.  (A-09-21-03002) 
Psychotherapy Services Billed by a New York City Provider Did Not Comply With Medicare 
Requirements.  We estimated that the New York City provider received $1.1 million in Medicare 
overpayments for psychotherapy services, that did not comply with Medicare requirements for 
all 100 sampled beneficiary days.  For example, the beneficiaries treatment plans associated 
with these services were not provided or did not contain required elements (e.g., frequency or 
duration of services). This heightens the risk that treatments were inappropriate or unnecessary 
and could have a significant effect on the beneficiaries quality of care received.  We also found 
that services billed to Medicare did not meet incident-to requirements or were conducted by a 
therapist that was not licensed or registered in New York State.  CMS followed up with the New 
York City provider regarding the steps taken to address our recommendations.  The provider 
implemented a compliance program and implemented corrective action plans.  For example, the 
provider has taken steps to develop policies and procedures, as well as a training program for its 
therapists, to ensure that treatment plans:  (1) contain all required elements, (2) are maintained 
and signed by the treating physician, (3) the performing therapists and supervising physicians 
comply with the requirements related to incident-to-services, (4) include psychotherapy services 
conducted by therapists that meet Medicare qualification requirements, (5) document time spent 
on psychotherapy services, and (6) include treatment notes signed and maintained to support the 
services billed.  (A-02-21-01006) 
Medicare Improperly Paid Durable Medical Equipment (DME) Suppliers an Estimated $8 
Million of the $40 Million Paid for Power Mobility Device (PMD) Repairs.  Not all suppliers 
complied with Medicare requirements when billing for PMD repairs.  Suppliers submitted PMD 
repair charges that did not comply with Medicare requirements when billing for PMD repairs. 
Specifically, documentation did not adequately support the charges for PMD repairs, the labor 
62  time associated with PMD repairs was not documented, or PMD repair charges were not 
reasonable and necessary.  We also identified questionable charges for PMD repairs associated 
with the sampled beneficiaries.  Although the billing of these PMD repairs did not reflect 
noncompliance with Medicare requirements, suppliers did not meet documentation standards 
established by guidance or submitted charges that may not have been reasonable and necessary, 
resulting in questionable Medicare payments and associated beneficiary coinsurance payments.  
On the basis of our sample results, we estimated that $7.9 million of the $40.1 million paid for 
PMD repairs was improperly paid.  We also estimated that Medicare could have saved as much 
as an additional $3.7 million for questionably paid PMD repairs.  In addition, we estimated that 
Medicare beneficiaries could have saved as much as $3.0 million in coinsurance for the 
improperly and questionably paid PMD repairs. 
We recommended that CMS instruct the DME Medicare contractors to recover the overpayments 
for PMD repairs and to notify suppliers to refund the coinsurance.  Further, based upon the 
results of this audit we recommended that CMS notify appropriate suppliers so that they can 
exercise reasonable diligence to identify, report, and return any overpayments.  We also 
recommended that CMS work with the DME Medicare contractors to improve the education of 
suppliers on Medicare requirements for PMD repairs, implement system edits, and establish 
Medicare requirements that include documentation standards, specify that accumulated costs of 
repairs made during their five-year reasonable useful lifetime must not exceed a certain 
threshold, and specify that suppliers must provide warranties for repairs made to PMDs.  (A-09-
20-03016) 
Medicare Critical Care Services Provider Compliance Audit: Lahey Clinic, Inc.  Lahey 
complied with Medicare billing requirements for 36 of the 92 critical care services that we 
reviewed.  However, Lahey did not comply with Medicare billing requirements for the remaining 
56 critical care services.  All 10 of the inpatient admissions reviewed included at least 1 critical 
care service that did not comply with Medicare billing requirements.  Specifically, Lahey billed 
for 54 critical care services for patients whose conditions did not indicate that the critical care 
services were medically necessary or for which the physician did not directly provide services 
that were at the level of care required for critical care services.  In addition, Lahey billed for two 
critical care services that were billed using an incorrect Current Procedural Terminology code for 
the critical care service provided.  These billing errors resulted in Lahey receiving $6,015 in 
unallowable Medicare payments.  Lahey indicated partial concurrence with our first recommend-
dation and full concurrence with our procedural recommendations.  Lahey concurred with our 
results for 16 of the 56 critical care services, agreed that $1,461 should be refunded, and stated 
that it addressed or is in the process of addressing the procedural recommendations.  Lahey did 
not concur with the remaining 40 critical care services.  After review and consideration of 
Laheys comments, and because Lahey did not provide any additional medical record 
documentation to support its rebuttal of these 40 services, we maintain that our original findings 
remain valid.  (A-03-20-00002) 
Trends in Genetic Tests Provided Under Medicare Part B Indicate Areas of Possible Concern. 
Our analysis of nationwide trends in genetic testing under Medicare Part B showed that 
payments for genetic tests, the number of genetic tests performed, the number of laboratories that 
63  received more than $1.0 million for performing genetic tests, and the number of providers 
ordering genetic tests for beneficiaries all increased during our audit period (CYs 2016 through 
2019). Although there are legitimate reasons that genetic testing has increased, these increases 
indicate areas of possible concern, such as excessive genetic testing and fraud, which may 
negatively affect beneficiaries.  In addition, Medicare requirements and guidance related to 
coverage of genetic testing have been limited and have varied among Medicare Administrative 
Contractor (MAC) jurisdictions.  Oversight by CMS and the MACs is critical to prevent fraud, 
waste, and abuse related to genetic testing and to protect Medicare beneficiaries.  The 
information in this data brief may help CMS and other stakeholders to identify changes in the 
Medicare program, such as increased oversight, that could prevent fraud, waste, and abuse and 
protect Medicare beneficiaries.  Because this report contains no recommendations, CMS did not 
provide written comments on our draft report but did provide technical comments, which we 
addressed as appropriate.  (A-09-20-03027) 
Medicare and Beneficiaries Paid Substantially More to Provider-Based Facilities in Eight 
Selected States in Calendar Years 2010 Through 2017 Than They Paid to Freestanding 
Facilities in the Same States for the Same Type of Services.  Both the Medicare program and its 
beneficiaries could have realized significant savings for Evaluation and Management (E&M) 
services if those services had been paid as if provided at freestanding facilities.  If the physicians 
in the selected States had been paid at the freestanding PFS non-facility rate and hospitals paid 
nothing under the Outpatient Prospective Payment System for our audit period, the Medicare 
program could have realized cost savings of $1.3 billion and its beneficiaries could have realized 
cost savings of $334.0 million, for combined savings totaling more than $1.6 billion.  In addition, 
beneficiaries would have been required to make only one coinsurance payment rather than two 
(as they are currently required to do), and the cost-sharing would generally be lower because it 
would be based only on the freestanding facility rate.  CMS has taken some steps intended to 
equalize payments.  If these changes had been in effect during the period covered by our audit, 
the potential cost savings of these changes for E&M services in the selected States for our audit 
period could have been a combined $1.4 billion for the Medicare program and its beneficiaries. 
However, the combined $1.4 billion in potential cost savings would still have been less than the 
$1.6 billion in potential cost savings if E&M services had been paid at the freestanding PFS non-
facility rate.  We recommend that CMS pursue legislative or regulatory changes to lower costs 
for both the Medicare program and beneficiaries, by equalizing payments as appropriate between 
provider-based facilities and freestanding facilities for E&M services.  CMS did not directly 
agree or disagree with our recommendation; it referred to regulatory action it had taken and 
added that any changes to further implement our recommendation may require legislative 
action. We commend CMS for the regulatory action it has taken and note that its comments are 
closely aligned with our findings and recommendation. (A-07-18-02815) 
Medicare Dialysis Services Provider Compliance Audit - Dialysis Clinic, Inc. (DCI).  DCI 
claimed reimbursement for dialysis services that did not comply with Medicare requirements for 
70 of the 100 sampled claims.  Specifically, DCI submitted claims for which:  (1) comprehensive 
assessments or plans of care did not meet Medicare requirements, (2) dialysis treatments were 
not completed, (3) dialysis services were not documented, (4) beneficiaries height or weight 
measurements did not comply with Medicare requirements, and (5) the medical record did not 
64  have a monthly progress note by a physician or other qualified professional.  While DCI had 
established corporate-wide internal controls to monitor and maintain complete, accurate, and 
accessible medical records at all its facilities, these controls were not always effective in 
ensuring that DCI's claims for dialysis services complied with Medicare requirements.  We 
estimated that DCI received unallowable Medicare payments of at least $14,193,677 for dialysis 
services that did not comply with Medicare requirements.  Many of the errors we identified did 
not affect DCIs Medicare reimbursement for the services since they were reimbursed on a 
bundled per treatment basis or related to Medicare conditions for coverage.  However, the 
deficiencies could have a significant impact on the quality of care provided to Medicare 
beneficiaries and could result in the provision of inappropriate or unnecessary dialysis services.   
We recommend that DCI refund an estimated $14,193,677 to the Medicare program.  We also 
made a series of recommendations to strengthen DCIs internal controls to ensure that dialysis 
services comply with Medicare requirements.  In written comments on our draft report, DCI did 
not concur with our recommendations but described actions it has taken and plans to take to 
address some of them.  (A-05-20-00010) 
Other HHS-OIG Fraud and Abuse Prevention Activities 
Data Analytics 
HCFAC funding supports HHS-OIGs advanced data analytics initiatives to expand our tools, 
models, and customized analytics with artificial intelligence (AI) and cloud computing to: 
(1) proactively monitor and target our oversight of high-risk HHS programs and health care 
providers; (2) identify trends, outliers, and potential investigative or audit targets; (3) enhance 
decision making; (4) optimize HHS-OIG processes; and (5) support mission needs.  HHS-OIGs 
team of highly trained data analysts, data scientists, statisticians, and data engineers partner with 
HHS-OIG investigators, auditors, attorneys, and evaluators to identify HHSs most significant 
risks and better target fraud, waste, and abuse.  HHS-OIG applies predictive and geospatial 
analytics, leverages dashboards, machine learning, and AI capabilities including neural networks 
and text mining to identify and support prosecutions of sophisticated fraud schemes as well as 
potential audit and evaluation findings by utilizing high-value health care, grant, contract, law 
enforcement, and operational data.  More than 760 unique staff members used HHS-OIG 
analytic tools for mission-focused work to generate more than 44,000 provider-specific reports 
and claims exports, page views, and other analytic insights, during the fiscal year. 
HHS-OIGs ability to use data proactively has become even more important during the 
COVID-19 pandemic.  HHS-OIG analytics have helped to inform a range of Medicare-focused 
topics that are subjects of recent and future HHS-OIG reports including COVID-19 testing; 
possible fraud, waste, and abuse in laboratory billing; the use of telehealth services; emergency 
preparedness; the challenges of COVID-19 in nursing homes; audits and investigations involving 
the CARES Act Provider Relief Fund , Uninsured Individuals Program; Paycheck Protection 
Program; and other programs. 
HHS-OIG analytics staff quickly pivoted to monitor COVID-19 testing, treatment, and billings 
for other services such as DME, allergy, genetic, respiratory, and other testing to detect patterns 
of inappropriate bundling of services and billing for services not rendered.  HHS-OIG also 
monitored changes in services delivered through telemedicine to identify inappropriate billing 
65  schemes.  HHS-OIG analytics supported more than 130 agency investigative actions that led to 
criminal charges filed in U.S. courts including telemedicine and genetic testing schemes totaling 
more than $400.0 million in false claims and a nationwide coordinated law enforcement action to 
combat health care-related COVID-19 fraud involving charges against 21, defendants 
contributing to $149.0 million in COVID-19 related false billings announced by DOJ and HHS 
in April 2022.  Furthermore, HHS-OIGs data analytics continue to identify and support cases 
filed as part of the ARPO and the NEPO Strike Force efforts.  These included opioid-related law 
enforcement actions involving charges against 14 defendants, including 12 medical professionals 
for their alleged participation in the illegal prescription and distribution of opioids in May 2022. 
Our data and technical experts are also partnering with HHS-OIG auditors and evaluators to 
provide custom data and analytics support focused on pandemic- and mission-related work.  As 
of September 30, 2022, HHS-OIG analytics staff had supported 56 audits, 21 evaluations, and 
137 criminal investigations across the Medicare and Medicaid portfolios as well as dozens of 
COVID-19 related projects and exploratory work. 
Outreach and Guidance 
HHS-OIG strives to cultivate a culture of compliance in the health care industry through various 
educational and outreach efforts. 
Advisory Opinions  
HIPAA established an advisory opinion process through which parties may obtain binding legal 
opinions on the application of the Federal AKS and other HHS-OIG administrative enforcement 
authorities to existing or proposed health care financial arrangements.  
During FY 2022, HHS-OIG, in consultation with DOJ, issued 25 advisory opinions.  During the 
26 years of the HCFAC program, HHS-OIG has issued more than 400 advisory opinions, 
modified 23 advisory opinions, terminated four opinions, and rescinded one opinion. 
Collaborations With Private Sector Partners 
HHS-OIG regularly engages with public stakeholders to combat fraud.  For example, HHS-OIG 
is an active partner in HFPP, described in more detail elsewhere in this report, and with the 
National Health Care Anti-Fraud Association, both of which are public-private partnerships that 
address health care fraud by sharing data and information for the purposes of detecting and 
combating fraud and abuse in health care programs.  HHS-OIG frequently shares information 
about prescription drug fraud schemes, trends, and other matters related to health care fraud, as 
appropriate.  As a further example, HHS-OIG has collaborated with DEA to provide antifraud 
education at numerous Pharmacy Diversion Awareness Conferences held across the United 
States.  The conferences were designed to assist pharmacy personnel with identifying and 
preventing diversion activity.  Since 2013, HHS-OIG has delivered presentations at conferences 
in 50 states and Puerto Rico.  Furthermore, HHS-OIG regularly delivered presentations at 
various health care compliance conferences across the country. 
66  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 AI/AN Training website. 
HHS-OIG also engages with stakeholders to seek insights regarding how to promote compliance 
while encouraging innovation in the health care industry.  For instance, HHS-OIG published a 
Request for Information in 2021 seeking to identify ways that it could modernize the 
accessibility and usability of our publicly available information. 16  HHS-OIG then coordinated 
with the Health Care Compliance Association and the American Health Law Association to host 
roundtables with stakeholders in early 2022 to solicit further feedback on this topic.  During 
these roundtables, HHS-OIG heard from an experienced and diverse group of participants and 
gathered information that will inform HHS-OIG as it proceeds with its modernization efforts. 
Centers for Medicare & Medicaid Services 
In FY 2022, Congress appropriated CMS $658.6 million in discretionary funds to support its 
comprehensive program integrity strategy for Medicare, Medicaid, the Childrens Health 
Insurance Program (CHIP), and the Health Insurance Marketplaces.  In FY 2022, Congress 
continued to direct HHS to fund the Administration for Community Livings (ACL) Senior 
Medicare Patrol (SMP) Program; therefore, $30.0 million of CMSs $658.6 million in 
discretionary funding was allocated to ACL to support the program.  More information on the 
SMP Program activities and accomplishments are discussed in the ACL section of this report. 
With the HCFAC funds, CMS works to ensure that accurate payments are made to legitimate 
individuals and entities for allowable services or supplies provided to eligible beneficiaries of 
Federal health care programs.  
CMS also performs many program integrity activities that are beyond the scope of this report 
because they are not funded directly by the HCFAC Account or discretionary HCFAC funding.  
This includes activities such as the Recovery Audit Program and Medicare Secondary Payer.  
CMSs program integrity activities are discussed at length in the annual Medicare and Medicaid 
Integrity Programs Report to Congress, which can be found on the CMS website. 17 
16 HHS-OIG, OIG Modernization Initiative To Improve Its Publicly Available ResourcesRequest for Information, 
86 Fed. Reg. 53072 (Sept. 24, 2021). https://www.govinfo.gov/content/pkg/FR-2021-09-24/pdf/2021-20558.pdf. 
17 https://www.cms.gov/About-CMS/Components/CPI/CPIReportsGuidance 
67  Address the Full Spectrum of Fraud, Waste, and Abuse 
Program integrity focuses on paying the right amount, to legitimate providers and suppliers, for 
covered, reasonable and necessary services provided to eligible beneficiaries, while concurrently 
taking aggressive actions to eliminate fraud, waste, and abuse.  Federal health programs are 
quickly evolving; therefore, CMSs program integrity strategy must keep pace to address 
emerging challenges. 
This section describes the wide range of program integrity activities funded by the HCFAC 
account that CMS utilizes to comprehensively address fraud, waste, and abuse.  These activities 
include many different approaches to program integrity, such as data analysis, investigations and 
audits, recovery actions, and outreach and education. 
Unified Program Integrity Contractors (UPICs) 
One way that CMS investigates instances of suspected fraud, waste, and abuse in Medicare and 
Medicaid is through the activities of the UPICs.  CMS contracts with the UPICs for the 
prevention, detection and deterrence of fraud, waste and abuse by Medicare and Medicaid 
providers through investigation and audits, both proactively and from referrals.  Currently, the 
UPICs are carrying out program integrity activities in all five geographic jurisdictions:  Midwest, 
Northeast, West, Southeast, and Southwest.  UPICs undertake activities including provider and 
beneficiary interviews and site visits, recommending appropriate Medicare administrative actions 
(e.g., prepayment edits, payment suspensions, revocations), and performing program integrity 
reviews of medical records and documentation.  While a variety of other contractors also 
perform medical review, the UPIC reviews are uniquely focused on fraud detection and 
investigation.  For example, the UPICs look for possible falsification of documents from 
providers and suppliers that may be associated with an attempt to defraud the Medicare and 
Medicaid programs.  Various UPIC administrative actions result in Medicare savings, including 
automated edit claim denials, non-automated review claim denials, provider revocations and 
deactivations, overpayment recoveries, and law enforcement referrals.  CMS publishes savings 
from UPIC activities in the Annual Report to Congress on the Medicare and Medicaid Integrity 
Programs. 
CMS also contracts with the UPICs to review the actions of Medicaid providers.  The UPICs 
work closely with states to perform numerous functions to detect, prevent, and deter specific 
risks and broader vulnerabilities to the integrity of the Medicaid program, including conducting 
provider investigations and audits, which can result in the identification of overpayments, 
potential fraud referrals to law enforcement, and other referrals for state administrative action. 
Fraud Prevention System (FPS) 
FPS is the predictive analytics technology required under the Small Business Jobs Act of 
2010.18 FPS analyzes FFS claims using sophisticated algorithms to target investigative 
resources; generate alerts for suspect claims or providers and suppliers; and provide information 
to facilitate and support investigations of the most egregious, suspect, or aberrant activity.  CMS 
uses the FPS information to prevent and address improper payments using a variety of 
18 Public Law 111-240.
68  administrative actions, including claim denials, payment suspensions, Medicare billing privilege 
revocations, and law enforcement referrals. 
During FY 2022, the FPS generated alerts that resulted in 960 new leads for program integrity 
contractors and augmented information for 759 existing leads or investigations.  The program 
integrity contractors reported initiating FPS-attributable actions against 786 providers in FY 
2022. 
Medicare FFS and Medicaid National Correct Coding Initiative (NCCI) 
NCCI promotes national correct coding methodologies and reduces improper coding that may 
result in inappropriate payments in Medicare FFS.  NCCI Procedure-to-Procedure edits prevent 
inappropriate payment for billing code pairs that should not generally be reported together by the 
same provider for the same beneficiary and date of service, while NCCI Medically Unlikely 
Edits define for each HCPCS/CPT code the maximum units of service reported on the vast 
majority of appropriately reported claims by the same provider/supplier for the same beneficiary 
for the same date of service.  Estimated savings from Medicare NCCI edits are published in the 
Annual Report to Congress on the Medicare and Medicaid Integrity Programs. 19 
Section 1903(r) of the Social Security Act requires states to use NCCI methodologies to process 
applicable Medicaid claims. CMS provides assistance to state Medicaid agencies using NCCI 
methodologies in their Medicaid programs. 
Integrated Data Repository and the One Program Integrity (One PI) Portal 
One PI provides CMS program integrity contractors, law enforcement personnel, HHS-OIG 
investigators, and other organizations a centralized single access point to analytical tools and 
data needed to fight Medicare and Medicaid fraud, waste, and abuse.  One PI provides access to 
Medicare and Medicaid data from the Integrated Data Repository (IDR), which allows users to 
investigate improper payments, identify fraud schemes, create and enhance fraud prevention 
models, take administrative actions, pursue civil and criminal penalties, and more to protect 
Medicare and Medicaid taxpayer dollars.  One PI augments the Medicare Parts A, B (including 
DME and home health claims), Part C encounter data, and Part D prescription drug event 
records, as well as beneficiary data that is available in the IDR to provide a comprehensive view 
of claims data, beneficiary data, and prescription drug information as well as T-MSIS data and 
Medi-Medi formats.  CMS is currently working to integrate One PI with the Unified Case 
Management (UCM) system and the FPS to become the centralized reporting hub for CMS.  One 
PI is a critical element of CMSs efforts to ensure program integrity. 
Coordinated Program Integrity Activities 
In FY 2018, CMS began a Major Case Coordination (MCC) initiative that includes 
representation from the HHS-OIG, DOJ, and CMS.  This initiative provides an opportunity for 
Medicare and Medicaid policy experts, law enforcement officials, clinicians, and fraud 
investigators to collaborate before, during, and after the development of fraud leads.  This level 
19 https://www.cms.gov/About-CMS/Components/CPI/CPIReportsGuidance. 
69  of collaboration has contributed to several successful coordinated law enforcement actions and 
helped CMS to better identify national fraud trends and program vulnerabilities. 
As a result of the MCC, there has been a marked increase in the number and quality of law 
enforcement referrals from CMS.  Since implementation of the MCC, there have been over 4,000 
cases reviewed at MCC, and law enforcement partners have made over 2,600 requests for CMS 
to refer reviewed cases.  CMS program integrity activities and investigations continue to 
contribute to law enforcement investigations, CMS administrative actions and CMS initiatives.  
In FY 2022, CMS reviewed 1,109 cases at MCC meetings, and law enforcement partners made 
512 requests for CMS to refer reviewed cases. 
Examples of the ways in which CMS has provided support to the HHS-OIG and DOJ throughout 
FY 2022 include: 
  On April 20, 2022, DOJ announced criminal charges against 21 defendants for their 
alleged participation in various health care related fraud schemes that exploited the 
COVID-19 pandemic in a coordinated law enforcement action with the HHS-OIG and 
CMS.  CMS took administrative actions against over 29 providers for their involvement 
in health care fraud schemes relating to abuse of CMS programs during the pandemic. 
  On May 4, 2022, DOJ announced criminal charges against 14 defendants for their alleged 
involvement in crimes related to the unlawful distribution of opioids in a coordinated law 
enforcement action with the HHS-OIG and CMS.  CMS took administrative actions 
against six providers for their alleged involvement in these offenses. 
  On July 20, 2022, DOJ announced criminal charges against 36 defendants for more than 
$1.2 billion in alleged fraudulent telemedicine, cardiovascular and cancer genetic testing, 
and DME schemes in a coordinated law enforcement action with the HHS-OIG and 
CMS.  CMS took administrative actions against 52 providers involved in similar 
schemes. 
Provider Compliance 
  Accuracy reviews 
CMS uses the Medical Review Accuracy Contractor (MRAC) to conduct medical 
reviews of claim determinations made by the MACs, UPICs, and the Supplemental 
Medical Review Contractor (SMRC).  The MRAC helps CMS by measuring the accuracy 
rate for each contractor to ensure the contractors are consistent in their medical review 
decisions in compliance with Medicare and Medicaid coverage, coding, payment, and 
billing policies.  It also feeds information into the MAC Award Fee Component to 
determine where policy/issues/medical review inconsistencies may be present.  Because 
CMS is only able to perform a limited number of accuracy reviews using its own 
clinicians, the MRAC is able to help CMS complete more accuracy reviews and provide 
additional analysis to CMS. 
70    Prior Authorization 
In a final rule, CMS established an initial Master List of certain DMEPOS that are 
frequently subject to unnecessary utilization and established a prior authorization process 
for these items.  
In FY 2022, CMS continued the prior authorization of certain DMEPOS items.  CMS 
requires prior authorization as a condition of payment on 40 power mobility device 
codes, five pressure reducing support service codes, and six lower limb prosthetic codes.    
Six additional power mobility device codes were selected for required prior authorization 
and began nationwide on April 13, 2022.  Additionally, on April 13, 2022, prior 
authorization of five prosthetic codes were required in California, Florida, Illinois, and 
New York.  Prior authorization for these codes expanded to Arizona, Georgia, Kentucky, 
Maryland, Michigan, Missouri, New Jersey, North Carolina, Ohio, Pennsylvania, Texas, 
and Washington on July 12, 2022, and will expand nationwide to all remaining states and 
territories in FY 2023.  The DME MACs review requests for prior authorization for the 
noted items, communicate decisions with suppliers and physicians, and provide ongoing 
education and customer service. 
In a final rule, CMS finalized a prior authorization process for certain hospital outpatient 
department (HOPD) services as a method to control unnecessary increases in volume.  In 
FY 2022, CMS continued to require, nationwide, prior authorization of Blepharoplasty, 
Botulinum Toxin Injections, Panniculectomy, Rhinoplasty, Vein Ablation, Implanted 
Spinal Neurostimulators, and Cervical Fusion with Disc Removal.  Moreover, CMS 
proposed the addition of Facet Joint Interventions to the list of services that require prior 
authorization, as part of the CY 2023 Outpatient Prospective Payment System/ 
Ambulatory Surgical Center (OPPS/ASC) proposed rule, published on July 26, 2022.  
The MACs review requests for prior authorization for the noted services, communicate 
decisions to providers, and provide ongoing education and customer service. 
  Comparative Billing Reports 
Comparative Billing Reports (CBRs) are educational tools providers can use to support 
efforts to protect the Medicare Part B Trust Fund.  These reports compare an individual 
provider or suppliers billing and/or prescribing practices for a specific billing code, 
providers about Medicare coding, billing, and coverage guidelines and strategies for 
implementing self-audit processes into their practices, where appropriate.  Currently, 
CBRs are available for download by the provider or supplier on a secure electronic portal 
as well as mailed in full via postal mail.  Since 2011, CBRs have been issued on topics 
such as opioid prescriptions, physical therapy, and eye exam claims. Typically, CBRs 
are sent to approximately 5,000 outlier providers per topic based on data analysis for a 
defined period of time.  Topics are based on GAO and HHS-OIG reports, Comprehensive 
Error Rate Testing program findings, and agency and contractor data analysis.  A CBR 
does not necessarily indicate improper billing and/or prescribing by the provider and only 
in select instances are providers and suppliers referred for additional review or education.  
71  In FY 2022, CMS issued a total of ten CBRs on eight unique topic areas including critical 
care, lipid panel testing, ambulance ground transport, and cataract surgery. 
Outreach and Education 
CMSs provider education and outreach helps reduce the Medicare improper payment rate by 
giving Medicare providers the timely and accurate information needed to bill correctly the first 
time.  
The Medicare FFS claims processing contractors, known as MACs, educate Medicare providers 
and suppliers about Medicare policies and procedures, including local coverage policies, 
significant changes to the Medicare program, and issues identified through review of provider 
inquiries, claim submission errors, medical review data, and Comprehensive Error Rate Testing 
program data.  The MACs use a variety of strategies and communication channels to offer 
Medicare providers and suppliers a broad spectrum of information about the Medicare program. 
CMS continues to work with providers and suppliers, states, and others to protect CMS programs 
from fraud, waste, and abuse schemes.  CMS is focused on safeguarding programs and 
protecting beneficiaries from fraud, waste, and abuse, while also working to minimize 
unnecessary provider burden.  Providing education and training opportunities in ways that 
explain how to avoid improper payments and also alert stakeholders to fraud, waste and abuse 
schemes protect the financial security of CMSs programs by reducing improper payments and 
curtailing emerging fraud schemes.  By offering regular in-person and virtual events and 
trainings, as well as clear and concise information online, CMS continues to provide needed 
information that is responsive to the realities of clinical practice. 
Proactively Manage Provider Screening and Enrollment 
Provider enrollment is the gateway to the Medicare and Medicaid programs and is the key to 
preventing ineligible providers and suppliers from entering either program.  CMSs role in the 
provider and supplier enrollment process differs between the Medicare and Medicaid programs. 
CMS directly administers Medicare and oversees the provider enrollment and screening process 
for providers and suppliers participating in the Medicare FFS program.  CMS uses provider and 
supplier enrollment information in a variety of ways, such as claims payment and fraud 
prevention programs.  States directly oversee the provider screening and enrollment process for 
their Medicaid programs, and CMS provides regulatory guidance and technical assistance to 
states.  CMS is committed to maintaining operational excellence in its provider enrollment and 
screening process.  Through provider screening and enrollment, CMS continues to prevent and 
reduce fraud, waste, and abuse in the Medicare program and ensure that only eligible providers 
are caring for beneficiaries and receiving payment.  CMS also works with states to support 
proper enrollment and accurate billing practices to detect and combat fraud, waste, and abuse in 
their Medicaid programs. 
Medicare Provider Screening and Site Visits 
CMS regulations establish three levels of provider and supplier enrollment risk-based screening: 
limited, moderate, and high, and each provider and supplier specialty category is assigned 
to one of these three screening levels.  Providers and suppliers designated in the limited risk 
72  category undergo verification of licensure and a wide range of database checks to ensure 
compliance with all provider- or supplier-specific requirements.  Providers and suppliers 
designated in the moderate risk category are subject to unannounced site visits in addition to all 
the requirements in the limited screening level, and providers and suppliers in the high-risk 
category are subject to fingerprint-based criminal background checks (FCBCs) in addition to all 
of the requirements in the limited and moderate screening levels.  In FY 2022, CMS resumed 
FCBCs, although the PHE remained in effect. CMS denied approximately 718 enrollments and 
revoked four enrollments as a result of the FCBCs or a failure to respond. 
The Advanced Provider Screening system (APS) automatically screens all current and 
prospective providers and suppliers against a number of data sources, including provider and 
supplier licensing and criminal records, to identify and highlight potential program integrity 
issues for proactive investigation by CMS.  In FY 2022, APS utilization resulted in more than 
7.7 million screenings.  These screenings generated more than 3,000 criminal alerts for 
potentially fraudulent providers and suppliers for further review by CMS.  APS review resulted 
in approximately 134 revocations based on a felony conviction, 317 revocations based on a state 
medical license action, and 24 deactivations based on a state medical license action. 
Site visits are a screening mechanism used to identify providers and suppliers that are not in 
compliance with program requirements and likely to pose a risk to the Medicare program, 
preventing them from enrolling or maintaining enrollment.  CMS-authorized site-visit 
contractors validate that the provider or supplier complies with Medicare enrollment 
requirements during these visits.  In FY 2022 this work resulted in about 225 revocations due to 
non-operational site visit determinations for all providers and suppliers. 
CMSs provider screening and enrollment initiatives in Medicare have had a significant impact 
on removing ineligible providers and suppliers from the program.  In FY 2022, CMS deactivated 
approximately 123,000 enrollments and revoked 2,290 enrollments.  Site visits, revalidation, and 
other initiatives have contributed to the deactivation 20 and revocation 21 of more than one million 
enrollment records since FY 2012, when CMS started implementing these screening and 
enrollment requirements. 
Provider Enrollment, Chain and Ownership System (PECOS) 
PECOS is the system of record for all Medicare Provider/Supplier enrollment data, which 
includes Part A, Part B, and DME.  It is the Internet-based system that providers and suppliers 
use to enroll, revalidate, or update their enrollment information in the Medicare FFS program.  
PECOS stores all information furnished by providers and suppliers; tracks all enrollment 
processing and the results of MAC evaluation; and provides feeds to FFS claims payment 
systems, which are used in processing all claims.  Medicare FFS claims processing cannot occur 
without provider/supplier enrollment information from PECOS.  All provider/supplier updates 
and validations, both systematic and those performed manually by MACs, are stored and sent by 
20 Deactivation means the providers or suppliers billing privileges were stopped but can be restored upon the 
submission of updated information.   See 42 CFR  424.540. 
21 Revocation means the providers or suppliers billing privileges are terminated.   See 42 CFR  424.535. 
73  PECOS.  It is integrated with and supports multiple enterprise systems and CMS operations for 
the Merit-Based Incentive Payment System (MIPS), demonstrations and model tests, and 
DMEPOS competitive bidding, providing direct access to information on the relationships 
between individuals and organizations stored in enrollment records.  PECOS is a critical part of 
CMSs program integrity strategy and is used along with the APS, as a data source by the FPS 
and many other program integrity partners, including the UPICs, Recovery Audit Program, the 
HHS-OIG, and state program integrity programs.  
PECOS is the source for vetting CMSs Accountable Care Organization programs and models 
and provides information that is used as a primary factor to determine program and model 
eligibility.  PECOS supports data transparency through interfacing with programs such as Open 
Payments, Physician Compare, and Nursing Home Compare and also supports CMS data 
management initiatives through Master Data Management (MDM), UCM, Pricing, Data 
Analysis and Coding (PDAC), One PI, IDR, Health Information Technology for Economic and 
Clinical Health (HITECH), and other data analysis teams.  State Medicaid programs also rely on 
data-sharing efforts to support requirements for screening providers and suppliers.  CMS is 
focused on transitioning PECOS to a modernized, enterprise resource that is a platform for all 
provider/supplier enrollments across Medicare, Medicaid, and other CMS programs.  This single 
platform is intended to allow streamlining and consistency in user workflows and standardize 
interfaces with systems internal and external to CMS.  
In FY 2022, CMS made significant changes to PECOS to simplify access, improve usability and 
enhance the security of the system, including the following changes:  
  Updated PECOS to validate Clinical Laboratory Improvement Amendments (CLIA) 
numbers to improve accuracy of CLIA numbers entered into PECOS; 
  Implemented necessary enhancements to ensure all Part B and DMEPOS Medical 
Records Correspondence Address data that flows to the claims system comes directly 
from PECOS; 
  Updated PECOS to systematically increase the screening level of high-risk 
Providers/Suppliers to ensure that they are properly screened; 
  Implemented the enhancements necessary to ensure all Part A, DMEPOS CMS-588 
Electronic Funds Transfer (EFT) data that flows to the claims system comes directly from 
PECOS; 
  Updated PECOS in support of regulation to allow Physician Assistants to directly bill 
Medicare and be directly reimbursed for their services; 
  Created a new Data Mart report to identify Clinics/Groups Practices without 
reassignments and/or Physician Assistants for 90 or more days for MACs to take 
appropriate action upon; 
  In support of rule CMS-1734-F that expanded deactivation authorities, PECOS added two 
new deactivation status Reasons and updated the descriptions of three existing 
deactivation status reasons; 
  Implemented various updates that improved the reporting process and data quality of the 
DMEPOS accreditation data loaded into PECOS; 
74    Updated PECOS to allow users to list the Home Infusion Therapy (HIT) services 
rendered in patients homes in multiple states. 
Medicaid Provider Screening and Enrollment 
As part of its oversight role in Medicaid, CMS works closely with state Medicaid agencies 
(SMAs) to provide regulatory guidance, technical assistance, and other support with respect to 
provider screening and enrollment.  SMAs can comply with Federally required Medicaid 
screening and enrollment requirements by using CMSs Medicare screening results for dually 
enrolling providers, eliminating the need and burden associated with states re-screening such 
applicants.  States may use Medicare screening data, including site visits, payment of application 
fees, and FCBCs.  For Medicaid-only FFS providers, SMAs must at a minimum follow the same 
risk-based screening procedures as required for Medicares screening and enrollment process. 
During FY 2022, CMS continued to expand its efforts to assist states with meeting Medicaid 
screening and enrollment requirements.  These efforts include enhanced sharing of Medicare 
enrollment and screening data with states, enhancing the data compare service to help states 
identify providers for which the state is able to rely on Medicares screening, providing technical 
assistance to states through individual state calls, clarifying guidance in the Medicaid Provider 
Enrollment Compendium (MPEC), continuing monthly Technical Assistance Group (TAG) 
calls, and continuing to facilitate a TAG call dedicated solely to screening and enrolling 
Medicaid managed care network providers. 
CMS shares the Medicare provider enrollment record via the PECOS administrative interface 
and in bulk data extracts from PECOS.  Additionally, CMS launched the PECOS states page in 
January 2017, and included provider enrollment information such as Medicare enrollment status, 
site visit information, fingerprint results, ownership information, Medicare risk levels, and more.  
Since May 2016, CMS has offered the data compare service that more easily enables a state to 
rely on Medicares screening, in lieu of conducting state screening.  Using the data compare 
service, a state provides an extract of its actively enrolled provider population to CMS and then 
CMS returns information to the state indicating for which providers the state is able to rely on 
Medicares screening.  CMS continuously works to enhance this service, and more recent 
enhancements include tailoring the type of comparison to meet a states specific needs (for 
example, supplying provider ownership information reported to Medicare, practice location 
information, deactivated National Provider Identifiers (NPIs) and deceased providers). 
In FY 2018, CMS launched the Data Exchange (DEX) system, which is used to share data 
among CMS and the separate Medicaid programs of every state.  This system stores all state-
submitted for cause terminations as well as all Medicare revocations, HHS-OIG exclusion data, 
provides states access to the Social Security Administrations Death Master File, and enhances 
collaboration, improves reporting, and creates transparency through this process.  In FY 2022, 
CMS continued the Medicaid screening pilot process to screen Medicaid-only providers through 
its APS system on behalf of states and produce a report of providers with licensure issues, 
criminal activity, and Do Not Pay activity. CMS believes centralizing this process will improve 
efficiency and coordination across Medicare and Medicaid, reduce state and provider burden, 
and addresses one of the biggest sources of error as measured by the PERM program today.  In 
75  FY 2022, CMS provided APS alerts to Iowa, Missouri, Oklahoma, Nevada, North Dakota, 
Tennessee, Colorado, Rhode Island, Oregon, and West Virginia. 
CMS provides ongoing guidance, education, and outreach through targeted technical assistance 
to states on Federal requirements for Medicaid screening and enrollment.  In addition, CMS 
continues to publish updates to the MPEC, which is sub-regulatory guidance designed to assist 
states in applying certain regulatory requirements.  The latest update published in March 2021 
clarified Medicaid screening and enrollment policies and procedures for the state Medicaid 
agencies.22 
Continue to Build States Capacity to Protect Medicaid 
CMS assists states in building their internal capacity to conduct program integrity activities for 
their Medicaid programs.  CMS continues to use HCFAC program discretionary funds and other 
funding sources to develop and implement enterprise systems that support state Medicaid 
programs.  In particular, there is an initiative called the Medicaid and CHIP Business 
Information Solution (MACBIS) which is a CMS enterprise-wide initiative providing product 
development efforts and services to modernize and transform information and data exchanges 
with states and other key stakeholders aimed at ensuring that CMS protects access to coverage 
and care, advances healthy equity, and drives innovation and whole person care in Medicaid and 
CHIP. Through MACBIS, CMS, stakeholders, and states are provided the ability to gather and 
analyze data to improve monitoring, oversight, evaluation and to assess program integrity of the 
overall Medicaid and CHIP programs.  MACBIS provides operational, financial, pharmacy, 
quality, and business performance data through products and services such as the T-MSIS, 
Medicaid and CHIP Program (MACPRO), Medicaid and CHIP Financial (MACFin), and the 
Medicaid Drug Program to assist in preventing fraud, waste, and abuse.  
HCFAC funding also supports the preparation and dissemination of educational toolkits for 
states to use to enhance awareness of Medicaid fraud, waste, and abuse among providers, 
beneficiaries, managed care organizations, and others.  States participate in and receive support 
and technical assistance and education from CMS through: 
  Medicaid Technical Advisory Groups; 
  Voluntary state assistance site visits for technical assistance and education; 
  Webinars; 
  Medicaid Integrity Institute (MII); 
  Provider screening and enrollment strategies; 
  Onsite/virtual focused program integrity reviews; 
  Provider audits and investigations through the five UPICs; 
  Desk reviews of state processes and procedures; and 
  PERM corrective action plan and Medicaid Eligibility Quality Control (MEQC) 
oversight. 
22 March 2021 Medicaid Provider Enrollment Compendium 
https://www.medicaid.gov/sites/default/files/2021-05/mpec-3222021.pdf 
76  CMS also identifies areas of improvement and works with states to make sure their integrity 
programs are robust. 
State Audit Compliance and Financial Management Oversight 
The State Audit Compliance and Financial Management Oversight projects began in September 
2020.  To support this project, CMS acquired contractor assistance for two separate efforts.  
The first is to perform data analysis, collection, and evaluation, including the use of statistical 
sampling techniques, to review data provided by states related to payments to health care 
providers to determine if Medicaid claims submitted by states for Federal financial participation 
(FFP) are allowable under Federal guidelines.  As a whole, this work supports the overall 
responsibility of CMS to ensure that all claimed expenditures meet statutory and regulatory 
requirements and are appropriate for the Medicaid program to provide efficient review of 
activities relating to the performance of Financial Management Reviews (FMRs).  The second 
effort will develop, implement, and align measures that improve CMS approach to the annual 
OMB single state agency (SSA) audit and identify opportunities to optimize the compliance 
supplement that guides single state auditors as they review state Medicaid and CHIP programs.  
This project will also improve the analysis of the findings resulting from SSA and HHS-OIG 
audits of state Medicaid and CHIP programs to assist CMS in better identifying high risk policy 
areas.  CMS is actively engaged with contractors on both of these initiatives and anticipates 
continued contractor engagement in these areas through FY 2023. 
Medicaid Enterprise System 
State Medicaid agencies develop, implement, operate and maintain information technology 
systems to support their program operations.  The systems generally include eligibility and 
enrollment, managed care payment, encounter data and/or claims processing, pharmacy 
management, etc.  These systems work in concert with one another and must adhere to Federal 
regulation 23 and guidance, including the Medicaid Information Technology Architecture (MITA) 
framework, several standards and conditions, 24 and certification criteria.  Adhering to these 
mandates promotes the consistency of business and technical processes and IT platforms, as well 
as standards across the Medicaid Enterprise.  As noted above, CMS is working closely with 
states to support the delivery of comprehensive digital service products for MACBIS, an 
enterprise-wide initiative to empower states and the Federal Government to perform monitoring 
and oversight, inspect program integrity, evaluate demonstrations, perform actuarial and quality 
of care analysis, negotiate waivers, and enable the sharing of comprehensive program data with 
states, stakeholders, and the research community. 
CMS provides technical assistance to states with respect to IT and policy requirements, including 
monitoring and oversight, working with state-specific system requirements, IT system builds, 
and associated interfaces for all states and the territories.  Required technical artifacts are 
analyzed and tracked to assess state progress.  CMS State Officers remain closely engaged with 
23 Mechanized Claims Processing and Information Retrieval Systems (90/10) Final Rule 
https://www.Federalregister.gov/documents/2015/12/04/2015-30591/medicaid-program-mechanized-claims-
processing-and-information-retrieval-systems-9010). 
24 https://www.medicaid.gov/medicaid/data-and-systems/mita/index.html 
77  states during the implementation as well as the operation phase of the IT initiative.  As part of 
the engagement, project reports and evidence are reviewed on a regular basis to identify risks, 
challenges, barriers and/or opportunities to better ensure project success.  As systems enter 
production operations (aka go-live), they are reviewed in-depth by CMS to ensure that the 
system functions appropriately to implement the policy requirements (e.g., for provider 
enrollment or for eligibility and enrollment).  Certain state systems also undergo a certification 
review conducted by CMS as an additional step in ensuring proper operation. 
Federal and state governments have invested heavily in the development and operations of 
Medicaid claims processing and information retrieval systems that engage in high volume 
transactions.  On April 14, 2022, CMS released updated Medicaid Enterprise Systems (MES) 
Certification guidance to ensure a more comprehensive analysis of CMS funded state systems 
functionality.  The release of the Streamlined Modular Certification for Medicaid Enterprise 
Systems demonstrates CMS focus on increasing accountability and state flexibility by creating 
an outcomes-based oversight model for state systems certification. 25 This approach focuses on 
producing timely and accurate claims payment results, properly screening and enrolling 
providers, member management, and comprehensive data analytics and reporting capabilities 
including timely and accurate submissions of required Federal reporting such as T-MSIS.   
Improper Payment Rate Measurement and Increased Accountability in Medicaid and CHIP 
Programs 
The Payment Integrity Information Act of 2019 requires each agency to periodically review 
programs it administers and identify programs that may be susceptible to significant improper 
payments.  For those programs determined to be susceptible, the agency is required to estimate 
the number of improper payments, submit those estimates to Congress, and report on actions the 
agency is taking to reduce improper payments.  The Medicaid and CHIP programs have been 
identified as being at risk for significant improper payments.  CMS estimates improper payment 
rates in Medicaid and CHIP through the PERM program.  The improper payment rates are based 
on reviews of the FFS, managed care, and eligibility components of Medicaid and CHIP in the 
year under review.  CMS measures Medicaid and CHIP improper payment rates using a 17-state 
rotation so that each state is reviewed once every three years.  States are required to submit 
corrective action plans to CMS to address the root causes of errors and deficiencies in an effort 
to reduce improper payments. 
In the HHS FY 2022 Agency Financial Report (AFR), 26 CMS reported the national Medicaid 
improper payment rate based on measurements conducted in FYs 2020, 2021, and 2022.  The FY 
2022 national Medicaid improper payment rate was 15.6 percent, representing $80.6 billion in 
gross Federal improper payments.  The FY 2022 national Medicaid improper payment rates by 
component are 10.4 percent for Medicaid FFS, 0.03 percent for Medicaid managed care, and 
11.9 percent for Medicaid eligibility.  The FY 2022 national CHIP improper payment rate was 
26.7 percent, representing $4.3 billion in gross Federal improper payments.  The FY 2022 
25 https://www.medicaid.gov/Federal-policy-guidance/downloads/smd22001.pdf 
26 https://www.hhs.gov/about/agencies/asfr/finance/financial-policy-library/agency-financial-reports/index.html 
78  national CHIP improper payment rates by component are 11.2 percent for CHIP FFS, 0.6 percent 
for CHIP managed care, and 24.0 percent for CHIP eligibility. 
The areas driving the FY 2022 Medicaid and CHIP improper payment estimates are as follows: 
  Insufficient Documentation: Represents situations where the required verification of 
eligibility data, such as income, was not done at all and where there is an indication that 
eligibility verification was initiated but the state provided no documentation to validate 
the verification process was completed. This includes situations where medical records 
were either not submitted or were missing required documentation to support the medical 
necessity of the claim.  Insufficient documentation accounted for 13.6 percent or $70.0 
billion of total errors cited in Medicaid FFS, Medicaid managed care and Medicaid 
eligibility in FY 2022. 
  State Non-Compliance: Represents noncompliance with Federal eligibility 
redetermination requirements, enrolled providers not appropriately screened by the state, 
providers not appropriately rescreened at revalidation, providers not enrolled, and/or 
providers without the required NPI on the claim.  State compliance with provider 
enrollment or screening requirements has improved as the Medicaid FFS component 
improper payment estimate decreased from 13.9 percent in FY 2021 to 10.4 percent in 
FY 2022. COVID-19 review flexibilities afforded to states should also be considered in 
the identified decrease in the Medicaid FFS and eligibility components between FY 2021 
and FY 2022. 
  Improper Determinations (CHIP-specific): represents situations where the beneficiary 
was inappropriately claimed under Title XXI (CHIP) rather than Title XIX (Medicaid), 
mostly related to incorrect state calculations based on beneficiary income, the presence of 
third-party insurance, or household composition/tax filer status. 
See additional information regarding the eligibility component and establishment of a baseline 
measurement on pages 225-226 and 230-231 of HHS 2021 AFR. 27 
A majority of Medicaid and CHIP improper payments were due to instances where information 
required for payment was missing, an eligibility determination was missing from the state 
system, states did not follow the appropriate process for enrolling providers, and/or states did not 
follow the appropriate process for determining beneficiary eligibility.  However, these improper 
payments do not necessarily represent payments to illegitimate providers or on behalf of 
ineligible beneficiaries.  Had the missing information been on the claim and/or had the state 
complied with the enrollment or redetermination requirements, then the claims may have been 
payable.  Conversely, had the missing documentation been available, it could have affirmatively 
indicated whether a provider or beneficiary was ineligible for Medicaid and/or CHIP 
reimbursement and, therefore, the payment was improper. A smaller portion of improper 
payments are considered a known monetary loss to the program, which are claims where CMS 
has sufficient information to determine that the Medicaid or CHIP payment should not have 
occurred or should have been made in a different amount. 
27 Prior to FY 2014, the eligibility component was reviewed and self-reported by the states to CMS for national 
improper payment reporting. 
79  CMS works closely with states to develop state-specific corrective action plans to reduce 
improper payments.  All states are responsible for implementing, monitoring, and evaluating the 
effectiveness of their plans, with assistance and oversight from CMS. 
Additional information on the Medicaid and CHIP improper payments can be found in the FY 
2022 Agency Financial Report 28 and CMS websites. 29 
Medical Loss Ratio Examinations 
CMS conducts examinations of Medicaid managed care plans financial reporting in selected 
states, focused on Medical Loss Ratio (MLR) and rate setting.  CMS conducted a risk-based 
analysis to select additional states for review beginning in FY 2021.  In January 2021, CMS 
initiated a review of Oregons 16 Coordinated Care Organizations MLR reporting for the 
Medicaid managed care population, and this review is currently ongoing.  In FY 2022, CMS also 
conducted a risk-analysis to identify additional states for review beginning in FY 2023. 
Medicaid 1115 Financial Oversight 
Medicaid section 1115 demonstrations are an increasingly important vehicle for state innovation 
in Medicaid program development, expansion and financing.  Forty-nine states and the District 
of Columbia operate at least one section 1115 demonstration, and there are approximately 82 
active demonstrations representing estimated Federal outlays of $186.0 billion in FY 2022.  The 
Medicaid section 1115 demonstration portfolio continues to grow in number, Federal outlays, 
and policy importance and complexity.  CMS has committed additional staff and reorganized 
section 1115 demonstration work to develop and implement a more robust approach to monitor 
and oversee these demonstrations.  
CMS is exploring refinements to its section 1115 demonstration budget neutrality policy to 
assure fiscal integrity and to better accommodate certain investments through the use of section 
1115 expenditure authority to strengthen the provider safety net and make advancements in 
closing health disparity gaps.  The goal is to develop a budget neutrality policy that can adapt to 
real-world factors and maintain a balance between integrity and flexibility. 30  In addition, to 
strengthen the review of state-submitted quarterly budget neutrality performance reports, CMS 
has developed and continues to maintain a standardized budget neutrality reporting tool for states 
that will need to be updated for any modifications to budget neutrality policy. 
CMS continues to modify and improve this tool based on user feedback to continue improving 
consistency in state reporting and CMS tracking of spending under section 1115 demonstrations.  
The section 1115 IT reporting system, Performance Metrics Database and Analytics (PMDA), 
continues to be updated to support this revised workflow and the documentation of findings from 
the budget neutrality reviews.  Most recently, CMS engaged contractor support on an internal 
initiative to more thoroughly document and train staff on the underlying principles, assumptions 
28 https://www.hhs.gov/about/agencies/asfr/finance/financial-policy-library/agency-financial-reports/index.html 
29 https://www.cms.gov/ImproperPayments 
30 https://www.medicaid.gov/sites/default/files/Federal-policy-guidance/downloads/smd18009.pdf 
80  and data to be used in the formulation of the budget neutrality parameters reflected in the 
demonstration approval documents.  
Beyond budget neutrality, CMS continues to expand and make more robust its oversight of the 
integrity of demonstration implementations.  This has included the continued training on and 
implementation of standard operating procedures, as well as continuing to utilize user feedback 
to make updates and refinements to PMDA to strengthen internal controls and development of 
standardized reports that permit more efficient and meaningful review of demonstration 
performance relative to expectations established in the demonstration special terms and 
conditions.  Relatedly, CMS continues to provide technical assistance to states to assure they 
understand and implement these more robust monitoring standards.  
CMS staff also continue to develop specific monitoring metrics for demonstrations testing high 
profile policy areas such as substance use disorder and severe mental illness.  CMS staff and 
states are provided with training to understand the impact of these metrics. 
Extend Work in Medicare Parts C and D 
CMS is committed to expanding program integrity activities in capitated, managed care 
programs in Medicare.  For example, CMS has strengthened oversight of Medicare Part C and 
Part D plan sponsors by conducting audits that detect whether plans are delivering the 
appropriate health care services and medications for which they are being paid. 
Investigations Medicare Drug Integrity Contractor (I-MEDIC) 
As part of CMSs ongoing efforts to ensure effective oversight of the Medicare Part C and Part D 
programs, CMS contracts with two Medicare Drug Integrity Contractors (MEDICs).  The 
primary purpose of the I-MEDIC is to detect, prevent, and proactively deter fraud, waste, and 
abuse for high-risk prescribers/pharmacies in Medicare Part C and Part D by focusing primarily 
on complaint intake and response, data analysis, investigative activities, referrals to law 
enforcement partners, and law enforcement support, which includes requests for information .  In 
FY 2022, the I-MEDIC initiated 651 investigations; submitted 77 recommendations for provider 
revocations; submitted 162 referrals to law enforcement, including 31 immediate advisements; 
and submitted 167 referrals to other entities, such as state pharmacy and medical boards, 
Medicare quality improvement organizations, and other Medicare contractors. 
Plan Program Integrity Medicare Drug Integrity Contractor (PPI MEDIC) 
The PPI MEDIC has a national focus related to plan oversight pertaining to the following Part C 
and Part D program integrity initiatives:  identification of program vulnerabilities, data analysis, 
health plan audits, outreach/ education, and law enforcement support, which includes requests 
for information (RFI).  As a result of the PPI MEDICs data analysis projects and Part D plan 
sponsor self-audits, $640,833 was recovered from Part D sponsors in the first eight months of FY 
2022.  
Contract-Level Risk Adjustment Data Validation (RADV) Audits 
RADV audits are CMSs primary corrective action to recoup overpayments in Medicare Part C.  
RADV uses medical record review to verify the accuracy of enrollee diagnoses submitted by MA 
81  organizations for risk adjusted payment.  CMS expects payment recovery will have a sentinel 
effect on risk adjustment data quality submitted by plans for payment, because contract-level 
RADV audits increase the incentive for MA organizations to submit valid and accurate diagnosis 
information.  Contract-level RADV audits also encourage MA organizations to self-identify, 
report, and return overpayments.  In FY 2022, CMS conducted a preliminary analysis of medical 
record review results for the payment year (PY) 2014 RADV audits and continued reviewing 
medical records for the PY 2015 RADV audits. 
Medicare Parts C and D Marketing Oversight  
Each year CMS analyzes Annual Notice of Change (ANOC) documents and takes compliance 
action against Part C Plans, also known as Medicare Advantage Organizations (MAOs), Part D 
Prescription Drug Plans (PDPs), Section 1876 Cost Plans, and Medicare-Medicaid Plans 
(MMPs) that fail to send timely and accurate ANOC documents to Medicare enrollees.  The 
ANOC provides Medicare enrollees with vital information that can affect their ability to make 
informed choices concerning their Medicare health care and prescription drug options.  
Program Audits 
CMS conducts program audits of Parts C and D plan sponsors (including organizations offering 
Medicare-Medicaid Plans) and PACE organizations to evaluate their delivery of health care 
services and medications to beneficiaries.  In order to conduct a comprehensive audit of a 
sponsors operation and maximize CMSs resources, scheduled Parts C and D program audits in 
2022, as well as in prior years, occur at the parent organization level, though PACE audits are 
conducted at the contract level. 
CMS audits all program audit areas for sponsors and PACE organizations unless an area is not 
applicable to the entitys operation, or CMS is conducting a focused audit.  Each sponsor or 
PACE organization that has deficiencies cited in its audit report is required to correct all of the 
deficiencies and undergo a validation audit or monitoring to ensure the issues have been 
corrected before the audit can be closed. 
In general, program audits give CMS reasonable assurance that sponsors and PACE 
organizations deliver benefits in accordance with the terms of their contracts and plan benefit 
packages.  However, CMS also has the authority to take enforcement actions, up to and including 
termination, if warranted, for findings that involve direct beneficiary harm or the potential to 
result in such harm. 
CMS has greatly increased the level of transparency to the industry with respect to audit 
materials, the performance of audits, and the results of those audits, including any enforcement 
actions that may result.  CMS believes that program audits and consequences of possible 
enforcement actions are continuing to drive improvements in the industry and are increasing 
sponsors compliance with core program functions in the Medicare Parts C and D and PACE 
programs.  
Fraud, Waste and Abuse Oversight and Education 
82  CMS conducts audits of Medicare Part C and Part D plan sponsors, with a focus on reducing 
improper payments and targeting drugs that are at high risk of improper payments.  Each type of 
audit is different in scope but has the same goal of educating Part C and D plan sponsors on 
issues of fraud, waste, and abuse, as well as identifying, reducing, and recovering inappropriate 
payments.  In FY 2022, CMS conducted 13 Part C and D audits. 
CMS also conducts outreach and training sessions for Medicare Part C and Part D sponsors on 
program integrity initiatives, investigations, data analyses, and potential fraud schemes.  CMS 
held Opioid Education Missions in October 2021 and May 2022; a COVID-19 fraud, waste, and 
abuse webinar in February 2022; and an MA Organization and Prescription Drug Plan fraud, 
waste, and abuse webinar in September 2022.  CMS also provides Part C and D plan sponsors 
with a Fraud, Waste and Abuse Quarterly Plan Report that includes information related to 
schemes and trends that can be used to identify suspicious activities in their own organizations, 
including those related to opioid overprescribing.  CMS released the first Fraud, Waste and 
Abuse Quarterly Plan Report in FY 2022. 
Compliance and Enforcement 
CMS has a number of tools, including the imposition of administrative enforcement actions, to 
encourage program compliance.  These actions include: 
  CMPs; 
  Intermediate sanctions (i.e., suspension of marketing, enrollment, payment); and 
  CMS initiated contract terminations. 
CMS has the authority to take enforcement or contract termination actions against a Part C or 
Part D plan sponsor for program violations, including: 
  Substantially failing to comply with program and/or contract requirements; 
  Performance under a contract with CMS in a manner that is inconsistent with the efficient 
and effective administration of the Medicare Part C and Part D program requirements; 
and 
  Failure to substantially meet the applicable conditions of the Medicare Part C and D 
program. 
Part C Benefits Review Activities 
Each year, CMS requires Part C organizations to submit bids and plan benefit packages detailing 
how their Part C plans will provide coverage to beneficiaries for the following year.  MAOs 
submitted to CMS more than 7,300 Part C plan benefit packages on June 6, 2022, and project to 
cover nearly 31.8 million enrollees in contract year 2023.  Bid and plan benefit submissions are 
reviewed to ensure they do not discriminate against beneficiaries and comply with CMS 
regulations.  Plan standards are established and communicated annually, and the following 
reviews are performed: 
  Low Enrollment PlansCMS evaluates existing Part C plans that have low total 
enrollment to make sure these plans are sustainable over time and protect beneficiaries 
from selecting a potentially unsustainable plan. 
83    Total Beneficiary Cost (TBC)CMS evaluates increases in beneficiary cost sharing or 
decreases in plan benefits from one year to the next.  This evaluation ensures 
beneficiaries receive value in their benefit package selection and protects them from large 
increases in out-of-pocket costs. 
  Maximum Out of Pocket Costs (MOOP)CMS conducts this review to examine the 
maximum out-of-pocket costs for enrollees in Part C and protect beneficiaries from very 
high out of pocket medical costs. 
  Service Category Cost-Sharing StandardsCMS evaluates the cost-sharing that plans 
include in their bids and plan benefit packages to ensure the plans do not exceed 
established limits and are not discriminatory.  
  Actuarial EquivalenceCMS reviews bids to make certain the estimated cost sharing 
presented in the bid is actuarially equivalent to the cost-sharing levels under FFS.  CMS 
currently examines four categories for actuarial equivalence and this review helps guard 
against plans imposing discriminatory cost-sharing on beneficiaries. 
  Supplemental BenefitsCMS conducts several reviews in this area, including a review 
of supplemental benefits that helps make sure that any optional supplemental benefits 
offered are of reasonable value, as well as a review to make certain the benefits are 
offered in a non-discriminatory fashion. 
CMS carefully conducts all of these reviews to ensure that plans make all necessary changes to 
their bids and plan benefit packages.  These reviews are conducted between early June and 
August, and, as necessary, involve communications with Part C organizations to correct issues 
and resubmit their bids and plan benefit packages.  Following bid and plan benefit approval, Part 
C organizations must complete the contracting process with CMS and may market to 
beneficiaries beginning October 1 of each year.  Part C benefit review standards and processes 
are intended to protect beneficiaries from discrimination and to ensure that Part C plans provide 
value to enrollees. 
Encounter Data Processing System 
CMS requires MAOs to submit encounter data for each item and service provided to MA plan 
enrollees.  CMS established and maintained the Encounter Data System (EDS), which to date, 
has collected approximately eight billion encounter data records (EDRs). 
The encounter data detail each item and service provided to MAO enrollees.  These records are 
comparable in format and detail to claims FFS providers submit to the MACs.  The encounter 
data collected by the EDS allows CMS to make accurate payments reflecting the patterns of care 
and the predicted costs of diseases for MA enrollees.  CMS also uses the information to evaluate 
service utilization, assess quality of care, and assess the MAOs performance. 
84  In CY 2015, CMS began to use encounter data as an additional source of diagnoses to risk adjust 
payments to MAOs.  For PACE organizations, CMS has continued the policy of using encounter 
data as an additional source of diagnoses for risk score calculation through CY 2024.  For 
organizations other than PACE, CMS began the transition from Risk Adjustment Processing 
System (RAPS) to encounter data in CY 2016 by calculating risk scores using both RAPS and 
encounter data, with RAPS-based risk scores weighted at 90 percent and encounter data-based 
risk scores weighted at 10 percent.  In CY 2022, CMS completed the transition to encounter data 
by calculating MAO risk scores using diagnoses entirely from encounter data and FFS data. 
Encounter Data Oversight and Integrity Activities 
Since complete and accurate encounter data are integral to risk adjustment payments and other 
uses of encounter data, CMS has developed an encounter data oversight and integrity plan to 
support efforts to ensure the completeness and accuracy of the MA data collected by CMS.  This 
plan aligns with direction provided by the GAO and lays out an incremental approach to assess 
and drive encounter data submission and quality over multiple years.  Major components of the 
plan include outreach, analysis, monitoring, and compliance of MAOs encounter data 
submissions. 
Improper Payment Rate Measurement in Medicare Advantage (Part C) and Medicare 
Prescription Drug Benefit Programs (Part D) 
Each year, CMS publishes national improper payment rates for Medicare Part C and Part D in 
accordance with the Payment Integrity Information Act of 2019. 
The Part C Improper Payment Measure (IPM) is an annual measurement of payment error for the 
Medicare Advantage (MA) program due to inaccurate diagnoses submitted by MA plans.  To 
calculate the projected IPM error rate, CMS selects a random sample of enrollees with one or 
more CMS Hierarchical Condition Categories (CMS-HCCs) and requests medical records to 
support each condition.  Independent coders abstract diagnoses from medical records, and the 
analytical contractor calculates corrected risk scores based on the abstracted diagnoses.  The 
difference between the original and corrected risk scores forms the basis to calculate the IPM. 
For FY 2022 (based on the 2020 payment year), the projected Part C improper payment estimate 
is 5.4 percent, representing $13.9 billion in improper payments.  In FY 2022, CMS finalized 
policy regarding treatment of new additional CMS-HCCs in the improper payment rate 
calculation.  Diagnoses that were not submitted to CMS for payment have been excluded from 
the payment error calculation to get a true measure of payment error.  In previous years, these 
potential payments were included in the underpayment rate and overall payment error 
calculation, biasing the IP rate upward, resulting in an overstatement.  The implemented policy 
for FY 2022 contributed to a decrease in the projected improper payment rate, representing a 
new baseline for Part C. 
The Part D gross improper payment estimate reported for FY 2022 (based on the 2020 payment 
year) was 1.5 percent or $1.4 billion, which represents payment error related to PDE data.  For 
the Part D Improper Payment Measurement, CMS measures the inconsistencies between the 
information reported on PDEs and the supporting documentation submitted by Part D sponsors: 
85  prescription record hardcopies (or medication order, as appropriate), and detailed claims 
information.  Based on these reviews, each PDE in the audit sample is assigned a gross drug cost 
error.  A representative sample of beneficiaries undergoes a simulation to determine the Part D 
improper payment estimate.  
Beginning in FY 2022, HHS simplified the standard error calculation simulation process to 
adhere to statistical best practice, resulting in a lower margin of error and more accurate 
estimate.  Further, HHS updated the data sources used to calculate the denominator in FY 2022; 
ensuring the calculation only considers Part D expenditures that may be identified through IPM 
clinical validation of PDE cost and payment amounts. 
To improve the Part D error rate, CMS has implemented the following actions: 
  Training:  In FY 2022, CMS continued national training sessions on payment and data 
submission with detailed instructions as part of the improper payment estimation process 
for Part D sponsors. 
  Outreach:  CMS continued formal outreach to plan sponsors with respect to invalid or 
incomplete documentation.  CMS distributed Final Findings Reports to all Part D 
sponsors participating in the PDE review process.  This report provided feedback on their 
submission and validation results against an aggregate of all participating plan sponsors. 
Additional information on Medicare Part C and Part D improper payments can be found in the 
FY 2022 Agency Financial Report 31 and CMS website. 32 
Ensure Program Integrity in the CMS Marketplace 
The Federally Facilitated Marketplace (FFM) and the State-based Marketplaces (SBMs) 
continued to expand their focus on program integrity.  In FY 2022, CMS triaged more than 
25,000 complaints from consumers who alleged they were enrolled in FFM policies without their 
consent or that incorrect information was submitted on an application by an agent or broker, or 
that other misconduct had occurred.  Issuers confirmed that over 11,000 of these policies met the 
unauthorized enrollment criteria and subsequently cancelled the policies.  Furthermore, issuers 
identified more than 23,000 additional policies attributable to fraud through their own 
investigations resulting in more than 34,000 overall policies being cancelled due to consumers 
being enrolled into a policy without their consent or knowledge in FY 2022.  CMS and its 
program integrity contractors continuously analyzed plan enrollments and other types of data to 
identify trends and early warning signs of fraud, conducted dozens of investigations of outlier 
and high-risk agents and brokers, and made recommendations for administrative action, such as 
termination of an agents and/or brokers registration to sell policies on the FFM.  CMS also 
performed over 700 license verifications to identify agents and brokers potentially noncompliant 
with states licensure statutes and regulations and reported license non-compliance to the 
appropriate state Department of Insurance (DOI).  CMS also supported ongoing HHS-OIG and 
DOI investigations by fulfilling requests for records regarding consumer FFM enrollments and 
financial assistance, complaints, and results of CMS investigations.  Sixty-one (61) such requests 
31 https://www.hhs.gov/about/agencies/asfr/finance/financial-policy-library/agency-financial-reports/index.html 
32 https://www.cms.gov/ImproperPayments 
86  were received and fulfilled in FY 2022.  Lastly, CMS hosted bi-monthly meetings with SBMs to 
share best practices for identifying and deterring fraud and notifying SBMs of specific schemes 
being investigated by the FFM and/or one or more SBMs. 
Following an FY 2016 risk assessment, HHS concluded the Advance Payment of the Premium 
Tax Credit (APTC) program is susceptible to significant improper payments and is required to 
establish and report an improper payment estimate.  In FY 2021, the Department commenced the 
improper payment measurement program for the Federally Facilitated Exchange (FFE) and 
reported for the first time in the FY 2022 AFR.  HHS continues to develop the improper payment 
measurement methodology for the State-based Exchanges (SBEs).  As with similar HHS 
programs, developing an effective and efficient improper payment measurement program 
requires multiple time-intensive steps, including contractor procurement; developing 
measurement policies, procedures, and tools; and extensive pilot testing to ensure an accurate 
improper payment estimate. 
The Exchange Improper Payment Measurement (EIPM) is an annual measurement of payment 
error for the FFE to determine if it properly paid APTC benefits under the regulatory 
requirements relating to eligibility and payment determinations.  CMS performs the reviews on a 
statistically valid random sample of 2,000 applications.  The improper payment rate and amounts 
estimated from this sample reflect all health insurance applications with APTC payments 
processed by the FFE for CY 2020. States that do not use the FFE to administer the APTC 
program, and instead have elected to operate independent SBEs, were not considered in the 
sample. 
FFE improper payment estimate for FY 2022, for measurement of CY 2020, is 0.6 percent or 
$255.8 million. The improper payment estimate due to lacking or insufficient documentation is 
0.04 percent or $16.8 million, representing 6.6 percent of total improper payments. The 
estimated percentage of APTC dollars paid correctly was 99.4 percent.  This means the FFE paid 
an estimated $41.0 billion correctly in FY 2022. 
The primary cause of overpayments was manual errors associated with determining consumer 
eligibility for APTC payments, representing 94.3 percent of overpayments, or $222.6 million. 
Most health insurance applications have consumer eligibility verified using automated processes. 
Automated processes refer to those functions which are executed using computer programming, 
and do not involve manual intervention.  Certain eligibility verifications consist of electronically 
comparing information provided by a consumer to that of third-party databases and determining 
if any inconsistencies exist that may impact a consumers eligibility.  For certain applications, 
manual eligibility verifications are necessary because of the circumstances of a consumers 
application (for example, an application submitted past the open enrollment period due to certain 
qualifying life events), or because the automated verification process identified a need for 
additional information to be provided by the consumer to verify their eligibility.  Manual 
verifications involve complex rules and a large variety of documentation types and formats, and 
therefore have a heightened risk of error. 
Combined Improper Payment Data 
87  The APTC program represents the first of two potential payment streams for the overall 
Premium Tax Credit program.  The second payment stream relates to additional Premium Tax 
Credit amounts claimed by taxpayers at the time of their tax filings, referred to as Net Premium 
Tax Credits (Net PTC).  That is, total Premium Tax Credit outlays are equal to APTC payments 
plus Net PTC claims.  The Internal Revenue Service measures improper payments associated 
with Net PTC claims, and for CY 2020 reported Net PTC claims of $1.3 billion, improper 
payments of $342.1 million, and an improper payment rate of 27.4 percent.  The combined 
APTC and Net PTC improper payment estimate is $597.9 million out of $42.5 billion total 
Premium Tax Credit outlays/claims, or 1.4 percent.  Note that similarly to the APTC improper 
payment information provided above, this combined APTC and Net PTC improper payment 
information does not reflect payments made by SBE. 
In an effort to improve the APTC improper payment rate, CMS has implemented the following 
corrective actions: 
  Systems Automation:  Some errors relate to the actual generation of APTC payments and 
others relate to the application of policies or procedures to the automated processes 
associated with APTC.  HHSs corrective actions include identifying and remediating 
system defects within the Exchanges that may impact APTC payments.  These defects 
become known through various mechanisms, including internal quality control activities 
and external reviews of APTC eligibility determinations made by the Exchanges.  HHS 
continually evaluates the policies and procedures that underlie the automated processes 
associated with APTC to identify and address weaknesses that may surface as they 
become operationalized.  HHS implemented process automation to reduce human error 
introduced during adjudication and processing of supporting documentation.  HHS will 
continue to encourage and require that additional tasks be automated to further reduce 
manual errors and improve the accuracy and quality of required adjudication tasks. 
  Training:  All eligibility support contractor personnel undergo a rigorous training when 
onboarded to the workforce.  They also receive annual refreshers and quick training 
lessons when program policy or operations are updated.  Ad hoc training is added as 
additional training needs are identified. HHS conducted additional training sessions 
related to Data Matching Issues verifications, casework, and outreach. 
  Audits:  Both the automated and the manual processes of the exchanges are subject to 
rigorous annual testing of key internal controls as required by OMB Circular A-123, 
Appendix C.  External audits by HHS-OIG and GAO are another common mechanism 
that help to identify potential payment integrity risks within the exchanges, specifically 
by evaluating APTC eligibility determinations made by the exchanges within the context 
of Federal statute and regulations. 
  Predictive Analytics: The Marketplace Program Integrity Contractor has implemented a 
risk model, which incorporates many risk factors that may be indicative of potential fraud 
or misconduct by agents or brokers.  The result is a risk profile and weighted risk score 
for each agent or broker.  Those that pose the highest risk, based on weighted risk score, 
are prioritized for investigations.  The risk profile is also leveraged as part of a prioritized 
88  investigation and significant discoveries may be used to inform interview questions or as 
supporting evidence in overall case findings. 
Additional information on FFE improper payments can be found in the FY 2022 Agency 
Financial Report and CMS website. 
Provide Greater Transparency into Program Integrity Issues within Medicare and 
Medicaid 
CMS is dedicated to providing greater transparency into program integrity issues through 
education, outreach, partnership, strategic communications, and data releases.  CMS is well-
positioned to work with its partners and stakeholders to share promising practices and lessons 
learned in program integrity.  Increased transparency and accountability ensure program 
efficiency and effectiveness. 
Health care Fraud Prevention Partnership (HFPP) 
The HFPP is a voluntary, public-private partnership consisting of the Federal Government, state 
agencies, law enforcement, private health insurance plans, and health care anti-fraud 
associations.  The overall mission of the HFPP is to protect the public by identifying and 
reducing health care fraud, waste, and abuse through collaboration, data and information sharing, 
and cross payer research studies.  The HFPP delivers actionable data to Partners to develop 
strategies to proactively disrupt existing and emerging fraud trends and contribute to cost 
savings.  This is achieved by:  
  Providing an unparalleled cross-payer data source, representing the full spectrum of the 
health care industry, to enable the performance of sophisticated data analytics and 
information-sharing for the benefit of all partners; 
  Achieving meaningful participation by partners and establishing strategic collaborations 
with diverse stakeholders; and 
  Leveraging HFPP resources and relationships to generate real-time, comprehensive 
approaches that materially impact efforts to reduce health care fraud, waste, and abuse. 
Section 1128C(a) of the Social Security Act (42 U.S.C. 1320a7c(a)) was amended by the 
Consolidated Appropriations Act, 2021 to provide explicit statutory authority for the HFPP 
including the potential expansion of the public-private partnership analyses. 
In FY 2022, the HFPP reached a total membership level of 267 partner organizations, comprised 
of six Federal agencies, 73 law enforcement agencies, 15 associations, 117 private payers, and 56 
state and local partners. 
The HFPP uses a diverse variety of approaches to identify vulnerabilities in Partner data.  These 
methods include standard searches to detect anomalies that may implicate the existence of fraud, 
waste, and abuse; scanning of incoming claims information against existing data sets, such as 
lists of deactivated providers; creation of reference files that list providers that may be suspect 
based on known risks; and creation of informational content to support stakeholders in 
addressing vulnerabilities (e.g., white papers).  The HFPP has also expanded its study 
89  methodology to collect frequently updated data, including, and consistent with all applicable 
privacy requirements, personally identifiable information (PII) and protected health information 
(PHI). The HFPP is currently using professional and institutional claims and began collecting 
pharmacy claims to be used in studies beginning in FY 2022. 
Over 56 billion professional claim lines were submitted by partners through FY 2022 for the 
purpose of conducting cross-payer analyses, and the HFPP has commenced 13 studies during FY 
2022 providing participating partners with detailed results that can be used for corrective actions 
within their organizations.  Examples of studies initiated in FY 2022 include the identification of 
problematic billing in the following areas: 
  COVID-19 add-on laboratory testing; 
  Psychotherapy, physical therapy/occupational therapy improbable days; 
  Applied Behavioral Analysis (ABA) therapy; 
  Footbaths; 
  Substance Use Disorder (SUD) treatment; and 
  Psychotropics in nursing facilities. 
The HFPP also continued its efforts to foster collaboration among partners in FY 2022 by 
hosting five virtual information-sharing sessions, small group discussions, and quarterly 
Executive Board meetings.  These meetings are used to share fraud schemes and provider alerts, 
provide updates on law enforcement activities, and strategize on how to broaden the HFPPs 
impact in the private and public sectors.  In addition, the HFPP held focus groups to ascertain 
from Partners their thoughts on the strategic direction of the Partnership. 
Open Payments 
Open Payments is a statutorily required national transparency program designed to provide the 
public with information regarding the financial relationships between applicable manufacturers 
and group purchasing organizations (collectively referred to as reporting entities) and physicians, 
physician assistants, advanced practice nurses, and teaching hospitals (collectively referred to as 
covered recipients).  Open Payments data includes payments and other transfers of value (such as 
gifts, honoraria, consulting fees, research grants, and travel reimbursements) that reporting 
entities provide to covered recipients, as well as the ownership and investment interests held by 
physicians or their immediate family members in these companies.  HHS is required to collect 
and display the data on the public website, where the reported data can be searched, downloaded, 
and evaluated.  
The Program Year 2021 data publication was the first publication that included the Substance 
Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and 
Communities (SUPPORT) Acts expanded definition of covered recipients adding five provider 
types to the Open Payments data.  The additional provider types as of Program Year 2021 and 
going forward are: physician assistants, nurse practitioners, clinical nurse specialists, certified 
registered nurse anesthetists and anesthesiologist assistants, and certified nurse midwives. 
Within the Open Payments program, the added provider types are collectively referred to as 
non-physician practitioners or NPPs. 
90  For Program Year 2021 (January 1, 2021-December 31, 2021), CMS published $10.90 billion in 
payments and ownership and investment interests that were made from reporting entities to 
covered recipients.  This amount is comprised of approximately 12.10 million total records 
attributable to 533,056 physicians, 233,471 non-physician practitioners and 1,237 teaching 
hospitals. Payments in the three major reporting categories included:   
        $2.55 billion in general (i.e., non-research related) payments; 
        $7.09 billion in research payments; and 
  $1.26 billion of ownership or investment interests held by physicians or their immediate 
family members. Ownership or Investment Interests include those held by physicians or 
their immediate family members. This category is not applicable to non-physician 
practitioner covered recipients or teaching hospitals. 
Over the past seven years, CMS has published a total of 78.8 million records, accounting for 
$63.2 billion in payments and ownership and investment interests. 
Administration for Community Living 
The mission of the Senior Medicare Patrol (SMP) program is to empower and assist Medicare 
beneficiaries, their families, and caregivers to prevent, detect, and report health care fraud, 
errors, and abuse through outreach, counseling, and education.  In FY 2022, HHS allocated $30.0 
million in HCFAC appropriations, plus an additional $48,226 in carryover funding from FY 
2021 to the Administration for Community Living (ACL) to support SMP program infrastructure 
and provide grants to SMPs in 54 states and territories. 
Until FY 2016, ACL received funding from a separate Congressional appropriation (the Older 
Americans Act) to support SMP grants.  However, the Consolidated Appropriations Act of 2016 
required the SMP program to be fully funded by CMS discretionary HCFAC appropriations 
beginning in FY 2016.  This language was modified in FY 2018 to require that the program be 
funded at no less than $17.6 million, still from CMS discretionary HCFAC appropriations.  In   
FY 2021, Congress increased the floor for SMP funding to $20.0 million from CMS 
discretionary HCFAC appropriations, and again in FY 2022 to $30.0 million.  In addition, 
Congress provided ACL, for the first time in FY 2021, with authority to be funded from CMS 
discretionary appropriations, wedge funding, or both.  Based on that authority, in FY 2022, ACL 
requested and received $2.0 million for a one-time effort supported by wedge funding to expand 
efforts of the program both nationally and at the state and local level to reach people in underserved 
communities. 
SMP Project Activities and Outcomes 
ACL uses the majority of its HCFAC allocation to fund SMP projects in every state, the District 
of Columbia, Puerto Rico, Guam, and the U.S. Virgin Islands.  During FY 2018, ACL held a 
new SMP grant competition and awarded $15.5 million in funding to 54 SMPs nationwide, 
91  including eight new SMP grantees.  In FY 2022, ACL provided continuation awards to the 54 
grantees totaling $15.6 million.  Each SMP grantee received a standard, base amount of funding 
to support the operation of their project, as well as an additional, variable amount of funding 
based on the number of Medicare beneficiaries residing in the state and the rural areas of the 
state.  SMP projects use this funding to educate and empower Medicare beneficiaries to prevent, 
detect, and report Medicare fraud, errors, and abuse.  Due to the increased in funding for this 
fiscal year, grantees also received administrative supplements totaling $11,453,839.  The 
additional funding was distributed using the SMP grant formula which considers the number of 
Medicare beneficiaries in each state and territory.  SMP projects proposed to use this funding to 
increase base grant activities. 
COVID-19 Fraud Schemes 
Fraud schemes relating to COVID-19 became prevalent beginning in March 2020 and continued 
throughout FY 2021 and FY 2022.  The majority of complaints received by the SMP grantees 
continued to relate to COVID-19 treatments, testing, vaccines, and cures, followed by other 
pandemic related fraud.  Other COVID-19 related fraud identified by the SMP program included 
fraud related to health insurance solicitation, false charities and investments schemes, and 
financial scams.  Additional schemes reported included those related to general COVID-linked 
medical services or pandemic supplies and equipment.  Most reported COVID-19 fraud or 
schemes occurred in-person, followed by fraud via text and telephone attempts.  Though the 
SMP programs education and outreach activities were largely limited to virtual methods during 
this period as opposed to typical face-to-face means, grantees responded quickly to COVID-19 
fraud attempts.  Throughout this crisis, ACL has carefully recorded and analyzed complaint 
details nationally and prepared sanitized summary reports that are shared regularly with the SMP 
grantees, HHS-OIG, CMS, FBI, and SSA. 
In addition, ACL, the HHS-OIG, and the SMP National Resource Center worked together on 
national level media campaigns to get the word out on COVID-19 related fraud schemes.  The 
SMP National Resource Center developed, released, and continually updated COVID-19 
Consumer Fraud Alerts focused on COVID-19 fraud schemes occurring nationally in order to 
warn Medicare beneficiaries and their families to take precautions.  Covered fraud schemes 
involve topics such as unsolicited marketing tactics to enroll beneficiaries in hospice services, 
COVID-19 vaccines and treatments, and genetic testing.  Produced materials advise beneficiaries 
to be suspicious of strangers who offer unsolicited COVID-linked items, services, or testing.  
They also advise beneficiaries to be wary of scare tactics used to pressure them into acting, and 
to be cautious about sharing their personal information, including their Medicare identification 
number.  In addition, these materials warn that personal information could be used to fraudu-
lently bill Medicare and Medicaid.  Materials include consumer tip sheets on a variety of general 
and specific COVID-19-focused topics, Medicare coverage FAQs, infographics, and videos, 
most of which are available in both English and Spanish.  As reported in the most recent HHS-
OIG report on SMP (OIG Final Report:  2021 Performance Data for the Senior Medicare Patrol 
Projects (OEI-02- 22-00310)), the SMP projects conducted 645 group education events covering 
COVID-19 fraud issues in 2021, reaching a total of 26,704 people.  In addition, they conducted 
144 instances of media outreach on this topic, reaching an estimated 17.2 million people. 
92  Genetic Testing Fraud Schemes 
Genetic testing fraud continued to be a widespread issue nationally in FY 2022 with company 
representatives approaching seniors and other Medicare beneficiaries to solicit genetic tests at 
senior and community centers, health/senior fairs, other community events, and senior housing 
complexes.  In mid-FY 2021, scammers started offering Medicare beneficiaries cardiac genetic 
testing (cardiogenetics) in order to obtain their Medicare information for fraudulent purposes and 
this scheme continued and intensified in FY 2022.  The SMP grantees have received reports of 
company representatives going door-to-door in the community and within housing complexes in 
addition to extensive advertising on Facebook and other social media platforms.  ACL and the 
SMP grantees continued to conduct targeted public education and outreach efforts on this topic 
during this period along with the HHS-OIG.  A topic-focused fraud alert was developed as part 
of this effort.  The alert cautions beneficiaries about sharing personal information that can be 
used fraudulently. The SMP projects conducted 505 group education events covering genetic 
testing fraud issues in 2021; these events reached 24,562 people.  In addition, they conducted 
144 instances of media outreach on this topic, reaching 17.2 million people. 
Annual SMP OIG Report 
Each year, the HHS-OIG completes an annual performance report on the SMP program and 
grantees.  The most recent report covers CY 2021 (OEI-02-22-00310).  In CY 2021, the SMP 
projects had a total of 5,346 active team members who conducted 12,660 group outreach and 
education events, reaching an estimated 556,980 people.  In addition, the projects had 239,625 
individual interactions with, or on behalf of, a Medicare beneficiary.  For CY 2021, the SMP 
projects reported $2.5 million in expected Medicare recoveries.  Over half of these recoveries 
came from one project that uncovered a genetic testing fraud scheme in which residents of a 
senior house complexes were persuaded to submit genetic testing specimens to a laboratory 
without sufficient involvement of a health care professional. 
Since the SMP programs inception, the program has received more than 3.7 million inquiries 
from Medicare beneficiaries about preventing, detecting, and reporting billing errors, potential 
fraud, or other discrepancies.  SMP projects have also educated more than 42.6 million people 
through group presentations and community outreach events.  The primary focus of these 
sessions is on education, prevention, and teaching beneficiaries how to protect themselves and 
avoid fraud in the first place.  This is the true value of the SMP program.  However, the impact 
of these education and prevention activities is extremely difficult to quantify in dollars and cents.  
As HHS-OIG indicated in their 2020-2022 reports on the SMP program: 
We note that the projects may not be receiving full credit for recoveries, savings, and cost 
avoidance attributable to their work.  It is not always possible to track referrals to 
Medicare contractors or law enforcement from beneficiaries who have learned to detect 
fraud, waste, and abuse from the projects.  In addition, the projects are unable to track the 
potentially substantial savings derived from a sentinel effect whereby Medicare 
beneficiaries scrutiny of their bills reduces fraud and errors. 
93  Despite the factors that have limited ACLs ability to quantify the value of the SMP program in 
preventing, identifying, and reporting health care fraud, HHS-OIG has documented over $148.5 
million in savings attributable to the SMP program since its inception in 1997. 
Medicare Fraud Prevention Week 
In FY 2022, the first Medicare Fraud Prevention Week was held June 5-11, 2022, marking the 
SMP programs 25th anniversary year.  When it was identified that no event existed that included 
similar scope, mission, and key players, ACL and the SMP Resource Center took on this 
important inaugural task.  The event focused on the actions that everyone could take to prevent 
Medicare fraud, errors, and abuse.  Each day of the week focused on a different audience with 
different messages and action steps around fraud prevention.  Medicare beneficiaries, caregivers, 
families, partners/professionals, health care providers, and the community were all targeted 
audiences.  For this first Medicare Fraud Prevention Week, the goals were to: 
  Engage SMP projects and create excitement around participating; 
  Create resources for SMP and public use; 
  Increase social media follows, reach, impressions, and video views across all social 
media platforms; and 
  Work with partners in sharing the SMP program information. 
Overall, this awareness week was an incredible success.  Analytics were closely tracked and 
included outcomes such as: 
  Many national-level resources developed including paid advertisements, general 
informational program videos and infographics, two new topic-specific videos focused on 
How to Read Your Medicare Summary Notice and How to Use a My Health Care 
Tracker; 
  14,988 Google page views from 2,992 users; 
  130,652 Facebook reach including 923 event responses and 72,222 Twitter impressions 
from paid ad campaigns; 
  5,925,477 Hulu ad impressions; 
  354 new YouTube viewers including 575 video views for a 2,200 percent increase in 
views; and 
  23 national level partners and 80 local agencies and organizations participating 
electronically. 
SMP Infrastructure and Program Support 
SMP Resource Center 
During FY 2020, ACL competed and selected the Northeast Iowa Area Agency on Aging for a 
new five-year grant to serve as the SMP National Resource Center (the Center).  In FY 2022, the 
Center received a continuation award totaling $850,000.  In addition, the Center received base 
and HCFAC Wedge supplements totaling $700,000 to focus on the continuation of previously 
planned grant activities and increases in diversity, equity, and inclusion efforts internally and 
among state SMP projects.  The Center has provided technical assistance, support, and training 
to the SMP projects since 2003.  The goal of the Center is to provide professional expertise and 
94  technical support, serve as an accessible and responsive central source of information, maximize 
the effectiveness of the SMP projects in health care fraud outreach and education, and ensure a 
comprehensive national approach to reaching Medicare beneficiaries.  The Center has also been 
instrumental in supporting ACL efforts to forge national visibility for the SMP program.  
Highlights of the SMP National Resource Centers planned work during the next five-year 
period include maintaining a new national SMP-focused mobile application, producing 
additional in-depth grantee resources and SMP Consumer Alerts as need arises, and acting as a 
clearinghouse for ACL on complex case data and referral information in emerging fraud trends. 
SMP Information and Reporting System 
Since FY 2016, ACL has supported a national SMP information and reporting system (SIRS) to 
support the evolving needs of the SMP projects.  SIRS is expected to last at least 10 years and 
provides SMPs with advanced reporting features and data analytics to help them better manage 
their programs.  In FY 2022, ACL continued to work with SMPs to prioritize and implement 
ongoing system improvements to ensure SIRS continues to meet their needs and best support 
their programs.  
SMP Customer Satisfaction Survey 
During FY 2020, ACL developed a request for proposals to award a new expanded State Health 
Insurance Assistance Program (SHIP)33 and SMP National Beneficiary Satisfaction Survey 
contract.  The goal of this contract, which entered Year 3 in FY 2022, is to ascertain the quality 
and effectiveness of the services provided by the SHIP and SMP program.  The scope of the 
Beneficiary Surveys is to evaluate and measure satisfaction with SHIP and SMP educational 
presentations and Medicare one-on-one counseling sessions.  The surveys assess how benefi-
ciaries value the services and information they receive, identify opportunities for continuous 
improvement, and comply with regulatory requirements regarding data collection.  The 
evaluation includes two types of surveys:  (1) for individual counseling sessions with Medicare 
Beneficiaries, and (2) for individuals that attended an educational presentation.  The results will 
create a baseline understanding of satisfaction with counseling services and educational 
presentations and identify opportunities for recognition as well as overall network improvements.  
The second year of the surveys indicate high rates of satisfaction with both the one-on-one 
interactions and group outreach conducted by the SMP projects nationally.  The average national 
ratings were as follows (1= Strongly Disagree, 5 = Strongly Agree): 
Group Outreach Activities: 
o  4.74  This Presentation provided me with useful information 
o  4.75  Overall, I am satisfied with the presentation today 
o  4.65  I would contact the presenter for help or information 
o  4.75  I would recommend this presentation to others 
33 The SHIP (State Health Insurance Assistance Program) is a sister program to the SMP administered by ACL that 
provides direct assistance to Medicare beneficiaries and their families to help them understand, enroll in, and 
navigate their Medicare benefits.   The ACL Medicare beneficiary satisfaction surveys are administered together 
given the similarities and overlap between the SHIP and SMP programs. 
95  One-on-One Interactions: 
o  4.07  I was able to find and contact SMP in a timely fashion 
o  4.28  The information provided to me was useful 
o  4.24  SMP provided me with useful information 
o  4.36  Overall, I was satisfied with my interaction with SMP 
o  4.12  I would contact SMP again for assistance 
o  4.26  I would recommend SMPs service to others 
The overall survey results were consistent across states and territories.  There was a strong 
correlation between the usefulness of information respondents received and the beneficiarys 
overall satisfaction with the service provided by the SMP. 
Office of the General Counsel 
In FY 2022, HHS allocated the Office of the General Counsel (OGC) $7.7 million in HCFAC 
funding to support OGCs program integrity activities.  Such activities focused on litigation 
aimed at the recovery of program funds and review of CMS programs to strengthen them against 
potential fraud, waste, and abuse.  OGCs HCFAC activities in FY 2022 helped the Government 
establish approximately $1.3 billion in judgments, settlements, or other types of recoveries, 
savings, or receivables. 
FCA and Qui Tam Actions 
OGC supports DOJs FCA work by interpreting complex Medicare, Medicaid, and CHIP rules 
and policies, which assists DOJ in discerning which allegations involve program violations and 
helps focus government resources on the matters that are most likely to result in recovery.  In 
addition, OGC provides significant litigation support by assisting DOJ in interviewing and 
preparing CMS personnel who may act as witnesses and in responding to requests for documents 
and information.  
In FY 2022, OGC worked collaboratively with DOJ and HHS-OIG on numerous FCA matters 
regarding a variety of issues such as:  price-fixing drugs, physician self-referral, supplier billing 
of tests and services that were not rendered or that were medically unnecessary, failure to report 
discounted prescription drug prices, misrepresentations under the Medicare Electronic Health 
Records (EHR) incentive programs, kickbacks and other unlawful marketing practices in 
connection with the marketing of EHR products, billing for grossly substandard skilled nursing 
services, and billing for rehabilitation therapy services that were not reasonable, necessary, or 
skilled.  OGC efforts on these and other FCA matters in FY 2022 helped the Federal 
Government recover approximately $1.14 billion. 
96  Civil Monetary Penalties 
CMS is responsible for administering CMP laws that are aimed at combatting fraud, waste, and 
abuse.  OGC, in turn, advises CMS on its development and imposition of CMPs.  OGC also 
defends CMS in numerous administrative appeals and judicial litigation related to the imposition 
of CMPs.  The decisions in such cases can immediately affect the quality of care provided to 
affected beneficiaries, save program funds, and set precedents that demonstrate HHSs 
commitment to policing this area. 
OGC obtained several favorable outcomes regarding the imposition of CMPs during FY 2022, as 
the COVID19 pandemic continues to spotlight health care facilities responses to infection 
control issues.  OGC has advised CMS on numerous actions related to facilities responses to 
infection outbreak and has also worked with CMS on nursing home enforcement actions 
involving infection control, including cases associated with COVID19 and other pathogens.  For 
example, OGC successfully defended CMSs determination of immediate jeopardy and its 
imposition of CMPs totaling $427,950 for a facilitys failure to implement its infection 
prevention and control program.  Forty-four (44) residents tested positive for COVID-19 and 14 
of them died in less than a month.  Yet the facility defended its failure to follow its infection 
control policies by arguing that the interventions were useless and too difficult to follow.  The 
administrative law judge (ALJ) ultimately upheld CMSs findings, including that the facility 
failed to:  (1) provide signs for doors of residents rooms showing they were under droplet 
precautions, (2) establish an effective method of communicating COVID-19 positive status to 
staff, and (3) isolate multiple symptomatic residents from asymptomatic residents. 
Provider/Supplier Suspensions and Enrollment Revocations or Denials 
Payment suspensions, enrollment revocations, deactivations and denials all play a critical role in 
protecting program funds.  These actions help protect the Trust Funds by ensuring that providers 
and suppliers who have committed certain conduct or acts or against whom there are credible 
allegations of fraud are not given, or do not retain, the ability to submit claims.  OGC assists with 
this work by advising CMS on whether to suspend payment to Medicare providers and suppliers; 
interpreting CMS enrollment regulations; reviewing proposed enrollment rules, manual changes, 
and correspondence related to enrollment issues; and providing litigation support and program 
guidance in defense of suspensions, revocations, and denials. 
For example, in FY 2022, OGC successfully defended CMSs revocation of a supplier based on 
improper prescribing practices, in particular, over-prescription of opioids.  As part of a CMS 
audit, the physician was flagged as a practitioner who frequently prescribed drugs, including 
opioids, to Medicare beneficiaries.  Review of his medical records indicated generic and vague 
justifications for his prescriptions, with little to no follow-up when patients exhibited other risk 
factors for potential drug misuse.  The ALJ issued a decision upholding CMSs action, finding 
that every factor CMS relied upon for revocation was supported by the record. 
Part C and Part D Compliance 
During FY 2022, OGC provided extensive advice to CMS on a variety of Part C and Part D 
compliance issues, including identifying enforcement options against plan sponsors that were 
noncompliant or violated program rules.  When challenged, OGC defends CMSs imposition of 
97  CMPs in administrative hearings and, in conjunction with DOJ, in Federal court.  OGC also 
continued its review of compliance-related correspondence that CMS issues to Part C plans and 
Part D sponsors, which include warning letters, imposition of corrective action plan letters, 
intermediate sanctions, CMP notices, and non-renewal or termination notices.  OGC also defends 
CMS non-renewal or termination actions of Part C and Part D plan contracts. 
Regulatory Review and Programmatic Advice 
In FY 2022, OGC advised CMS on a variety of regulatory and program issues aimed at 
combating fraud and preventing the wrongful disbursement of program funds in the first 
instance.  For example: 
  Generally, OGCs COVID-19 related work subsided in FY 2022, as compared to 2021, 
nevertheless OGC continues to provide support and counsel on a wide variety of topics in 
the context of Medicare, Medicaid, and CHIP.  OGC has advised on issues related to 
section 1135 waivers, adjustments to permissible sites of care for the provision of 
medical screening for emergencies, Emergency Medical Treatment and Labor Act 
requirements, survey and certification processes, including enforcement and oversight 
policies, provider/supplier enrollment, the COVID-19 Accelerated and Advanced 
Payments program, debt recovery requirements, improper payment measurement 
processes, waivers of the physician self-referral law, or the Stark Law, and other fraud 
and abuse requirements.  OGC has provided expeditious responses to support the 
clearance of numerous rules that address the COVID-19 public health emergency.  OGC 
worked extensively with CMS on issues related to unwinding certain PHE flexibilities. 
  OGC advised CMS on multiple issues regarding the implementation of the COVID-19 
Health Care Staff Vaccination rule (vaccine rule ) (press, guidance, and enforcement), 
including providing advice on programmatic implications involving CMS and state 
oversight functions.  Several states opposed the rule and would not permit state surveyors 
to conduct surveys to determine compliance. 
  OGC spent extensive time advising DOJ in litigation before Federal district and appellate 
courts challenging CMSs vaccine rule for staff in health care facilities subject to the 
regulation.  OGC attorneys provided exceptionally expeditious assistance reviewing 
briefs and other pleadings to ensure that legal propositions concerning CMSs programs 
are accurately stated.  In March, the Supreme Court stayed a preliminary injunction 
against the rule and allowed it to go into effect nationwide. 
  OGC continues to spend extensive time on various opioid-related issues, primarily related 
to Touhy requests and discovery in continuing opioid matters and to potential CMS 
monetary recoveries stemming from other parties settlements, judgments, and 
bankruptcy actions. 
  OGC continues to counsel the CMS Quality, Safety, and Oversight Group (QSOG), 
formerly known as the Survey & Certification Group, which provides oversight and 
enforcement of certified institutional providers with program health and safety 
98  requirements intended to assure basic levels of quality and safety.  OGC advises QSOG 
regarding the development of enforcement policies, authorities regarding various 
enforcement remedies such as CMPs and program termination, rulemaking, reviewing 
interpretive guidance, and administrative litigation issues. 
  OGC reviewed several rules designed to improve Medicare program integrity, including 
proposed and final rules related to enrollment and medical review requirements, a new 
provider-type known as rural emergency hospitals (REH), and the establishment of 
survey and enforcement requirements for hospice programs. 
  OGC continues to counsel the CMS Innovation Center, which tests payment and delivery 
models to reduce expenditures and preserve or enhance quality of care for Medicare, 
Medicaid, and CHIP beneficiaries.  OGC provides ongoing advice regarding the 
development of contracts, the imposition of corrective action plans, participant screening, and 
recovery of funds for such models.  In addition, OGC continues to provide counsel to CMS 
on program integrity issues in the Medicare Shared Savings Program, including advice 
regarding program integrity screenings for applicants to the program, appeals of application 
denials and the implementation of its Beneficiary Incentive Program. 
  OGC continues to collaborate with DOJ and the Health Resources and Services 
Administration on issues arising in connection with the Provider Relief Fund created by 
the CARES Act, enacted in March 2020. 
Physician Self-Referral (Stark Law) 
In FY 2022, OGC provided extensive counsel to CMS regarding its Medicare Physician Self-
Referral Disclosure Protocol (SRDP), which was created to enable Medicare providers to self-
disclose technical violations of the Stark Laws physician self-referral prohibition.  OGC 
continued to have a significant role in advising CMS on navigating the complexities of the Stark 
Law.  In FY 2022, OGC continued to assist and advise CMS following the publication of its rule 
modernizing and clarifying the Stark regulations, which went into effect last year.  Further, OGC 
provided advice related to the blanket waivers of sanctions under the Stark Law for COVID-19 
purposes, which action provided vital flexibility for physicians and providers in the fight against 
COVID-19.  In addition, as discussed above, OGC continued to provide guidance to CMS and 
DOJ in navigating the complexities of the physician self-referral law in FCA cases.  These 
consultations help build stronger cases and focus investigatory efforts, leading to successful 
results for the Government.   
Medicare and Medicaid Third Party Liability 
OGCs efforts to recover Medicares conditional payments for which other payers bear primary 
payment responsibility directly support the HCFAC statutory goal of facilitating the enforcement 
of all applicable legal remedies for program fraud and abuse.  As part of this work in FY 2022, 
OGC assisted DOJ in its efforts to protect Federal Medicare and Medicaid interests in Federal 
opioid lawsuits as HHS continues to find ways to abate the opioid epidemic.  
99  Denial of Claims and Payments 
CMS and its contractors engaged in various activities and initiatives to detect and prevent 
abusive and fraudulent billing practices.  These measures included provider, supplier, and 
beneficiary education, use of claim sampling techniques, and rigorous scrutiny of claims with 
increased medical review.  For example, in Wilensky v. Becerra, after proceeding through the 
administrative review process, the plaintiff appealed the denial of Medicare Part D coverage for 
a drug (Alosetran) to Federal district court.  Coverage had been denied because the drug was not 
FDA-approved for the plaintiffs condition, and therefore the drug was not prescribed for a 
medically accepted indication, as required for reimbursement under Medicare Part D.  The 
plaintiff sought discovery in Federal court, arguing that the Secretarys reasons for denying 
coverage were pretextual and seeking information about possible past coverage of the drug.  
Plaintiff had requested the same information below, but the Medicare Appeals Council denied 
the request as irrelevant to the issue on appeal.  The U.S. District Court for the District of 
Minnesota held that the plaintiffs request for discovery during the administrative review process 
was not supported by any authority requiring the Medicare Appeals Council to grant his request, 
and that the Councils refusal to allow discovery did not create a basis for permitting discovery 
in Federal court.  Once the ruling was made, the plaintiff notified the court of his intent to 
voluntarily dismiss the case. 
Bankruptcy Litigation 
OGC protects Medicare funds from waste in bankruptcy cases by asserting CMS recoupment 
rights to collect overpayments, arguing to continue suspension or termination actions against 
debtors, seeking adequate assurances from the bankruptcy court that CMS interests in the 
debtors estate will be protected, arguing for the assumption of Medicare provider agreements as 
executory contracts, and petitioning for administrative costs where appropriate.  OGC also 
handles change of ownership issues related to bankrupt Medicare providers to ensure successor 
financial liability and to protect patient health and safety.  For example, in FY 2022, OGC 
handled several matters involving issues arising under the COVID-19 Accelerated and Advanced 
Payments program and bankruptcy.  OGC represented CMS and HRSA in the bankruptcy of 
Gulf Coast Health Care LLC, which included over fifty skilled-nursing facilities.  OGC worked 
with DOJ to file objections to the financing order and management and operations transfer 
agreements because they did not provide full Medicare successor liability and because they 
intended to use provider-relief funds for improper purposes.  OGC and DOJ negotiated changes 
in these documents so that the transactions complied with regulatory, statutory, and HRSA 
guidance and requirements.  OGC also prepared and filed approximately 80 proofs of claim and 
administrative claims for the over $40.0 million in PRF payments the entities received. 
State Medicaid Disallowances 
Over the past several years, upon identifying an increasing number of questionable state 
financing schemes designed to maximize Federal payments under Medicaid, CMS has taken an 
increased number of Medicaid disallowances.  Correspondingly, OGC continues to see a 
significant increase in its workload regarding proposed disallowances, requested reconsider-
ations, and defense against Medicaid disallowance appeals before the Departmental Appeals 
Board.  As a result of OGCs advocacy, CMS has prevailed in matters in FY 2022 that have 
upheld millions of dollars in disallowances. 
100  In summary, OGCs efforts in FY 2022 directly supported the HCFAC programs goals.  As part 
of its program integrity work, OGC coordinated with CMS, DOJ, and HHS-OIG to enforce 
various statutes and regulations applicable to health care fraud and abuse, to the benefit of the 
Medicare, Medicaid, and CHIP programs. 
Food and Drug Administration Pharmaceutical Fraud Program 
In FY 2022, $11.9 million in HCFAC funding was made available for the FDA 
Pharmaceutical Fraud Program (PFP).  The PFP was instituted to enhance the health care 
fraud-related activities of FDA's Office of Criminal Investigations (OCI) and the Office of the 
General Counsel Food and Drug Division (OGC-FDD).  OCI, with the support of OGC-FDD, 
investigates criminal violations of the Federal Food, Drug, and Cosmetic Act (FDCA), the 
Federal Anti-Tampering Act, and related Federal statutes. 
The PFP is designed to detect, prosecute, and prevent pharmaceutical, biologic, and medical 
device fraud.  The PFP gathers information from sources inside and outside FDA and focuses 
on fraudulent marketing schemes, application fraud, clinical trial fraud, and flagrant 
manufacturing- related violations concerning biologics, drugs, and medical devices.  The goal 
of the program is the early detection and prosecution of such fraudulent conduct.  This furthers 
FDAs public health mission by protecting the public from potentially dangerous medical 
products, helping to reduce health care costs, in most cases before they are incurred, and 
deterring future violators.  By initiating investigations of medical product fraud schemes 
earlier in their lifecycle, FDA is able to preclude potential public harm by barring medical 
products, which have not followed the legal FDA approval processes and do not meet FDA 
standards, from making it to market, saving valuable health care dollars from being spent. 
The PFP has identified multiple alleged medical product fraud schemes through various avenues.  
Since the inception of the PFP, OCI has opened a total of 325 criminal HCFAC investigations.  
In FY 2022, OCI, through its PFP, opened 16 criminal investigations, including investigations 
involving drug compounders, clinical trials, and foreign and domestic medical-product 
manufacturers.  FDA is committed to tackling emerging public health concerns.  In FY 2022, the 
PFP has opened two COVID-19 related criminal investigations related to fraudulent treatment 
and prevention of COVID-19.  
The 16 criminal investigations opened through PFP in FY 2022 are broken down as follows: 
  Four investigations involving allegations of application fraud.  One of the investigations 
involves fraudulent documents being submitted in support of an application by a biologic 
manufacturer. One investigation involves a biologic manufacturer exploiting the 
application process to avoid having to apply for an Investigational New Drug (IND). 
Another investigation is into a device manufacturer after FDA regulatory issued a recall 
due to serious malfunctioning that could result in severe injury or death.  One 
101  investigation is into a medical group that rendered the use of a medical device as 
misbranded and adulterated. 
  Three investigations concerning allegations of flagrant manufacturing practices of human 
drugs. One investigation alleges significant current good manufacturing practices 
(cGMP) violations at a manufacturing facility.  Another investigation is focusing on 
allegations of falsified records related to the manufacturing of prescription drug products 
knowing there were contamination issues.  One investigation alleges the potential 
adulteration of manufacturing sterile injectable pharmaceuticals that placed patients at 
risk of serious injury and death. 
  Five investigations involving allegations of clinical trial fraud.  Two of the investigations 
involve firms operating clinical trials overseas suspected of falsifying data related to 
applications submitted to the FDA.  One investigation is regarding a device manufacturer 
failing to report or reporting inaccurate information to FDA related to their medical 
device trial.  One investigation alleges a clinical investigator was using blood samples 
and medical records from one individual to create and enroll multiple subjects.  Another 
investigation is concerning an individual suspected of falsifying documents during a for-
cause inspection related to a controlled study. 
  Four investigations involving alleged fraudulent marketing schemes.  One investigation 
alleges that a pharmacy is providing financial incentives for health care providers to write 
drug prescriptions.  One investigation into a medical provider using unapproved 
regenerative medicine treatments to manage pain.  Another investigation into a doctor 
advertising convalescent plasma therapy for the treatment of a variety of viruses, 
including Coronavirus. One investigation alleges a firm was administering unapproved 
cancer medications to patients. 
As noted in previous reports, the types of criminal investigations conducted through the PFP are 
typically complex investigations, such as application fraud and marketing fraud, requiring 
extensive document review.  It is not unusual for these complex fraud investigations to last for 
five years or more from initiation to conclusion.  Yet investigations under the PFP have produced 
numerous prosecutions. 
Significant prosecutions that occurred in FY 2022 are as follows: 
  In November 2021, in the Central District of California, a physician was found guilty on 
26 felony charges for fraudulently distributing an unapproved cancer treatment.  The 
doctor submitted IND applications to FDA stating their intentions to engage in a clinical 
trial.  The applications were placed on clinical hold due to deficiencies in the 
submissions.  The doctor proceeded to mislabel the drug as a supplement and sell the 
product throughout the country and internationally. 
102    In January 2022, in the Northern District of California, a defendant was found guilty in 
connection to a multi-million-dollar scheme to defraud investors.  The defendant courted 
investors by providing false representations regarding the accuracy and efficacy of a 
blood testing device.  The defendant was convicted on wire fraud counts including a wire 
transfer totaling more than $140.0 million.  An additional defendant was found guilty in 
July 2022 in the same scheme.  In November 2022, the first defendant was sentenced to 
135 months (11 years, 3 months) in Federal prison and three years of supervision 
following release from prison.  In December 2022, the second defendant was sentenced 
to 155 months (12 years, 11 months) in Federal prison and three years of supervision 
following release from prison.  Hearings to determine the amount of restitution to be paid 
by both defendants are pending. 
  In January 2022, in the Southern District of Florida, a defendant was sentenced to 30 
months confinement and ordered to pay $2.1 million in restitution for their role in 
falsifying clinical trial data.  The defendant worked at a clinical research firm and 
falsified data related to several studies.  Some of the data was made to appear as though 
subjects were participating in the trials when they were not.  Two additional defendants 
entered guilty pleas in July 2022 related to the same clinical trial data falsification 
scheme. 
  In June 2022, in the Northern District of Texas, a licensed pharmacist and owner of a 
compounding pharmacy was sentenced after entering a guilty plea in October 2021. The 
pharmacist pled guilty to distributing an adulterated drug used in cataract surgeries.  The 
drug contained an excessive amount of inactive ingredient thus causing its purity and 
quality to fall below what was represented to the medical community.  The pharmacist 
was sentenced to two years' probation, $40,000 criminal fine and $25 special assessment. 
  In September 2022, in the Southern District of Florida, the former owner and CEO of a 
drug manufacturing company was sentenced to 37 months in Federal prison.  The 
defendant was convicted of manufacturing and distributing medication that was 
contaminated with Burkholderia cepacian (B.cepacia).  The defendant lied to FDA 
investigators about distributed products and steps the company had taken to mitigate 
future contamination.  The contaminated products caused infections in pediatric patients 
at two childrens hospitals. 
  In September 2022, in the Southern District of Florida, a defendant was sentenced after 
entering a guilty plea related to obstructing an FDA inspection.  The defendant 
knowingly lied to FDA investigators during a regulatory inspection of the clinical 
research site. The site was testing asthma medication in children.  The defendant falsely 
portrayed the clinical trial as having been conducted legitimately when they knew the 
trial had been falsified.  Four defendants that have been sentenced were ordered to pay 
$555,214 in restitution. A fifth defendant is awaiting sentencing. 
The FDA believes that various investigations already initiated under the PFP may lead to future 
103  judicial action that may include criminal prosecution and monetary recoveries.  These 
investigations include drug manufacturers and clinical investigators under investigation for data 
integrity and other violations, which possibly pose a risk to the publics health and safety. 
Finally, the FDA continues to train its employees and conduct outreach activities to maximize 
the agencys ability to prevent and detect fraud involving medical products.  Due to the COVID-
19 pandemic, FDA moved to a virtual training model to adapt to the needs of its workforce. 
Examples of the training that occurred in FY 2022 are listed below: 
  In October 2021, FDA conducted a one-day training session for newly hired criminal 
investigators in Charleston, South Carolina, at the Federal Law Enforcement Training 
Center.  Training topics included health care fraud and PFP-related material. 
  In March 2022, FDA conducted a one-day training session for the Office of Regulatory 
Affairs, Consumer Safety Officers for New Hire Fundamentals.  This training addressed 
proactive initiatives and investigative priorities in the PFP.  The course objectives 
included providing new Consumer Safety Officers with an awareness of how regulatory 
inspections, electronic resources, and evidence obtained during regulatory activities, can 
result in the identification of health care fraud. 
  In June 2022, FDA conducted a one-day training session for the Center for Biologics and 
Evaluation Research for new and existing Consumer Safety Officers.  The training 
provided opportunities to discuss investigative priorities associated with the PFP and the 
best practices for identifying potential criminal violations. 
104  DEPARTMENT OF JUSTICE 
United States Attorneys 
The United States Attorneys were allocated $73.2 million in FY 2022 HCFAC funding for civil 
and criminal health care fraud enforcement efforts.  These funds supported Assistant U.S. 
Attorneys, paralegals, auditors, and investigators, as well as litigation expenses for health care 
fraud investigations and cases.  The USAOs play a major role in health care fraud enforcement 
by bringing criminal and affirmative civil cases to enjoin ongoing fraud, deter future fraud, and 
to recover funds wrongfully taken through fraud and false claims from the Medicare Trust 
Funds, other taxpayer-funded health care providers, and private insurers.  In addition to 
protecting the public fisc, many cases handled by USAOs stopped ongoing patient harm and 
protected vulnerable victims from exploitation by health care providers.  USAOs play a central 
role in bringing civil penalty actions against pharmaceutical manufacturers, distributors, 
pharmacies and providers for violations of the Controlled Substances Act including the diversion 
of opioids.  USAOs also criminally prosecute health care providers contributing to the opioid 
crisis through pill mills and other illegal prescribing practices. 
Criminal Prosecutions34 
In FY 2022, USAOs opened 809 new criminal health care fraud investigations and filed criminal 
charges in 419 cases involving 680 defendants.  During that same time period, 477 defendants 
were convicted of health care fraud-related crimes. 
Civil Matters and Cases 35 
In FY 2022, USAOs opened 774 new civil health care fraud investigations and had 1,288 civil 
health care fraud matters pending at the end of the fiscal year. 
USAOs litigate the full spectrum of health care fraud matters, both independently and in 
partnership with the Civil and Criminal Divisions.  USAOs receive many health care fraud 
referrals directly from investigative agencies and increasingly are developing cases in-house 
through data analytics.  They also receive referrals through the filing of qui tam (or whistle-
blower) complaints.  USAOs coordinate closely both internally, with AUSAs developing parallel 
cases with their civil or criminal colleagues, and with other USAOs, collaborating on 
investigations that cross district borders, to combat new schemes marketed to and taken up by 
providers nationwide. 
34 FY 2022 numbers are actual data through the end of September 2022.   This data includes records classified with 
the 03GHealth Care Fraud program code.   
35 FY 2022 numbers are actual data through the end of September 2022. This data includes records classified with 
the FRHCHealth Care Fraud civil code. 
105  Qui tam cases and other civil health care fraud FCA cases either are handled jointly with trial 
attorneys in the Departments Civil Fraud Section or litigated independently by USAOs.  Civil 
AUSAs also handle civil penalty cases alleging violations of the Controlled Substances Act 
against defendants ranging from manufacturers down to individual licensed providers.  
USAOs handle most criminal cases independently, but also partner with the Departments 
Criminal Division on Medicare Fraud Strike Force Teams which currently operate in 27 areas 
across the country. Each Strike Force team consists of dedicated AUSAs and support personnel 
from the USAO, as well as from the Criminal Division and law enforcement agencies.  
Since 2018, the USAOs for 10 Federal districts in six states 36 have joined with Criminal Division 
attorneys, as well as law enforcement partners at the FBI, HHS-OIG, and DEA, to form the 
ARPO Strike Force, a joint law enforcement effort to identify and investigate health care fraud 
schemes in the Appalachian region and surrounding areas, and to effectively and efficiently 
prosecute medical professionals and others involved in the illegal prescription and distribution of 
opioids. 
In addition, the USAO allocation supports AUSAs in 11 districts under the Opioid Fraud and 
Abuse Detection Unit (OFAD) program.  OFAD focuses specifically on opioid-related health 
care fraud using data to identify and prosecute individuals that are contributing to the 
prescription opioid epidemic.  
USAOs partner with the Civil and Criminal Divisions on major initiatives.  In FY 2022, USAOs 
continued their pursuit of civil and criminal investigations for gross failure of care as part of the 
National Nursing Home Initiative.  USAOs also take an active part in nationwide criminal health 
care fraud enforcement actions. 
Since March 2020, USAOs have been actively pursuing pandemic-related fraud, including using 
civil injunctions and seizures to shut down fraudsters and their websites hawking phony cures, 
vaccines, and PPE; criminally prosecuting COVID-19-related scams; investigating failure of care 
at nursing facilities impacted by COVID-19; and investigating civil and criminal matters alleging 
fraud on Medicare, Medicaid, HRSA, and other Federal payors related to the pandemic or 
stimulus health care funding. 
Examples of successful health care fraud cases are discussed above, but, notably, many of these 
cases involve vulnerable victims and risk of patient harm in addition to financial fraud.  This 
year, USAOs prosecuted cases involving schemes that exploited or harmed: 
  Children who were recruited for unnecessary drug testing and, in another case, were used 
for falsely recording mental health diagnoses so defendants could fraudulently bill 
36 The USAOs are the Northern District of Alabama, Eastern District of Kentucky, the Western District of 
Kentucky, the Southern District of Ohio, the Eastern District of Tennessee, the Middle District of Tennessee, the 
Western District of Tennessee, the Northern District of West Virginia, the Southern District of West Virginia, and 
the Western District of Virginia. 
106  Medicaid; 
  Older adults who were disenrolled from Medicare Advantage plans without their consent 
in order to obtain higher payments from traditional Medicare, potentially impacting the 
residents out-of-pocket payments, the scope of the services and care covered, and their 
drug coverage plan; 
  Addicted patients who paid cash to defendants for services that were also paid for by 
Medicaid; 
  Dental patients whose teeth were broken so that the defendant dentist could fraudulently 
bill for crowns; 
  Hospital patients who were provided saline for pain because a Registered Nurse had 
stolen morphine from the vials; and 
  Home health aides who were paid less than lawful wages and benefits despite their 
employers receiving millions of dollars in Medicaid funding intended to pay them. 
Moreover, USAOs are also handling complex, resource-intensive cases involving a number of 
emerging trends including: 
  Multi-district telehealth, COVID-19 testing, genetic testing, and DME schemes; 
  Electronic Health Record kickback and other schemes; 
  Medicare Part C fraud involving the manipulation of diagnosis codes of millions of 
beneficiaries; 
  Sophisticated kickback and other fraud schemes involving complex ownership structures 
of health care entities, including by private equity and real estate investment vehicles; 
  Nationwide investigations of alleged Controlled Substances Act violations; and 
  Pharmaceutical pricing cases brought under the FCA and AKS based on allegations of 
price-fixing and market allocation in the generic pharmaceutical industry.  
In addition to funding AUSAs, auditors, paralegals and investigators, the Executive Office for 
U.S. Attorneys (EOUSA) provides critical support for these complex health care fraud 
investigations and litigation.  Using HCFAC funds, EOUSA supports contract forensic 
investigators and auditors, as well as nurse consultants, who have been indispensable to the 
USAOs successes in complex cases.  EOUSA partners with the Civil Division to provide 
support for other initiatives, including sophisticated data analytics (which have been instrumental 
in many large opioid prescribing investigations), and nursing home consultants to assist on the 
Nursing Home Initiative.  EOUSA provides other tools to USAOs, including the Special 
Investigation Resource and Intelligence System (SIRIS) Resource Center, which gives USAO 
personnel access to the NHCAAs SIRIS database. 
As well as managing national-level support, EOUSA provides districts with case-specific 
funding for litigation support for extraordinary needs.  In FY 2022, HCFAC money funded more 
than 55 such requests from USAOs totaling more than $3.0 million.  This support pays for 
consultants in such highly technical areas as software experts in EHR cases, economic experts in 
pharmaceutical pricing cases, and medical consultants in highly paid specialties, and is essential 
to investigating and developing these complex cases. 
107  To ensure a focused and coordinated approach to health care fraud enforcement, each USAO has 
designated criminal and civil health care fraud coordinators.  These coordinators host working 
group and/or task force meetings within their districts, attended by Federal investigative 
agencies, state MFCUs, private sector representatives and others.  Coordinators also conduct 
training and outreach to a variety of audiences, including medical and hospital associations, the 
defense and relators bar, and Medicare beneficiaries. 
EOUSA also organizes extensive training for AUSAs, as well as paralegals, investigators, and 
auditors on a wide variety of health care fraud enforcement matters.  Although in-person training 
was not possible in FY 2022, EOUSA presented webinars throughout the year focused on 
emerging health care fraud issues.  
Civil Division 
The Civil Division received approximately $49.6 million in FY 2022 HCFAC funding to support 
the health care fraud activities of the Commercial Litigation Branchs Fraud Section and the 
Consumer Protection Branch.  This amount also included funding to support the Department of 
Justices Elder Justice Initiative.  In FY 2022, civil health care fraud settlements and judgments 
under the False Claims Act exceeded $1.6 billion. 37 
The Commercial Litigation Branchs Fraud Section 
The Civil Divisions Commercial Litigation Branch (Fraud Section) investigates complex health 
care fraud allegations and files suit under the civil FCA to recover money on behalf of defrauded 
Federal health care programs including Medicare, Medicaid, TRICARE, the VA, and the 
FEHBP.  The Fraud Section works closely with the USAOs and often teams with other law 
enforcement partners to pursue allegations of health care fraud.  
The Fraud Section investigates and resolves matters involving a wide array of health care 
providers and suppliers.  The Fraud Section continues to pursue schemes that violate the AKS, 
which prohibits the willful solicitation or payment of remuneration to induce the purchase of a 
good or service for which payment may be made under a Federal health care program.  For 
example, the Fraud Section resolved allegations that drug company Mallinckrodt paid kickbacks 
in the form of copay subsidies for its drug Acthar Gel, in violation of the AKS, from 2010 
through 2014, so it could market the drug as free to doctors and patients while increasing its 
price significantly. Since acquiring Acthar, Mallinckrodt allegedly raised its price from 
approximately $40 per vial to over $28,000 per vial by the end of 2013 and to approximately 
$40,000 per vial thereafter.  The United States also resolved allegations that medical device 
company Biotronik paid kickbacks to physicians in the form of, among other things, holiday 
parties, winery tours, and lavish meals with no legitimate business purpose.  Other matters 
37As stated earlier, the amount reported only reflects the Federal settlements and judgments and therefore does not 
reflect state Medicaid monies won or negotiated as part of any global Federal-state settlements. As in prior years, 
the reported settlements and judgments include matters the United States pursued, as well as matters pursued by 
relators/whistleblowers under the qui tam provisions of the False Claims Act. 
108  related to AKS violations involved drug companies (kaleo), medical device companies 
(Respironics, Arthrex, Essilor, Reliance), and hospitals (Flower Mound Hospital Partners). 
The Fraud Section also continues to pursue schemes impacting Medicaid, which provides health 
care for the financially neediest Americans and is jointly funded by the Federal Government and 
the states.  This work often includes cases where the same alleged fraudulent conduct harms both 
Medicaid and other Federal health care programs (for example, the Flower Mound, Providence, 
Biotronik, and Essilor matters discussed earlier).  But, as in years past, the Fraud Section also 
pursued matters involving fraud schemes specifically targeting and harming Medicaid (such as 
the Mallinckrodt Medicaid rebate, Baycare, and Gold Coast matters discussed earlier).  
As in years past, the Fraud Section also resolved a number of matters in which providers billed 
Federal health care programs for medically unnecessary services or services not rendered as 
billed.  For example, the MD Labs, Radeas, Providence, and PPOA matters discussed earlier all 
involved allegations that either hospitals, laboratories, or other providers defrauded Medicare 
into paying for medically unnecessary services.  Relatedly, the Fraud Section also pursues 
schemes involving the use of medically unsupported diagnosis codes as a way to bill Federal 
health care programs, for example, the Eargo matter discussed above.  
The Fraud Section also continues to pursue matters involving schemes perpetrated by managed 
care health systems, networks, or providers, including those participating in Medicare Part C or 
Medicaid managed care.  For example, as discussed above, this year the Fraud Section secured 
the first settlement of its kind involving Medicaid Adult Expansion fraud against several 
defendants, including the Ventura County Medi-Cal Managed Care Commission d/b/a Gold 
Coast Health Plan (the Gold Coast matter discussed above).  The Fraud Section is also 
continuing to investigate or litigate a number of significant matters involving alleged FCA 
violations concerning Medicare Part C plans or providers, covering a large variety of allegedly 
fraudulent conduct resulting in inflated federal reimbursements.  These matters include 
whistleblower actions filed under the qui tam provisions of the FCA.  In pursing these matters, 
the Fraud Section is coordinating closely with HHS-OIG and CMS.  
In addition, the Fraud Section is continuing to investigate potential FCA violations in connection 
with fraudulent schemes targeting government programs arising from the COVID-19 pandemic.  
This past year, the Fraud Section opened investigations into a wide array of COVID-19 related 
schemes, including allegations of health care providers billing for unproven or medically 
unnecessary tests or providing or causing the provision of COVID-19 vaccines to ineligible 
persons, ineligible providers exploiting HHS pandemic-related waivers, and fraud on COVID-19 
relief programs.  The Fraud Sections investigations of pandemic-related allegations include 
whistleblower actions filed under the qui tam provisions of the FCA.  In investigating potential 
FCA violations arising from the COVID-19 pandemic, the Fraud Section is closely coordinating 
with HHS-OIG and CMS, as well as non-Federal entities, including state Attorneys General and 
state MFCUs. 
109  Because the Fraud Section receives every FCA complaint filed by whistleblowers across the 
country, it has a unique vantage point over health care fraud trends and developments nationwide 
and therefore regularly handles some of the most complex matters and coordinates national 
investigations with its law enforcement partners.  Likewise, given the diversity of health care 
fraud cases pursued by the Fraud Section, it frequently provides training and guidance on the 
FCA and health care fraud issues to AUSAs and agents.  The Section works closely with HHS-
OIG, including its Office of Counsel, in all settlements of health care fraud allegations to ensure 
that the administrative remedies possessed by HHS are appropriately considered and to enable 
the negotiation of compliance terms that diminish the risk that the offending conduct will be 
repeated.  The Section also collaborates with and counsels HHS-OIG and CMS on interagency 
initiatives and proposed rules and regulations.  
Finally, the Department of Justices Elder Justice Initiative is housed in the Civil Division.  The 
Elder Justice Initiative helps to support and coordinate the Departments nursing home failure of 
care investigations and prosecutions.  The Initiative also supports the efforts of state and local 
elder fraud prosecutors, law enforcement, and other elder justice professionals to combat elder 
abuse, neglect, financial exploitation, and fraud through the development of resources, training 
and tools.  These include a curriculum for law enforcement on conducting forensic interviews of 
older adults, a toolkit for probate judges to collect relevant information for guardianship 
proceedings, and a free online resource for law enforcement on investigating elder abuse and 
fraud.  All of the Initiatives resources, trainings and tools can be found on the Departments 
Elder Justice Website (justice.gov/elderjustice). 
The Consumer Protection Branch 
The Consumer Protection Branch (CPB or the Branch) enforces consumer protection laws to 
deter and punish dangerous practices that both risk and result in harm to Americans.  The Branch 
aggressively pursues both civil and criminal cases against those who unlawfully manufacture, 
distribute, or sell pharmaceuticals, medical devices, or dietary supplements causing harm and 
loss to consumers and the government.  As the Department component charged with enforcing 
the Federal Food, Drug, and Cosmetic Act (FDCA), the Branch works closely with the FDA to 
investigate matters.  It also partners extensively with the DEA and other law enforcement 
agencies.  The Branch coordinates closely with the USAOs and the Commercial Litigation 
Branchs Fraud Section to prosecute matters, including major health care fraud cases.  In recent 
years, especially in FY 2022, the Branch has dedicated particular focus to advancing civil and 
criminal actions against individuals and entities up and down the prescription opioid supply 
chain, seeking to hold accountable those responsible for the opioid crisis and to recoup billions 
of dollars for the United States and victims, and resulting in more than $125.0 million in fines, 
forfeitures, and penalties for the Federal fisc. 
With respect to opioid-related work, the Branch continues to lead a number of multi-component 
investigations and active cases against pharmaceutical opioid manufacturers, wholesale 
distributors, pharmacies, and health care providers.  The Branch is advancing this work through 
state-of-the-art data analysis and evidence-review tools, a large contract staff, and an enormous 
commitment of prosecutorial resources.  Indeed, Branch prosecutors dedicated more than 30,000 
110  hours to the matters in FY 2022, a substantial increase over our already-robust FY 2021 
numbers.  Each of the matters has the potential to return hundreds of millions, or even billions, of 
dollars to the Federal Government.  The Branch also is continuing coordination responsibilities 
established through the Departments Prescription Interdiction and Litigation Task Force. 
With respect to chain pharmacies, the Branch led a multi-component effort that, in December 
2020, filed suit against Walmart, Inc., asserting nationwide violations of the Controlled 
Substances Act in the dispensing of opioids from, and distribution of opioids to, Walmarts more 
than 5,500 pharmacies.  The complaint details Walmarts substantial contribution to the opioid 
epidemic and seeks billions of dollars for the government and significant injunctive relief.  The 
case is now in litigation, taking up thousands of hours of Federal attorney and contractor time 
each month and requiring a significant litigation-support apparatus.  Several similarly large 
investigations are well underway.  The Branch is litigating subpoena demands and engaging in 
settlement discussions with other national manufacturers, distributors, and national chain 
pharmacies.  The Branch expects in the coming year to reach resolutions, or advance 
investigations and litigation, as to numerous other companies in the opioid supply chain.  Each of 
these matters will likely require a resource commitment as large as that of the Walmart litigation.  
Branch attorneys also continued over the past year to partner regularly with USAOs on local-
impact civil and criminal cases involving community pharmacies and practitioners.  The Branch 
and its partners successfully enjoined and secured money judgments from individuals and 
entities involved in the illegal dispensing of opioids in North Carolina and Florida.  Through this 
work, the Branch immediately curtailed opioid diversionand related unlawful billing to 
Federal health care programsby identifying and shutting down actors fueling the opioid abuse 
epidemic in their communities.  The Branch is advancing a number of other similar actions 
around the country and expects to bring more actions next year.   
CPB is also developing a number of initiatives to combat the surge of counterfeit pills laced with 
fentanyl that are killing people in record numbers in this country.  An increasing portion of 
overdose deaths are among teens who buy pills over social media.  Fentanyl used as an 
undeclared ingredient in counterfeit pills is incredibly dangerous and increasingly prominent.  
The DEA Laboratory has found that of the fentanyl-laced fake prescription  pills analyzed in 
2022, six out of ten now contain potentially lethal doses of fentanyl.  This is not surprising, given 
that as little as 2 milligrams is considered a lethal dose.  Use of these products does not always 
involve the telltale signs of abuse that parents and friends might traditionally notice.  Overdoses 
have supplanted suicide, traffic accidents, and gun violence to become the leading cause of 
preventable death among people ages 18 to 45.  According to the Journal of the American 
Medical Association, although experimental drug use by teenagers in the United States has been 
dropping since 2010, teen deaths from fentanyl went up almost 300 percent from 2015 to 2019.  
CPBs counterfeit pill initiatives are designed to disrupt the sale of certain chemical precursors, 
equipment, and even the pills themselves over e-commerce and social media platforms.  
In addition to its opioid enforcement efforts, the Branch continued to lead the Department in 
prosecuting pharmaceutical, dietary supplement, food, and medical device manufacturers and 
their executives for violations of the FDCA in the manufacturing and marketing of their 
111  products.  These efforts include the Branchs response to consumer fraud related to the COVID-
19 pandemic.  In FY 2022, CPB invested almost 65,000 hours into public health and safety 
work. This work included numerous criminal trial victories in areas CPB enforces, such as 
compounding pharmacies, clinical trial fraud, dietary supplements, and food safety.  
This year, the Branch continued its work with the USAO for the Southern District of Florida to 
advance a major initiative to address fraud affecting clinical trials for prescription drugs and 
medical devices.  In one such case, the Branch obtained a conviction at trial against a clinical 
research coordinator who made false statements to FDA investigators regarding her role in a 
fraudulently conducted clinical trial purportedly studying the effectiveness of asthma drugs in 
children.  This fiscal year also saw the resolution of many other clinical trial fraud matters 
through guilty pleas and sentencings. The Branch is advancing numerous other investigations in 
the clinical trial fraud arena as part of one of its largest ongoing criminal initiatives.  The results 
obtained in these actions have sent a powerful message against fraud in clinical trials and drug-
approval submissions to FDA. 
The Branchs work under the FDCA touches a wide variety of fraudulent conduct.  For example, 
in December 2021, following a month-long trial, a Federal jury convicted a pharmacy owner of 
conspiracy to commit health care fraud, multiple counts of mail fraud, and felony misbranding of 
a medication.  The owner and his 16 co-conspirators conspired to defraud pharmacy benefit 
managers, such as Express Scripts and CVS Caremark, by billing for fraudulent prescriptions.  
As part of the scheme, the conspirators procured the prescriptions by using telemarketers to call 
consumers and deceive them into agreeing to accept drugs, such as pain creams, scar creams, and 
vitamins, and providing their personal health insurance information.  As a co-owner of a 
pharmacy, the defendant purchased bogus prescriptions from a telemedicine company, knowing 
that those prescriptions were not issued under valid doctor-patient relationships.  He and his co-
defendants then shipped medications from compounding pharmacies they owned to thousands of 
unsuspecting patients across the country, all without collecting the required co-pays.  He and his 
co-conspirators billed over $900.0 million to private and public insurers, collecting over $174.0 
million of those invoices.  In addition to securing convictions against the defendant and his co-
defendants, CPB and the USAO for the Eastern District of Tennessee obtained seven corporate 
guilty pleas, each agreeing in pleading guilty to implement substantial enhanced compliance 
measures and, collectively, to pay more than $100.0 million in fines, forfeiture, and restitution. 
In December 2021, a Federal jury in Fort Lauderdale convicted a Florida man of one count of 
conspiracy to defraud the FDA and one count of conspiracy to distribute controlled substances.  
He was the eleventh defendant convicted in connection with Blackstone Labs, LLC, a Boca 
Raton company that sold millions of dollars of products falsely labeled as dietary supplements.  
The trial followed a years-long investigation into Blackstone that showed that the company and 
its executives conspired to defraud the FDA and to manufacture and distribute research 
chemicals and anabolic steroids that were controlled substances under the Designer Anabolic 
Steroid Control Act.  Multiple other corporate and individual defendants pleaded guilty and were 
sentenced in the run-up to trial, including both Blackstone Labs and Ventech Labs.  Collectively, 
the defendants have been ordered to pay nearly $9.0 million in restitution, forfeiture, and fines. 
112  CPB also enforces the FDCA as it regulates food producers and distributors.  In May 2022, a 
court in the Western District of Michigan entered a consent decree of permanent injunction 
against Abbott Laboratories (Abbott) and three high-ranking Abbott executives that allowed the 
company to resume manufacturing powdered infant formula at its Sturgis, Michigan, facility, but 
also requires it to take specific measures designed to increase safety and ensure compliance with 
the FDCA.  After investigating the case, CPB alleged that Abbott manufactured powdered infant 
formula under conditions and using practices that failed to comply with regulations designed to 
ensure the quality and safety of infant formula, including protection against the risk of 
contamination from bacteria. 
In another substantial food safety matter, in September 2022, Branch attorneys and the USAO 
for the Eastern District of Washington secured an indictment of the now-closed company Valley 
Processing Inc. (VPI) in Yakima, Washington, and the owner of that company, charging 12 
felony counts of fraud, conspiracy, false statements, and violating the FDCA by distributing 
adulterated and misbranded food products and failing to register certain company facilities. 
Branch attorneys also obtained injunctive relief to stop the adulteration and misbranding of 
dietary supplements, the adulteration of animal food, and the introduction of unapproved new 
drugs into interstate commerce. 
In December 2021, a Federal court permanently enjoined a New Jersey organization and two 
individual defendants from distributing unapproved and misbranded drugs touted as COVID-19 
treatments.  The Government alleged that Natural Solutions Foundation and the two individual 
defendants, distributed a nano silver solution product that they claimed, without scientific 
evidence, would prevent, treat, or cure COVID-19.  The defendants agreed to a consent decree of 
permanent injunction and instituted a recall for their nano silver products. 
Criminal Division 
The Criminal Division was allocated $39.3 million in FY 2022 HCFAC funding to support 
criminal health care fraud litigation and interagency coordination, which is carried out primarily 
by the Fraud Sections Health Care Fraud Unit and, to a lesser extent, the Organized Crime and 
Gang Section. 
The Fraud Section 
The Fraud Sections HCF Unit employs criminal prosecutors who focus exclusively on 
investigating and prosecuting health care fraud matters and prescription opioid distribution and 
diversion schemes.  In sum, the HCF Units core mission is to:  (1) protect the public fisc from 
fraud, waste, and abuse, and (2) detect, limit, and deter fraud and illegal prescription, 
distribution, and diversion offenses resulting in patient harm.  The HCF Unit also supports the 
USAO community by providing legal, investigative and data analytics support, guidance and 
training on criminal health care fraud and opioid-related matters.  
113  Beginning in March 2007, the Fraud Section, working with the local USAO, the FBI, HHS-OIG, 
and state and local law enforcement agencies, launched the Health Care Fraud Strike Force in 
Miami-Dade County, Florida, to investigate and prosecute individuals and entities that do not 
provide legitimate health care services but instead defraud Medicare and other government 
health care programs.  In FY 2022, the HCF Units Strike Force program provided attorney 
staffing, litigation support, and leadership and management to the Strike Forces operating in 27 
Federal judicial districts across the United States.  The current Strike Forces include operations 
in cities including, but not limited to, Miami and Tampa and Orlando, Florida; Nashville, 
Tennessee; Ft. Mitchell, Kentucky; Los Angeles, California; Detroit, Michigan; Houston, San 
Antonio and Dallas, Texas; Concord, New Hampshire; Brooklyn, New York; Baton Rouge and 
New Orleans, Louisiana; Chicago, Illinois; Newark, New Jersey and Philadelphia, Pennsylvania, 
along with the NRRSF located in Washington, D.C. 
In 2018, the HCF Unit created the ARPO Strike Force, a joint effort between DOJ, HHS-OIG, 
FBI, DEA, and local law enforcement partners to combat health care fraud and the opioid 
epidemic in nine Federal districts.  As of September 30, 2022, ARPO has charged 115 
defendants involving more than 115 million controlled substance pills.  These efforts have 
resulted in 62 guilty pleas and 9 trial convictions.  
In FY 2022, the HCF Unit achieved the following results: 
  Filed 126 indictments, criminal informations and complaints involving charges against 
163 defendants who allegedly collectively billed Federal health care programs and 
private insurers approximately $2.2 billion; 
  Obtained 218 guilty pleas and litigated 32 jury trials, with guilty verdicts against 36 
defendants; and 
  Securing imprisonment for 152 defendants sentenced, with an average sentence of over 
55 months. 
Since its inception, Strike Force prosecutors and USAOs in Strike Force districts filed more than 
2,700 cases charging more than 5,400 defendants who collectively billed Federal health care 
programs and private insurers approximately $27.0 billion, more than 3,700 defendants pled 
guilty and over 460 others were convicted in jury trials, and more than 3,300 defendants were 
sentenced to imprisonment for an average term of approximately 50 months.  Medicare payment 
trends demonstrate the positive impact of Strike Force enforcement and prevention efforts.  Each 
year, the HCF Unit coordinates large-scale, law enforcement actions with its partners.  
The nature and scope of health care fraud has evolved rapidly over the past few years with the 
advent of new technologies that have broadened the reach of health care and, consequently, 
health care fraud.  As a result, the Fraud Section in 2020 developed and launched the NRRSF:  a 
way to respond quickly to multi-jurisdictional health care fraud cases and priorities, without 
diverting attorneys from district-specific Strike Forces.  NRRSF prosecutors, who are based in 
Washington, D.C. (and, where appropriate, based in certain existing Strike Force locations), are 
dedicated exclusively to the immediate and decisive response to new and emerging health care 
114  fraud trends.  Like the other Strike Forces, the NRRSF coordinates with USAOs and Federal and 
state law enforcement partners prosecute these significant multi-jurisdictional and corporate 
fraud cases.  Examples of the types of cases prosecuted by NRRSF include the recent conviction 
at trial of the President of a Silicon Valley technology company who claimed to have invented 
revolutionary technology to detect allergies and COVID-19 using a single drop of blood, trial 
conviction of two defendants in a $1.4 billion rural hospitals fraud matter in the Middle District 
of Florida (one of the largest health care fraud cases ever charged), convictions in three separate 
trials (between December 2021 and June 2022) of sober homes operators and doctors who were 
responsible for hundreds of millions in loss, the prosecution of telemedicine company executives 
and medical professionals in cases involving billions of dollars in alleged fraud loss, and 
prosecutions of those seeking to criminally exploit the COVID-19 pandemic through health care 
fraud and related financial fraud schemes. 
The HCF Unit chairs an interagency COVID-19 fraud working group with Federal law 
enforcement and public health agencies to identify and combat health care fraud trends emerging 
during the COVID-19 crisis.  This has involved coordinating and training other Criminal 
Division and USAO prosecutors and offering support to their investigations and cases, including 
data analytics support.  The HCF Unit expects that the COVID-19 working group will continue 
to generate criminal prosecutions in several areas, including COVID-19 test bundling schemes, 
securities fraud cases involving health care technology companies, and PRF fraud cases.  
The HCF Unit coordinated three separate, targeted enforcement actions during FY 2022: 
COVID-19 Health Care Fraud; Opioid; and Telemedicine, Clinical Laboratory, and Durable 
Medical Equipment Enforcement Actions.  These enforcement actions were conducted on April 
20, 2022, May 4, 2022, and July 20, 2022, respectively.  In the 2022 COVID-19 Health Care 
Fraud Enforcement Action, criminal charges were brought against 21 defendants for their alleged 
participation in various health care related fraud schemes that exploited the COVID-19 
pandemic.  These cases allegedly resulted in over $149 million in COVID-19-related false 
billings to Federal programs and theft from Federally funded pandemic assistance programs.  In 
the 2022 Opioid Enforcement Action, criminal charges were brought against 14 defendants (12 
medical professionals) for their alleged involvement in crimes related to the unlawful distribution 
of opioids.  In the 2022 Telemedicine, Clinical Laboratory, and Durable Medical Enforcement 
Action, criminal charges were brought against 36 defendants for more than $1.2 billion in 
alleged fraudulent telemedicine, cardiovascular and cancer genetic testing, and DME schemes.  
As part of the COVID-19 Enforcement Action, for example, several cases involved defendants 
who allegedly offered COVID-19 testing to induce patients to provide their personal identifying 
information and a saliva or blood sample.  The defendants are alleged to have then used the 
information and samples to submit false and fraudulent claims to Medicare for unrelated, 
medically unnecessary, and far more expensive tests or services.  In one such scheme in the 
Central District of California, two owners of a clinical laboratory were charged with a health care 
fraud, kickback, and money laundering scheme that involved the fraudulent billing of over 
$214.0 million for laboratory tests, over $125.0 million of which allegedly involved fraudulent 
claims during the pandemic for COVID-19 and respiratory pathogen tests.  In two separate cases 
115  in the District of Maryland and the Eastern District of New York, owners of medical clinics 
allegedly obtained confidential information from patients seeking COVID-19 testing at drive-
thru testing sites and then submitted fraudulent claims for lengthy office visits with the patients 
that did not, in fact, occur.  The proceeds of these fraudulent schemes were allegedly laundered 
through shell corporations in the United States, transferred to foreign countries, and used to 
purchase real estate and luxury items. 
In another type of COVID-19 health care fraud scheme charged during the 2022 COVID-19 
Health Care Fraud Enforcement Action, defendants allegedly exploited policies that the CMS put 
in place to enable increased access to care during the COVID-19 pandemic.  For example, in the 
Southern District of Florida, one medical professional was charged with a health care fraud, wire 
fraud, and kickback scheme that allegedly involved billing for sham telemedicine encounters that 
did not occur and agreeing to order unnecessary genetic testing in exchange for access to 
telehealth patients.  Late last year, one defendant previously was sentenced to 82 months in 
prison in connection with this scheme. 
Finally, during the 2022 COVID-19 Health Care Fraud Enforcement Action, charges were 
brought against manufacturers and distributors of fake COVID-19 vaccination record cards who 
intentionally sought to obstruct the HHS and the CDC in their efforts to administer the 
nationwide vaccination program and provide Americans with accurate proof of vaccination.  For 
example, in the Northern District of California, three defendants were charged in a scheme to sell 
homeoprophylaxis immunizations for COVID-19 and falsify COVID-19 vaccination record 
cards to make it appear that customers received government-authorized vaccines.  One 
defendant, a naturopathic doctor, pleaded guilty for her role in offering and selling fraudulent 
immunizations and directing individuals on how to fill out false COVID-19 vaccination record 
cards, and is pending sentencing.  A second defendant was charged for his role in assisting the 
naturopathic doctor in offering and selling fraudulent immunization and is awaiting trial.  A third 
defendant admitted to, and was sentenced to a term of probation for misusing her position as the 
Director of Pharmacy at a northern California hospital to obtain real lot numbers for the Moderna 
vaccine that were then used by the naturopathic doctor to falsify COVID-19 vaccination record 
cards. 
Since 2007, the HCF Unit has deployed data analytics combined with investigative intelligence 
to great success.  In 2018, the HCF Unit formed its own in-house data team, which now consists 
of nine analysts with deep experience in Medicare and Medicaid data analysis, as well as 
financial analysis, who identify egregious health care fraud and prescription opioid-related 
targets to ensure the HCF Unit and its partners efficiently identify the worst offenders.  The 
concept and structure of the Data Analytics Team is regarded as ground-breaking for the 
Department.  The team uses data to identify billing patterns, suspicious prescribing practices, and 
curious relationships between doctors and patients that signify high-risk targets.  The 
investigations are then prosecuted by HCF Unit prosecutors or referred to USAOs and law 
enforcement partners in a targeting package, which includes data summaries and descriptions 
of why a pattern is suspect, such as submission of claims for dead beneficiaries, beneficiaries 
116  who live a great distance from the clinic they purportedly regularly attended in person, etc. 38  In 
FY 2022, the team has completed approximately 2,682 requests for data analysis assistance.  
During this same time, it has also created a multitude of specific district-by-district targeting 
packages to help advance the HCF Units mission. 
The Organized Crime and Gang Section (OCGS) 
The Criminal Divisions Organized Crime and Gang Section (OCGS) supports and conducts 
investigations and prosecutions of health care fraud and abuse targeting private sector health 
plans sponsored by employers and/or unions as well as health care fraud and abuse perpetrated 
by domestic and international organized crime groups.  There are more that 2.3 million such 
private sector health plans which cover some 135 million Americans.  OCGS also works to 
improve strategic coordination in the identification and prosecution of domestic and international 
organized crime groups engaged in sophisticated frauds posing a threat to the health care 
industry and provides legal advice and necessary approvals in the use of the RICO statute to 
combat health care fraud and abuse. 
In FY 2022, six OCGS attorneys conducted health care fraud prosecutions and investigations. 
In Knoxville, Tennessee, two OCGS attorneys continued working with the USAO for the Eastern 
District of Tennessee on the prosecution of a pain clinic co-owner and nurses for their roles in 
running pill mills.  The co-owner and three nurse practitioners were convicted following a 
three-month trial.  In October 2020, the clinic co-owner was sentenced to more than 33 years in 
prison and forfeiture of $3.6 million for her convictions of RICO conspiracy, two counts of drug 
conspiracy, money laundering offenses, and maintaining drug-involved premises.  In December 
2020, three nurse practitioners were sentenced to prison terms ranging from 30 to 42 months for 
their convictions of maintaining drug involved premises.  The drug conspiracy involved the 
operation of four clinics which were pill mills that distributed over 11 million tablets of 
oxycodone, oxymorphone, and morphine that generated over $21.0 million in clinic revenue, 
with a corresponding street value of $360.0 million.  Two investor-owners charged with RICO 
conspiracy were extradited from Italy and pled guilty in November 2022.  This partnership 
between OCGS and the Eastern District of Tennessee has resulted in the investigation and 
prosecution of over 140 individuals. 
In July 2021, two OCGS attorneys handled the retrial, in the District of Columbia, of a former 
union official resulting in a conviction for health care fraud.  The health care fraud charge 
stemmed from the union officials arranging for his girlfriend to be fraudulently placed on the 
unions health plan knowing that she was not a full-time employee of the union and, therefore, 
not eligible to participate in the health plan.  More than $66,000 in medical reimbursements were 
allegedly paid out of the unions health plan on behalf of his girlfriend to which she was not 
entitled.  In October 2021, the union official was sentenced to serve 24 months of imprisonment 
38 For a medical professional, for example, the targeting package includes: (1) the fraud scheme(s) the individual is 
likely to be operating; (2) the patients and amount of money involved; (3) additional medical professionals and health care 
entities tied to the alleged scheme(s); (4) the location of entities involved in the scheme(s); and (5) areas for follow up by 
the prosecutor/agent team. 
117  and ordered to pay the remaining restitution of losses in the amount of $155,000 following his 
jury conviction of health care fraud and a guilty plea in 2018 to embezzlement of union funds. 
OCGS attorneys routinely provide litigation support and advice to AUSAs and criminal 
investigative agencies in the investigation and prosecution of corruption and abuse of private 
employment-based group health plans covered by the Employee Retirement Income Security Act 
(ERISA) including fraud schemes by corrupt entities that sell unlicensed group health insurance.  
Private sector employment-based group health plans are the leading source of health care 
coverage for individuals not covered by Medicare or Medicaid.  OCGS provides litigation 
support as requested at any stage of the prosecution from indictment through trial and appeal.  
OCGS attorneys provide health care fraud and abuse training and legal guidance to AUSAs and 
to criminal investigators and agents of the Department of Labors Employee Benefits Security 
Administration and Office of Inspector General, FBI and IRS.  Such training and guidance cover 
prosecutions involving abuse of private sector employee health plans subject to ERISA and 
health plans sponsored by labor organizations, as well as fraud and abuse committed in 
connection with the operation of multiple employer welfare arrangements (MEWAs).  OCGS is 
also responsible for drafting and reviewing criminal legislative proposals affecting employee 
health benefit plans.  Finally, OCGS provides legal guidance to prosecutors and required 
approvals in the use of the RICO statute in prosecutions of racketeering enterprises involved in 
the distribution of opioids, fentanyl, and other pharmaceuticals; Medicare and Medicaid frauds; 
and private sector health care frauds.   
Civil Rights Division 
The Civil Rights Division was allocated $8.9 million in FY 2022 HCFAC funding to support 
Civil Rights Division litigation activities related to health care fraud and abuse.  The Civil Rights 
Division pursues relief affecting public, residential, and nonresidential health care facilities and 
service systems, and conducts investigations to eliminate abuse and grossly substandard care in 
public, Medicare, and Medicaid funded long-term care facilities.  Consistent with the ADAs 
integration mandate set forth in 28 C.F.R.  35.130(d), and the Supreme Courts ruling in 
Olmstead v. L.C., 527 U.S. 581 (1999), the Division also works to prevent the unnecessary 
segregation of individuals who require health care supports and services.  
The Division plays a critical role in the HCFAC Program.  The Special Litigation Section of the 
Civil Rights Division is the sole DOJ component responsible for enforcing the Civil Rights of 
Institutionalized Persons Act, 42 U.S.C. 1997 (CRIPA).  CRIPA authorizes the investigation of 
conditions of confinement at residential institutions owned or operated by or for state or local 
governments, including facilities for persons with developmental disabilities or mental illness, 
and nursing facilities, and initiation of a civil action for injunctive relief to remedy a pattern or 
practice violation of the Constitution or Federal statute.  In addition, both the Special Litigation 
Section and the Disability Rights Section have engaged in interagency coordination with the goal 
of combatting the misuse of Medicaid funding related to the unnecessary segregation of persons 
with disabilities. 
118  The Disability Rights Section of the Civil Rights Division has primary enforcement authority 
for the Americans with Disabilities Act (ADA).  Title II of the ADA authorizes the 
investigation of allegations of discrimination by public entities against individuals with 
disabilities, including discrimination in the form of unnecessarily segregating persons who 
require health care supports and services.  See Olmstead, 527 U.S. 581.  Title II also authorizes 
the initiation of civil actions to remedy discrimination in violation of the ADA.  In addition to 
violating the civil rights of individuals with disabilities, such unnecessary segregation often 
increases Medicaid costs.  Both the Disability Rights Section and the Special Litigation Section 
enforce the ADAs prohibition on unnecessary segregation. 
The Educational Opportunities Section of the Civil Rights Division also participates in the 
HCFAC Program to address the use of Medicaid funding for youth with disabilities who are 
unnecessarily placed in segregated education settings, including segregated residential 
placements, in violation of the ADA.  The Special Litigation, Educational Opportunities, and 
Disability Rights Sections work collaboratively with the USAOs and with HHS. 
FY 2022 Accomplishments 
Key litigation and enforcement accomplishments in FY 2022 of the Civil Rights Division are: 
  Number of matters in active enforcement:  20 
  Cumulative estimate of individuals with disabilities affected: 78,501 
  Number of institutional facilities affected:  2,276 
Special Litigation Section 
In FY 2022, the Sections enforcement efforts affected more than 1,400 health care facilities in 
seven states, and included the opening of one new investigation, the filing of a statement of 
interest, and monitoring compliance with six agreements impacting over 25,000 individuals with 
disabilities.  
In December 2021, the Section issued a findings report concluding there is reasonable cause to 
believe that the State of Iowa violates Title II of the ADA by failing to provide services to people 
with IDD in the most integrated setting appropriate to their needs.  As a result, many people with 
IDD are institutionalized in state facilities or placed at serious risk of institutionalization because 
of the lack of community-based services.  The Section and the State are discussing necessary 
remedial measures. 
The Section worked to negotiate appropriate remedial measures in two matters.  In December 
2020, the Section issued a CRIPA findings report concluding that there is reasonable cause to 
believe the State of Iowa subjects Glenwood Resource Center residents to unreasonable harm 
and risk of harm, in violation of their Fourteenth Amendment rights.  In April 2021, the Section 
issued a findings report concluding there is reasonable cause to believe that Alameda County, 
California is violating the ADA in its provision of mental health services. 
119  The Section continued monitoring implementation of settlements and court orders in Georgia, 
Louisiana, Mississippi, New Hampshire, Virginia, and West Virginia that are helping individuals 
with intellectual, developmental, and mental health disabilities avoid unnecessary 
institutionalization.  In addition, the Section continued monitoring implementation of a 
settlement in Texas regarding conditions and care within institutions for people with intellectual 
and developmental disabilities.  
In support of its enforcement mandates, in October 2021, the Section filed a statement of interest 
in Z.S. v. Durham County, 1:21-cv-663, (M.D. N.C.), in which an infant with disabilities alleged 
that Durham County discriminated against him by keeping him in a segregated, congregate 
setting.  The statement of interest clarified that:  (1) the integration mandate of the ADA and the 
Rehabilitation Act prohibits discrimination in the form of unnecessary segregation, regardless of 
the intent of the agency placing individuals with disabilities in institutional settings; (2) there are 
multiple ways to demonstrate that community placement is appropriate for an individual, only 
one of which is a determination by the public entitys treatment professionals; and (3) a plaintiff 
who alleges that access to an existing community-based service will prevent unnecessary 
institutionalization has alleged a plausible reasonable modification under the ADA and the 
Rehabilitation Act.  In March 2022, the court denied a motion to dismiss the plaintiffs claims in 
a ruling consistent with the statement of interest. 
In its pending litigation with the State of Texas regarding the right to receive community-based 
services for people with intellectual and developmental disabilities (IDD) housed in Texas 
nursing facilities, Steward et al v. Young et al, 5:10-cv-1025, (W.D. Tex. 2010), the Section 
awaits a ruling from a trial completed in FY 2019. 
Disability Rights Section 
In FY 2022, the Disability Rights Section issued a letter of findings in two investigations, 
submitted statements of interest in pending private litigation, successfully concluded a settlement 
agreement, filed an amended complaint in United States v. Florida, No. 12-cv-60460 (S.D. Fla.), 
and monitored compliance with seven settlement agreements under which more than 24,900 
people collectively will obtain relief. 
In March 2022, the Section concluded an investigation into complaints from Coloradans, and 
issued a letter of findings stating that Colorado is violating Title II of the ADA by unnecessarily 
segregating a significant number of adults with physical disabilitiesincluding older adultsin 
Medicaid funded nursing homes and failing to ensure that individuals have a meaningful 
opportunity to live in community-based settings appropriate to their needs. 
In June 2022, the Section issued a letter of findings to the State of Maine, notifying the State that 
it is violating Title II of the ADA by unnecessarily segregating children with behavioral health 
needs in psychiatric hospitals, residential treatment facilities, and a state-operated juvenile 
detention facility, and placing other children at serious risk of placement in these facilities, even 
though many of these children could stay in their homes with sufficient community-based 
services.  
120  In December 2021, the Sections litigation in United States v. Florida, which had been dismissed 
sua sponte in September 2016, became active again when the U.S. Court of Appeals for the 
Eleventh Circuit denied the States motion for rehearing en banc.  In June 2022, the Section filed 
an amended complaint and has engaged in extensive pre-trial discovery.  The amended complaint 
alleges that Florida unnecessarily segregates children with complex medical needs in nursing 
facilities, and places other children at risk of such segregation, in violation of Title II of the 
ADA.  Trial is scheduled for May 2023. 
In January 2022, the Section filed a statement of interest in A.A. v. Bimestefer, 21-cv-2381 (D. 
Colo.).  The case was brought on behalf of children with mental health disabilities who allege 
they are unnecessarily institutionalized in Psychiatric Residential Treatment Facilities and other 
institutions.  The statement explained that (1) plaintiffs who are segregated or at serious risk of 
segregation due to a lack of medically necessary services can establish they have an injury in fact 
sufficient to confer standing, and (2) unnecessary segregation constitutes discrimination on the 
basis of disability under the ADA and the Rehabilitation Act. 
In May 2022, the Section, along with the USAO for the District of Rhode Island, entered  a 
settlement agreement with the State of Rhode Island, resolving a complaint that the State failed 
to provide a child with autism with the community-based Medicaid services that Rhode Island 
had authorized, resulting in the childs placement in an out-of-state residential treatment facility 
for several months. Under the agreement, Rhode Island will modify its policies so that children 
with autism and other developmental disabilities will receive authorized Medicaid services to 
allow them to live with their families.  The complainants son will also receive $75,000 in 
damages. 
The Section completed monitoring an ADA settlement agreement with the State of Oregon after 
the State successfully implemented reforms substantially increasing supported employment 
services to help individuals with intellectual and developmental disabilities (IDD) obtain 
competitive integrated employment services, rather than work in sheltered workshops.  At the 
end of the agreement, Oregon had provided supported employment services so that over a 
thousand sheltered workshop workers received jobs in the community and had provided 
supported employment services to more than 7,000 peopleincluding more than 4,900 youth 
exiting school--according to State data.  In August 2022, the Court dismissed the case. 
In addition, the Section continued to monitor implementation of settlements in Maine, New 
York, North Carolina, North Dakota, and Rhode Island. 
For example, under an agreement with North Dakota, reached in December 2020, the State has 
transitioned 149 individuals from skilled nursing facilities to community homes and diverted 
over 400 individuals from unnecessary nursing facility admission by providing community-based 
services.  All told, North Dakota has provided state or Federally funded home and community-
based services to over 5,000 unduplicated adults since the signing of the settlement agreement. 
121  Educational Opportunities Section 
In May 2020, a multi-year stay of litigation was lifted in pending litigation against the State of 
Georgia.  The Section alleges that the State is violating Title II of the ADA in its use of 
segregated educational services for approximately 4,000 Georgia students with emotional and 
behavioral disabilities.  Trial is now anticipated in FY 2024.  
Finally, as part of a new enforcement effort to combat unlawful seclusion, EOS has resolved two 
investigations into districts that unnecessarily segregate children based on behavior that is related 
to their disability.  The agreements are in Frederick County, Maryland, and Cedar Rapids, Iowa. 
In response to the problems that led to improper seclusions in Frederick, the state legislature 
passed a statewide ban on the use of seclusion rooms in public schools.  We are negotiating 
similar agreements in Spokane, Washington; Anchorage, Alaska; and Okaloosa, Florida.  These 
districts routinely segregate students with disabilities for long periods of time through seclusion 
and restraint practices in violation of the ADA. 
Office of the Inspector General 
The Office of the Inspector General (DOJ-OIG) was allocated $0.9 million in FY 2022 HCFAC 
funding to address health care fraud as it directly impacts the DOJ operations.  The DOJ spends 
over $1.0 billion a year to provide health care to inmates of the Federal Bureau of Prisons (BOP) 
and the U.S. Marshals Service (USMS), and expends more than $115.0 million a year in annual 
workers compensation payments related to disabled and injured DOJ employees and informants.  
DOJ-OIG pursues a comprehensive approach to reducing fraud, waste, and abuse in the 
oversight of health care fraud among DOJ components.  One means by which DOJ-OIG 
accomplishes this is through the issuance of public reports that highlight internal control risks 
and recommend corrective actions on issues found.  The DOJ-OIG conducted two audits of BOP 
comprehensive medical services (CMS) contractors.  The objective of these audits was to assess 
BOPs administration of the contracts, and the contractors performance and compliance with the 
terms, conditions, laws, and regulations applicable to these contracts. 
Additionally, the DOJ-OIG Investigations Division collaborates with the DOJ-OIG Audit 
Divisions Office of Data Analytics (ODA) to detect and deter fraud, waste and abuse in these 
contracts and programs.  The DOJ-OIG ODA collects, cleans, validates, analyzes, and stores 
health care claims data to identify anomalous billing and prescription patterns and refers 
investigative leads to the Investigations Division for evaluation of investigative merit.  Although 
the DOJ-OIG can obtain standardized data for workers compensation payments and USMS 
health care claims data, BOP lacks a centralized system of inmate health care claims data.  Thus, 
the DOJ-OIG ODA invests additional resources to stand-up an IT infrastructure that securely 
stores and standardizes health care claims data received via OIG subpoena from numerous BOP 
CMS contractors.  The BOP, USMS, and workers compensation health care related data reside 
in a DOJ-OIG ODA data lake that contains stringent controls to safeguard this sensitive data. 
122  In FY 2022, the DOJ-OIG increased its outreach efforts and conducted health care fraud training 
to the BOP workers compensation and health services administration personnel.  The goals for 
the health care fraud briefings were to increase the awareness of the existence of health care 
fraud, share fraud indicators and schemes, and provide an open line of communication with DOJ-
OIG customers to report suspected fraud.  The DOJ-OIG conducted four health care fraud 
briefings. 
During FY 2022, the DOJ-OIG continued participating in two health care fraud working groups 
and continued to collaborate with other Federal agencies that investigate health care fraud.  
These efforts have provided opportunities for the DOJ-OIG to collaborate and share ideas with 
other organizations.  
The DOJ-OIG sought refreshed health care claims data directly from the BOP CMS providers.  
The additional data will help to build upon the DOJ-OIGs comprehensive BOP health care data 
bank, ensuring the ability to use historical data as the foundation for predictive analytics efforts.  
After an extended interruption of U.S. Department of Labor workers compensation claim data 
caused by the COVID-19 pandemic, the DOJ-OIG resumed a regular schedule of receiving 
workers compensation data.  The analysis of the Departments workers compensation data 
resulted in the multiple investigative leads for health care providers.  The DOJ-OIG continues to 
build upon its predictive analytics abilities.  
In FY 2022, the DOJ-OIG secured the services of a subject matter expert (SME) to review health 
care claims for two open and ongoing investigations.  The SME will help to determine if two 
BOP CMS providers billed the BOP at the appropriate level for the services rendered.  With the 
precedent set by the successful FY 2021 False Claims Act settlement (nearly $700,000), the 
DOJ-OIG has established relationships with prosecutors to pursue similar settlements with other 
CMS providers overbilling the BOP.  Since receiving initial funding, the DOJ-OIG has opened a 
total of 25 investigations related to DOJ health care-related activities and programs. 
In February 2022, the DOJ-OIG issued a Management Advisory Memorandum (MAM) to the 
BOP advising of concerns regarding potential overpayment by BOP for inmate health care 
services.  Specifically, CMS providers selecting the billing code level on behalf of the 
subcontractor that performed the services. 
In February 2022, the DOJ-OIG issued a MAM to the BOP advising of concerns identified 
during the course of an ongoing audit of the BOP procurements awarded to NaphCare, Inc. 
(NaphCare) for medical services provided to Community Corrections Management (CCM) 
inmates, which includes inmates in residential reentry centers (RRCs) and under home 
confinement.  The procurements awarded to NaphCare since October 2016 exceed $91.0 million. 
The audit assessed BOP and contractor compliance with applicable guidance in the areas of 
acquisition planning and procurement; contract management, oversight, and monitoring; billing 
and payments; and contractor performance.  The DOJ-OIG identified significant concerns with 
the acquisition planning and oversight of invoices, of particular interest given the BOPs 
impending acquisition for the next medical services award and provided two recommendations.  
123  Since that time, the DOJ-OIG identified additional concerns related to acquisition planning and 
administration of the procurements awarded to NaphCare for medical services.  In September 
2022, the DOJ-OIG issued a final audit report that included six recommendations for the BOP to 
address these concerns. 
In March 2022, the DOJ-OIG issued an audit report of the BOP Comprehensive Medical 
Services Contracts Awarded to the University of Massachusetts (UMass) Medical School.  The 
objectives of this audit were to assess the BOPs award and administration of the contracts, and 
UMasss compliance with the terms, conditions, laws, and regulations applicable to the contracts. 
The report contains 15 recommendations to assist the BOP in improving its acquisition process 
for medical services, contract administration, management of contract performance, and billing. 
In September 2022, the DOJ OIG issued a multi-discipline MAM to notify the BOP of concerns 
related to its procurement of medical services.  The MAM addressed deficiencies identified over 
years in connection with 11 DOJ Office Inspector General audits and reviews since 2016 
regarding the BOPs strategy for its medical service contracts.  In several of these audits and 
reviews, the DOJ-OIG has repeatedly observed deficiencies in the BOPs planning, 
administering, and monitoring of medical contracts that have led to inefficient management, 
suboptimal contractor performance, and ultimately a waste of taxpayer dollars. 
FY 2022 Accomplishments 
Key oversight accomplishments in FY 2022 for the DOJ-OIG include: 
  Management Advisory Memoranda issued to reduce program waste:  3, and 
  Audits performed to reduce program waste:  2 
124  APPENDIX 
Federal Bureau of Investigation 
The Federal Bureau of Investigation (FBI) was allocated $152.9 million in HCFAC Program 
funding in FY 2022 to support the facilitation, coordination and accomplishment of the goals of 
the program.  In addition, the FBI received $7.1 million in DOJ FY 2022 Discretionary HCFAC 
funding, which was primarily used by the FBI to align FBI investigative resources with DOJ 
prosecutive resources to address the health care fraud (HCF) threat.  The majority of the HCFAC 
funding the FBI received in FY 2022, was used to support a total of 837 positions (505 Agent 
and 332 Support).  In addition to funding personnel resources, the FBI utilized HCFAC Program 
funding to support both covert and undercover investigations and operations, financial and 
investigative analysis support, operational travel, and other investigative and operational costs.  
In FY 2022, the FBI opened 625 new HCF investigations, and 3,103 investigations were pending 
at the end of FY 2022.  Investigative efforts throughout the fiscal year produced 495 criminal 
convictions, 389 indictments, and 190 informations.  In addition, investigative efforts resulted in 
over 499 operational disruptions of criminal fraud organizations and the dismantlement of more 
than 132 HCF criminal enterprises. 
The FBI is the primary Federal agency responsible for identifying and investigating HCF 
targeting both public health care benefit programs and private health insurance plans of all sizes.  
HCF investigations are considered a top priority within the FBIs Complex Financial Crime 
Program.  Each of the FBIs 56 field offices has personnel assigned to identify and investigate 
HCF matters. 
The FBI approaches the HCF crime problem in a threat-based, intelligence-driven manner.  This 
approach requires the prioritization of threats and the development of detailed threat mitigation 
plans at both the national and field office levels.  This process is designed to ensure limited 
analytical and investigative resources are focused on the most significant entities committing 
health care fraud, waste, and abuse, in order to have the greatest impact on the threat.  As part of 
the HCF threat review and prioritization process, the FBI gathers relevant data and information 
from a variety of sources to gain an understanding of the impact of the HCF crime problem 
nationally and in each FBI Field Offices area of responsibility.  Each field office conducts a 
similar analysis to review and prioritize threats in their geographic area of responsibility, 
including setting forth the specific actions they will take to mitigate them.  This process also 
reveals intelligence gaps and areas which require additional research and analysis.  The process 
is on-going and requires collaboration not only among FBI components, but also with the public 
and private sectors.  As a result of the process, the FBI has determined that large-scale criminal 
enterprises; corporate-level fraud, waste, and abuse; and public safety and patient harm matters, 
to include those arising from the ongoing prescription opioid abuse epidemic, remain priority 
HCF threat areas of focus.  
125  FBI field offices throughout the U.S. address the HCF threat through joint investigative efforts; 
the collection, analysis, and sharing of intelligence; and the utilization of advanced and 
sophisticated investigative techniques.  FBI field offices participate in DOJ-led Medicare Fraud 
Strike Forces, FBI-led HCF task forces, and HCF working groups with Federal, state, and local 
law enforcement and regulatory partners, including local USAOs, HHS-OIG, DEA, IRS, FDA, 
and state MFCUs. The FBI also conducts significant information sharing and coordination 
efforts with private insurance partners through the National Health Care Anti-Fraud Association 
(NHCAA), the National Insurance Crime Bureau (NICB), and private insurance special 
investigative units.  The FBI is also actively involved in the HFPP, an effort to exchange 
information between the public and private sectors to reduce the prevalence of HCF. 
These collaborative relationships facilitate information sharing and coordination among the 
government agencies and private entities involved in addressing the HCF threat.  Moreover, 
these relationships allow for the identification of HCF threat trends and the initiation of new 
cases against the most egregious offenders involved in health care fraud, waste, and abuse. 
The FBIs Health Care Fraud Unit (HCFU), which is housed within the Criminal Investigative 
Divisions Financial Crimes Section, manages the FBIs HCF program, including providing 
operational and administrative support and guidance to 56 field offices to assist them in their 
efforts to identify and investigate health care fraud.  The FBIs HCFU also establishes national 
HCF program initiatives to ensure a coordinated approach to addressing the HCF threat.  In 
support of joint agency activities and general threat mitigation efforts, the HCFU established four 
national program initiatives in FY 2022, to include the Health Care Fraud Task Force and 
Working Group Initiative, Prescription Drug Initiative, Major Provider and Large-Scale 
Conspiracies Initiative, and the Health Care Fraud Outreach and Liaison Initiative. 
The Health Care Fraud Task Force and Working Group Initiative 
The Initiative was established to encourage the formation of FBI led Joint Health Care Fraud 
(HCF) Task Forces and HCF Working Groups throughout the country.  Joint Task Forces and 
Working Groups combine Federal, state, and local law enforcement and regulatory resources to 
address Health Care Fraud and other complex financial crimes (CFC).  Task forces serve as a 
force multiplier for FBI efforts by bringing the experience, expertise, and resources of our 
Federal, state, local, and tribal partners to bear to mitigate the HCF and CFC threats.  Task forces 
and working groups result in improved sharing of threat-related intelligence among participating 
agencies and expand criminal and civil tools for participants to use to identify and disrupt 
criminal activity.  Task force participants and their employing agencies also benefit from 
increased access to FBI training and equitable sharing arrangements.  In FY 2022, the FBI 
opened 245 joint HCF investigations with task force and working group partners, more than 125 
of which were opened and investigated by 17 established FBI HCF task forces.  To further this 
initiative, FBI personnel also participate on DOJ-led HCF Strike Forces throughout the country. 
FBI Participation in DOJ-Led Strike Forces 
As noted above, the FBI participates in DOJ Medicare Fraud Strike Forces throughout the 
country, the ARPO Strike Force in Appalachia, and the newly created New England Prescription 
Opioid (NEPO) Strike Force.  Specifically, FBI personnel serve on DOJ Medicare Fraud Strike 
126  Forces located in Florida (Miami, Tampa, Orlando), Los Angeles, Texas (Houston, Dallas, 
McAllen/Rio Grande Valley), the Gulf Coast (New Orleans, Baton Rouge, and Southern 
Mississippi), Northeast Regional (Newark/ Philadelphia), Detroit, Brooklyn (NYC), Chicago, 
and the NRRSF based in Washington, DC. 
In FY 2021, the FBI established the Health Care Fraud National Rapid Response Team 
(HCFNRT), a specialized team comprised of experienced Special Agents, Intelligence 
Analysts, and other professional staff members who are charged with investigating, or assisting 
in the investigation of, complex health care fraud cases throughout the county.  HCFNRT 
members work closely with the DOJ prosecutors serving on the DOJ National Rapid Response 
Strike Force, thus aligning FBI investigative resources with DOJ resources to address the 
growing health care fraud threat, which increasingly transcends field office areas of 
responsibility. 
As noted earlier in this report, in July 2022, the DOJ Criminal Divisions Fraud Section, in 
coordination with the FBI and other state and Federal agencies announced the results of the 2022 
National Health Care Fraud Telemedicine Fraud and Laboratory Fraud Law Enforcement Action 
(LEA).  The LEA was a rolling operation, which spanned 13 Federal judicial districts and 
involved health care fraud investigations in 12 FBI field offices.  The LEA resulted in charges 
filed against over 36 fraudsters, including more than 12 licensed medical professionals, as well 
as other co-conspirators engaged in schemes to defraud public and private health insurance 
companies and vulnerable patients.  The total amount of fraudulent billing to public and private 
health programs was approximately $1.2 billion, approximately $440.0 million of which was 
fraudulently paid.  
In addition to being charged criminally, three of the 12 medical providers charged received 
payment suspension notices from CMS.  Fifty-two medical providers, who were not charged 
criminally, received payment suspension notices from CMS in connection with the investigations 
underlying this LEA. However, their actions did not rise to the level of criminal conduct.  $8 
million in assets were seized during this LEA.  This operation was conducted jointly with HHS-
OIG, CMS, VA-OIG, IRS-CI, DEA, DCIS, and our state and local partners, including various 
state MFCUs. The continued support of DOJ Strike Force operations is a top priority for the 
FBI.  Additionally, the FBI coordinates and shares intelligence with HHS and DOJ components 
on other prevention and enforcement activities, to include efforts associated with the Large-Scale 
Conspiracies and Major Provider Fraud Initiative and the Prescription Drug Initiative. 
Appalachian Region Prescription Opioid (ARPO) Strike Force 
FBI personnel also serve on the ARPO North (Kentucky, Ohio, Virginia, and West Virginia), 
ARPO South (Tennessee and Northern Alabama), and NEPO (Boston/New Hampshire/Vermont) 
Strike Forces. 
As part of the DOJ ARPO Strike Force initiative to address the illegal diversion of prescription 
opioids in Appalachia, DOJ provided funding to the FBI to support the deployment of 14 Special 
Agents dedicated to identifying and investigating individuals, including medical professionals, 
who divert prescription opioids, and thus contribute to the nations opioid epidemic.  The ARPO 
127  Strike Force continues to operate in the Birmingham, Cincinnati, Knoxville, Louisville, 
Memphis, Pittsburgh, and Richmond Field Office areas of responsibility.  
In May 2022, the FBI participated the Department of Justice ARPO Enforcement Action, which 
charged 14 defendants in eight Federal districts across the United States for their involvement in 
crimes related to the unlawful distribution of opioids.  Twelve of the defendants were medical 
professionals.  One of the cases charged a Kentucky dentist with unlawfully prescribing 
morphine.  In August 2020, this dentist issued three opioid prescriptions to a 24-year-old patient 
in a five-day period.  The patient died from a morphine overdose from one of the prescriptions 
the dentist issued during those five days. 
New England Prescription Opioid (NEPO) Strike Force 
In June 2022, the FBI, along with the DEA and HHS-OIG, began serving on the newly 
established New England Prescription Opioid (NEPO) Strike Force.  The NEPO Strike Force 
was formed to address prescription opioid diversion cases in New England.  The NEPO Strike 
Force operates in a similar manner to the existing ARPO Strike Force currently operating in 
Appalachia.  NEPO, however, will operate in a manner that more closely adheres to the Strike 
Force concept where investigators and agents come into the area for a finite period of time to 
take on some of the biggest cases in order to have the greatest impact and a deterrent effect. 
The Prescription Drug Initiative 
The Prescription Drug Initiative was established to identify fraud and prosecute health care 
providers, individuals associated with health care providers, legitimate pharmaceutical 
wholesalers and manufacturers, and others involved in the fraudulent diversion of controlled 
substances, namely those listed in Schedule II through V of the Controlled Substances Act 
(CSA), including highly addictive opiates, from their lawful purpose into illicit drug traffic. 
In furtherance of this initiative, in July 2022, the FBI Pittsburgh Field Office opened an 
investigation into an individual who was reportedly leading an illegal prescription pill 
distribution network.  To advance the scheme, the individual obtained addictive prescription pain 
medications from physicians under the false pretense that he needed the medications and 
intended to use them himself.  His true intention, however, was to sell the medications to others 
suffering from addiction to make a profit.  The individual utilized a minor to transport some of 
the pills.  Ultimately, he was convicted in Federal court of violating Federal narcotics, firearms 
and health care fraud laws and sentenced to 25 years of imprisonment. 
The Major Provider and Large-Scale Conspiracies Initiative 
The purpose of this initiative is to encourage the initiation of traditional health care fraud cases 
involving the most significant schemes impacting public and private health insurance programs 
and plans.  This includes pursuing civil qui tam matters filed pursuant to the False Claims Act, 
Title 31 U.S.C.  3729, by private individuals, or "whistleblowers," with knowledge of fraud 
committed against the Federal Government.  Pursuant to this initiative, the FBI used all available 
resources to identify and target major medical providers, such as corporations, companies, and 
other groups, engaged in significant medical billing fraud and other schemes that resulted in, or 
were intended to result in, large monetary losses to private health plans and taxpayer funded, 
128  government health care benefit programs. Investigations targeting major providers are typically 
identified and initiated based upon data analytics, including the review of qui tam filings, and 
coordination with HHS-OIG and DOJs civil and criminal components.  Under this initiative, the 
FBI also sought to identify large-scale HCF conspiracies and investigate criminal enterprises and 
other organized groups who co-opt medical providers to collaborate in fraud schemes.  Such 
schemes include, among other things, the sharing and selling of beneficiaries personally 
identifiable information (PII), multi-tiered kickback schemes involving fraudulent referrals and 
billing for medically unnecessary services, or billing for services never provided. 
In FY 2022, FBI Boston initiated an investigation into a pharmaceutical company, based on 
allegations that the company knowingly underpaid rebates to insurers for a specialty drug. 
Pursuant to the Medicaid Drug Rebate Program, drug manufacturers are required to pay quarterly 
rebates to state Medicaid programs in exchange for Medicaids coverage of the manufacturers 
drugs. The statute requires manufacturers to pay inflation-based rebates for drugs, which are 
designed to insulate the Medicaid program from drug price increases outpacing inflation.  These 
rebates are calculated by comparing the drugs Base Date Average Manufacturer Price (AMP), 
which is the drugs price on the date that the dosage form and strength of the drug was first 
marketed or 1990, whichever is later, to its current price.  According to the complaint, the 
company and its predecessor began paying rebates for the drug in 2013 as if it was a new drug 
first marketed in 2013, rather than a drug that had been approved since 1952.  Allegedly, this 
practice meant the companies ignored all pre-2013 price increases when calculating and paying 
Medicaid rebates for the drug from 2013 until 2020.  The companys decision to disregard all 
previous price increases for Medicaid rebate purposes significantly lowered Medicaid rebate 
payments the company paid for the drug.  In 2016, CMS began warning the company against this 
practice and continued to warn the company. Despite the warnings, the company did not take 
corrective action.  In March 2022, the company agreed to pay approximately $233.7 million as 
part of a settlement to resolve allegations that it violated the False Claims Act.  This was a joint 
investigation with HHS-OIG. 
In FY 2022, the FBI Knoxville initiated an investigation into a large-scale conspiracy involving 
several medical providers and companies engaged in a billing fraud scheme involving the 
prescription of expensive compound medications to patients.  In many cases, the prescribers had 
never met or even spoken with the patients.  The providers sent the prescriptions to a pre-
determined pharmacy, and the pharmacy billed the insurance carriers high dollar amounts for 
the compounded medications.  The investigation revealed that from June 2015 through April 
2018, the providers and others, utilizing their companies, conspired to deceive tens of thousands 
of patients and more than 100 doctors located in the Eastern District of Tennessee and elsewhere 
for the purpose of defrauding health care benefit programs.  The subjects submitted over 
$930,000,000 in fraudulent claims for payment and received over $174.0 million.  In May 2022, 
one of the subjects was sentenced to 14 years of imprisonment, ordered to pay over $24.6 million 
in restitution, and forfeit assets valued at $2.5 million.  This case was investigated with HHS-
OIG, OPM-OIG, FDA-OCI HSI, and USPIS-OIG. 
129  Health Care Fraud Outreach and Awareness Initiative 
This national program initiative was established to ensure the FBI initiates and maintains 
ongoing and frequent contact with the general public, as well as our law enforcement, regulatory, 
and private sector partners regarding the health care fraud threat.  As the primary Federal agency 
responsible for identifying and investigating health care fraud targeting both public health care 
benefit programs and private health care plans, the FBI must undertake measurable outreach 
efforts to educate the public about the HCF threat, including increasing public awareness of 
potential indicators of health care fraud activity so that they are able to identify it when it is 
occurring and are aware of how to report it.  Further, the FBI must also establish and maintain 
liaison relationships with our law enforcement and regulatory partners, including conducting and 
attending HCF threat awareness briefings, exchanging threat information, and sharing best 
practices for addressing the threat.  Under this initiative, the FBI also established tripwire 
contacts within private health plans and with medical providers. 
To advance this initiative, HCFU worked with the FBIs Office of Public Affairs to launch 
a campaign to increase public awareness of potential indicators of health care fraud.  The 
campaign consisted of information designed to assist the public in identifying health care 
fraud activity and in reporting it.  The campaign also provided guidance to the public through 
various media advertisements, including a social media outreach component.  Furthermore, the 
HCFU updated the FBI.gov website with helpful information such as common health care fraud 
schemes and tips on how to avoid becoming a victim of health care fraud scams.  The FBI is also 
working with the CMS Administration for Community Living, Office of Health care Information 
and Counseling to reach the public regarding the HCF threat. 
COVID-19 Anti-Fraud Program 
Much like traditional HCF, COVID-19 related HCF schemes targeted government sponsored 
health care programs, particularly Medicare and Medicaid, private health insurance plans, and 
other government-sponsored pandemic relief programs.  Throughout the pandemic, medical 
providers engaged in common health care-related fraud including overbilling, billing for services 
not rendered, upcoding services, billing for medically unnecessary services, etc., particularly as 
more beneficiaries sought treatment and vaccinations. Additionally, the expansion of 
telehealth/telemedicine coverage for beneficiaries amid COVID-19 resulted in greater 
instances of fraud, as physicians, clinics, and labs billed for services not rendered or paid 
kickbacks to marketers in exchange for patient referrals.  Medical identity theft and fraud related 
to the production and sale of vaccine cards also occurred.  This program is designed to prioritize 
cases involving COVID-19 related HCF and the COVID-19 Anti-Fraud team will continue to 
coordinate closely with the DOJ Fraud Section in combatting pandemic-related investigations. 
In April 2022, the DOJ Criminal Divisions Fraud Section, in coordination with the FBI and 
multiple Federal agencies announced the results of the 2022 National Health Care Fraud 
COVID-19 Law Enforcement Action.  The cases included fraudulent billing, the sale of fake 
COVID-19 vaccination cards, theft from pandemic assistance programs, and kickback schemes.  
Several HCF Strike Force field offices took part in investigating the cases.  The operation, which 
spanned nine Federal judicial districts and five FBI field offices, resulted in charges filed against 
over 21 fraudsters, to include three licensed medical professionals, as well as other co-
130  conspirators engaged in schemes to defraud public and private insurance companies and 
vulnerable patients.  The total amount of fraudulent billing to public and private health programs 
was approximately $149.0 million.  As a result of the operation, $8.0 million in cash and other 
fraud proceeds were seized.  This operation was conducted with the HHS-OIG, CMS, DOI-OIG, 
FDA-OIG, DOL-OIG, DCIS-OIG, USPIS, VA-OIG and HSI. 
HCF Training & Enrichment Efforts 
The FBI actively provides training and guidance on HCF matters.  The FBI has partnered with 
the DOJ, HHS-OIG, and private insurance organizations to provide training in the priority threat 
areas of HCF.  Funded training has included innovative methods of employing advanced 
investigative techniques, basic HCF training for FBI Special Agents and professional staff newly 
assigned to investigate HCF, and sessions on new and current HCF trends and issues.  In FY 
2022, the HCFU continued its virtual trainings to address the educational needs of the FBI 
personnel throughout the pandemic in lieu of in-person training.  The virtual training platform 
made training more accessible to FBI personnel.  In FY 2022, eight virtual training sessions were 
held, and over 722 FBI employees participated in the training sessions.  Additionally, three 
virtual conferences were hosted in which 440 individuals participated from the FBI, DOJ, 
HHS/CMS, and VA-OIG.  A virtual training was also held for FBI Intelligence Analysts, 
Forensic Accountants, and Support Operations Specialists working in support of HCF 
investigations. 
Some of the topics covered included current trends in HCF, working with private insurance 
special investigations units, and HCF data analytics, among others.  The FBI HCF program will 
continue to support employees attendance to qualified virtual and in-person training offered by 
Federal and local law enforcements agencies along with the private sector. 
131  Return on Investment Calculation 
  The return on investment (ROI) for the HCFAC program is calculated by dividing the total 
monetary results to the Federal Government (not including relator payments) by the annual 
appropriation for the HCFAC Account in a given year (not including portions of CMS 
funding dedicated to the Medicare Integrity Program listed in the table on page 133). 
  The monetary results include deposits and transfers to the Medicare Part A Trust Fund and 
the Treasury, as well as restitution and compensatory damages to Federal agencies. 
  The HCFAC Account is made up of three funding sources: mandatory funding for HHS and 
DOJ, including HHS-OIG, appropriated through Section 1817(k)(3)(A) of the Social Security 
Act; mandatory funding for FBI activities appropriated through Section 1817(k)(3)(B) of the 
Social Security Act; and discretionary funding for the HCFAC Account appropriated through 
the annual Labor-HHS-Education appropriation. 
  FBI mandatory HIPAA funding is included in the HCFAC ROI calculations given the 
important role the FBI plays in achieving the monetary results reflected in the HCFAC 
annual report and because that statute states that the funds are for the same purposes as the 
funds provided for HHS and DOJ under the Social Security Act.  However, FBI spending 
and monetary results are not required to be reported per the statute.  Therefore, even though 
the FBI mandatory HIPAA funding is included in the HCFAC ROI calculation, it is not 
reflected in the table on page seven of this report. 
  Only certain portions of discretionary HCFAC Account funding are included in the ROI 
calculation.  All discretionary HCFAC funding for HHS-OIG and DOJ are included in the 
HCFAC report ROI since they spend their discretionary funding on the same types of 
activities that they support with mandatory funding.  Only the portion of CMS Medicare 
discretionary HCFAC funding that supports law enforcement is included in the HCFAC 
report ROI.  The remainder of CMSs HCFAC Medicare discretionary funding supports 
activities in the Medicare Integrity Program (MIP) that are included in the MIP ROI, which 
calculates the impact of the prevention activities supported by the MIP mandatory and 
discretionary funds is calculated separately from the HCFAC ROI and is reported outside of 
the HCFAC report.  Impacts for both the CMS Medicaid and Medicare program integrity 
funding are included in a separate report. 
132  Total Health Care Fraud and Abuse Control Resources 
The table below sets forth HCFAC funding, by agency, for health care fraud and abuse control 
activities in FY 2022, including sequester suspension.  The FBI also receives a stipulated amount 
of HIPAA funding for use in support of the Fraud and Abuse Control Program, which is shown 
below.  Separately, CMS receives additional Mandatory Resources under the Medicare Integrity 
Program (section 1817(k)(4) of the Social Security Act).  The inclusion of the activities 
supported with these funds is not required in this report, and this information is provided for 
informational purposes only.  Since 2009, Congress has also appropriated annual amounts to 
help carry out health care fraud and abuse control activities within DOJ and HHS.  Those 
amounts are set forth as Discretionary Resources in the table below and the results of the efforts 
supported with these funds are contained within this report. 
Mandatory Resources39  Fiscal Year 2022 
Office of Inspector General  $214,630,678 
Health and Human Services Wedge40  41,050,686 
Medicare Integrity Program41  963,369,475 
MIP/Medicare (non-add)  889,264,130 
Medi-Medi (non-add)  74,105,345 
Department of Justice Wedge40  67,013,606 
Federal Bureau of Investigation42  152,924,358 
Subtotal, Mandatory HCFAC  $1,438,988,803 
Discretionary Resources 
Office of Inspector General  $102,145,000 
CMS Program Integrity  658,648,000 
CMS Program Integrity (non-add)  628,648,000 
Senior Medicare Patrols (ACL non-add)  30,000,000 
Department of Justice  112,207,000 
Subtotal, Discretionary HCFAC  $873,000,000 
Grand Total, HCFAC  $2,311,988,803 
39 Section 3709 of the CARES Act (P.L. 116-136) suspended Medicare sequestration from May 1, 2020, through 
December 31, 2020; the Consolidated Appropriations Act, 2021 (P.L. 116-260) extended this suspension to March 
31, 2021; the Medicare sequester moratorium included in P.L. 117-7 extended the suspension again until December 
31, 2021; and the Protecting Medicare and American Farmers from Sequester Cuts Act (P.L. 117-71) extended the 
suspension for the last time through March 31, 2022. 
40 The HHS and DOJ Wedge funds are divided among multiple agencies within HHS and DOJ. Page 7 of this report 
includes the allocations of the HHS and DOJ Wedge by agency or activity. 
41 The Medicare Integrity Program (MIP) and Medicaid Integrity Program funds fraud prevention and detection 
activities within Medicare and is not part of this report to Congress.   A separate report to Congress addresses MIP, 
as well as the Medicaid Integrity Program. 
42 The FBI receives funding annually to conduct anti-fraud activities authorized by HIPAA.   This funding is 
included in the HCFAC ROI calculation for this report. 
133  Glossary of Common Terms 
The AccountThe Health Care Fraud and Abuse Control Account 
ACAAffordable Care Act 
AKSAnti-Kickback Statute 
ACLDepartment of Health and Human Services, Administration for Community Living 
AUSAAssistant United States Attorney 
CHIPChildrens Health Insurance Program 
CIACorporate Integrity Agreement 
CMPCivil Monetary Penalty 
CMPLCivil Monetary Penalties Law 
CMSDepartment of Health and Human Services, Centers for Medicare & Medicaid Services   
CPICenter for Program Integrity 
CYCalendar Year 
DEADrug Enforcement Administration 
DMEDurable Medical Equipment 
DOJDepartment of Justice 
FBIFederal Bureau of Investigation 
FCAFalse Claims Act 
FDAFood and Drug Administration 
FFSFee-for-Service 
FYFiscal Year 
HCFACHealth Care Fraud and Abuse Control Program or the Program 
134  HEATHealth Care Fraud Prevention & Enforcement Action Team 
HFPPHealthcare Fraud Prevention Partnership 
HHAHome Health Agency 
HHSDepartment of Health and Human Services 
HHS-OIGDepartment of Health and Human Services - Office of Inspector General 
HIHospital Insurance Trust Fund 
HIPAAHealth Insurance Portability and Accountability Act of 1996, P.L. 104-191 
MAMedicare Advantage 
MAOMedicare Advantage Organization 
MFCUMedicaid Fraud Control Unit 
MEDICMedicare Drug Integrity Contractors 
OCGSOrganized Crime and Gang Section 
OGCOffice of the General Counsel, Department of Health and Human Services 
PECOSProvider Enrollment, Chain and Ownership System 
PERMPayment Error Rate Measurement 
PFPPharmaceutical Fraud Pilot Program 
The ProgramHealth Care Fraud and Abuse Control Program 
SecretarySecretary of the Department of Health and Human Services 
SMPSenior Medicare Patrol 
UPICUnified Program Integrity Contractor 
USAOUnited States Attorneys Office 
135