Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
CMS H Y T E
    AS  ET  O  NFORCE 
 
S P
A   TATUTORY  ROVISION 
 
R R H
EL  ATED TO  URAL  EALTH 
 
C  
LINICS 
 
 
 
Suzanne Murrin 
Deputy Inspector General for 
Evaluation and Inspections  
 
September 2014 
OEI-05-13-00290   
   
EXECUTIVE SUMMARY:  CMS HAS YET TO ENFORCE A STATUTORY 
PROVISION RELATED TO RURAL HEALTH CLINICS  
OEI-05-13-00290 
 
WHY WE DID THIS STUDY 
The Rural Health Clinic (RHC) certification was created in 1977 to address the shortage 
of physicians in rural areas. RHCs had to meet two location requirements:  (1) being 
located in rural areas and (2) being located in areas that have a shortage of health care 
providers. RHCs receive enhanced Medicare and Medicaid reimbursements for most 
services.  
 
Prior to the enactment of the Balanced Budget Act of 1997 (BBA), RHCs retained their 
certifications indefinitely. However, the BBA removed their permanent status and 
allowed for the termination of RHCs that no longer met the location requirements as long 
as they were not determined to be essential provider RHCs. 
 
A 2005 Office of Inspector General report found that nearly 300 RHCs did not meet the 
location requirements and that the Centers for Medicare & Medicaid Services (CMS) had 
not issued regulations that would allow RHCs to apply as essential-provider RHCs.   
 
HOW WE DID THIS STUDY  
We plotted RHC locations onto a digital map to determine whether RHCs met the two 
location requirements in 2013.  Additionally, we used 2012 claims data to calculate the 
amount Medicare paid to the RHCs we determined did not meet the location 
requirements.  Finally, we reviewed Federal regulations and interviewed CMS staff to 
determine whether essential-provider criteria had been established or were in the process 
of being established. 
 
WHAT WE FOUND 
Approximately 12 percent of RHCs no longer met the location requirements in 2013.  
Pursuant to the BBA, these RHCs should continue to qualify as RHCsand receive 
enhanced reimbursementonly if they are determined to be essential providers.  
However, CMS has yet to issue final regulations that would allow RHCs that do not meet 
the location requirements to qualify as essential-provider RHCs.   
 
WHAT WE RECOMMEND   
More than 16 years have elapsed since Congress directed CMS to issue regulations that 
would allow RHCs that no longer meet location criteria to qualify as essential providers.  
Without these regulations, CMS can neither terminate RHCs nor identify them as 
essential providers in accordance with the BBA provision.  Consequently, RHCs that no 
longer meet location criteria continue to receive enhanced reimbursement.  To ensure that 
CMS can enforce the BBA provisions relating to RHCs, we recommend that CMS issue 
regulations to ensure that RHCs determined to be essential providers remain certified as 
RHCs. CMS responded to the report but neither concurred nor nonconcurred with our 
recommendation. 
 
   
   
TABLE OF CONTENTS 
 
Objective......................................................................................................1 

Background..................................................................................................1 

Methodology................................................................................................4 

Findings........................................................................................................6 

Approximately 12 percent of RHCs no longer meet the location 

requirements .....................................................................................6 

CMS has yet to issue final regulations that would allow RHCs that 

do not meet the location requirements to qualify as essential 

providers ..........................................................................................7 

Conclusion and Recommendation ...............................................................8 

Agency Comments and Office of Inspector General Response .......9 

Appendixes ................................................................................................10 

A: Definitions and Criteria for Health Care Shortage Areas  ........10 

B: Agency Comments  ...................................................................12 

Acknowledgments......................................................................................13
 
   
   
   
OBJECTIVES 
1. 	  To determine the extent to which Rural Health Clinics (RHCs) 
no longer meet the location requirements. 
2. 	  To determine whether the Centers for Medicare & Medicaid 
Services (CMS) has taken steps to address a prior Office of 
Inspector General (OIG) recommendation to issue regulations 
defining the criteria for RHCs to be deemed essential 
providers. 
BACKGROUND 
Rural Health Clinics 
The RHC certification was created in 1977 to address the shortage of 
physicians in rural areas by providing enhanced reimbursement.1   To  
ensure that RHCs could be located only in rural areas with documented 
physician shortages, CMS specified two location-based criteria 
(hereinafter known as the location requirements) in the RHC Conditions of 
Participation.2 RHCs had to be (1) located in nonurbanized areas, as 
defined by the Census Bureau (hereafter referred to as rural areas), and 
(2) located in one of the following types of health care shortage areas, as 
defined by the Health Resources and Services Administration (HRSA):3  
   Primary Care Geographic Health Professional Shortage Area 
(HPSA)4  
   Primary Care Population Group HPSA5  
   Medically Underserved Area (MUA)6  
   Governor-designated and Secretary-certified shortage area under 
the Omnibus Budget Reconciliation Act of 19897  
For a detailed description of each type of shortage area, see Appendix A. 
 
1 Rural Health Clinic Services Act of 1977, P. L. No. 95-210. 
2 Conditions  of  Participation are requirements that providers must meet to participate in  
Medicare. 
3 Social Security Act,   1861(aa)(2);  42  U.S.C.  1395x(aa)(2); CMS, Rural Health  
Clinic:  Rural  Health Fact Sheet Series, January 2013.  HPSAs are subject to annual 
reviews (76 Fed. Reg. 68198  (Nov. 3, 2011)).  MUAs are not subject to regular reviews 
(Negotiated Rulemaking Committee on the Designation  of  Medically Underserved 
Populations and  Health Professional  Shortage Areas:   Final Report to the Secretary, 
October 31, 2011, p.18).  

4 Public Health  Services (PHS) Act,    332(a)(1)(A). 

5  PHS Act,  332(a)(1)(B). 
 
6  PHS Act,  330(b)(3). 
 
7 Section 6213(c). 

 
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Most of the information that the RHC location requirements draw on 
is updated periodically.  Census-defined urbanized areas are updated every 
10 years, following the decennial Census.8 HPSAs are updated 
approximately once every 4 years; HRSA prioritizes designations that are 
more than 3 years old for recertification.9  Currently, MUAs are never 
updated.10  
RHCs receive enhanced reimbursements from Medicare and Medicaid.  
These enhanced reimbursements are based on costs.11 Medicare 
reimbursements to RHCs are subject to a per-visit payment limit, which 
was approximately $80 in 2013.12  Per-visit Medicare payment limits do 
not apply to RHCs that are part of a hospital with fewer than 50 beds.13  
In 2013, there were 4,019 RHCs providing services in 44 States in the 
United States. Medicare and beneficiaries paid approximately $1 billion 
for services provided at these RHCs.  
Creation of Essential Provider RHCs  
In 1996, both OIG and the Government Accountability Office (GAO) 
recommended that CMS ensure that the RHC certification apply only to 
facilities in areas that would otherwise be underserved, rather than in rural 
areas that are designated as health care shortage areas but have high 
concentrations of medical providers.14, 15    
In response to the OIG and GAO recommendations, the Balanced Budget 
Act of 1997 (BBA) removed RHCs permanent status and allowed for the 
creation of an exemption process for RHCs that would otherwise be 
 
8 United States Census Bureau, 2010 Census  Urban Area FAQs.  Accessed at 
http://www.census.gov/geo/reference/ua/uafaq.html on May 23, 2014.  
9  76  Fed.  Reg. 68198 (Nov. 3, 2011). 
10  Negotiated  Rulemaking Committee on the Designation  of  Medically Underserved 
Populations and  Health Professional  Shortage Areas:   Final Report to the Secretary, 
October 31, 2011, p.  18.  In  March  2014, HRSA staff stated that they are in the process of  
promulgating an interim final rule that would set a recertification schedule for MUAs.  
11 CMS, Rural Health Clinic:  Rural Health Fact Sheet Series, January 2013; Health  
Resources and Services Administration (HRSA), What are rural health clinics (RHCs)?  
Accessed at http://www.hrsa.gov/healthit/toolbox/RuralHealthITtoolbox/Introduction/  
ruralclinics.html  on May 23, 2014.   
12 CMS, Announcement of the Medicare Rural Health Clinic (RHC) and Federally 
Qualified Health Center (FQHC) Payment Rate Increases, November 23, 2012.  
Accessed at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-
MLN/MLNMattersArticles/downloads/MM8119.pdf  on May 23, 2014. 
13 CMS, Rural Health Clinic:  Rural Health Fact Sheet Series, January 2013. 
14 OIG,  Rural Health Clinics:  Growth, Access, and Payment,  OEI-05-94-00040, 

July 1996. 

15 GAO,  Rural Health Clinics:  Rising Program Expenditures Not Focused  on Improving 
 
Care in Isolated Areas,  GAO-HEHS-97-24, November 1996. 
 
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terminated from the Medicare program.  Prior to the BBA, RHCs that 
initially met the location requirements retained their RHC certifications 
indefinitely, effectively making the RHC certification permanent.  The 
BBA specified the RHCs that were in areas that no longer qualified as 
nonurbanized areas or shortage areas would continue to qualify as RHCs 
only if they were determined to be essential to the delivery of primary 
care services that would otherwise be unavailable in the geographic area 
served by the clinics (hereafter referred to as essential-provider RHCs).16   
Further, the BBA specified that the Secretary of Health and Human 
Services should issue regulations that would establish the criteria used to 
determine essential-provider RHCs, and that those regulations should take 
effect no later than January 1, 1999.17  
Rulemaking Process 
Agencies like CMS must follow the Administrative Procedure Act, which 
governs rulemaking.  Typically, an agency must publish a proposed rule in 
the Federal Register and invite the public to comment on it.  The agency 
uses the proposed rule and public comments as the basis for the final rule, 
which it publishesalong with the date the rule goes into effectin the 
Federal Register.18  
The Medicare Prescription Drug, Improvement, and Modernization Act 
(MMA), which became law on December 8, 2003, made a change to the 
rulemaking process for all agencies within the Department of Health and 
Human Services, including CMS.  Specifically, the MMA established that 
no more than 3 years may pass between the publication of a proposed rule 
or interim final and the publication of a final rule except under exceptional 
circumstances.  In the event of such circumstances, a notice of the 
different timeline must be published in the Federal Register.19  
Related Work 
OIG has a body of work that examines the location of RHCs.  In addition 
to its 1996 report, OIG issued a report in 2005 that found that, in 2003, 
279 RHCs were not located in rural areas or in health care shortage areas 
and that RHCs were often located near other health care providers.20 OIG 
recommended on the basis of these findings that CMS issue regulations 
 
16 Balanced Budget Act of 1997, P.L. No. 105-33    4205(d)(3)(A).  New RHCs are still 

required to meet the original location requirementsthat is, they must be located in  rural 

areas and in designated health care shortage areas. 
 
17  Balanced Budget Act of 1997, P.L. No. 105-33  4205(d)(4)(C)(ii). 
  
18  5 U.S.C.  553. 
 
19  Medicare Prescription Drug, Improvement, and  Modernization Act  of 2003, P.L.
  
No. 108-173  902(a)(1). 
 
20 OIG,  Status of the Rural Health Clinic Program, OEI-05-03-00170, August 2005. 

 
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defining essential-provider criteria for RHCs.  In its May 2005 comments 
on our report, CMS concurred with the recommendation and stated that it 
intended to issue new rules for RHCs in early 2006.   
METHODOLOGY 
Scope 
We analyzed RHC locations to identify those that in 2013 were no longer 
located in rural areas or in health care shortage areas.  We excluded RHCs 
with locations that we were unable to confidently determine.  We also 
calculated the amount that Medicare and beneficiaries paid to RHCs in 
2012. 
We focused on the 2005 OIG reports recommendation that CMS issue 
regulations defining essential-provider criteria for RHCs.   
Data Collection and Analysis 
We requested from HRSA a list of RHC addresses and corresponding 
latitudes and longitudes.  HRSA created this list using a three-step process:   
(1) compiling addresses for all RHCs enrolled in Medicare in 2013, using 
CMSs Certification and Survey Provider Enhanced Reports (CASPER); 
(2) running these addresses through the address standardizer 
Trillium 13.5;21, 22 and (3) identifying latitudes and longitudes for these 
standardized addresses using Esris StreetMap Premium 2013.23   There 
were 4,019 RHCs on this list. 
We excluded 498 RHCs from our analysis because they were geocoded 
only to the city, State, or ZIP Code level, rather than to the address level.24   
We felt that these levels of geocoding were not precise enough to 
determine whether these RHCs met the location requirements.   
We mapped the latitudes and longitudes of the remaining 3,521 RHCs 
onto a digital map using ArcGIS.  We used this map, along with the 
2013 boundaries of urbanized areas and health care shortage areas, to 
identify RHCs that did not meet the location requirements.   
 
21 The CASPER  database includes data  generated from certification surveys and includes 
information such as provider  addresses and enrollment dates.   

22 Trillium 13.5  standardizes name and address elements and  corrects spelling and other 

errors.   

23 StreetMap Premium is an enriched street  dataset that works with  Esris ArcGIS 

software to allow for geocoding, routing, and turn-by-turn  directions.  Geocoding is the 

process of turning standard addresses into latitude and longitude coordinates. 
 
24 These 498 RHCs had complete addresses but the geocoding software could map their 

locations with confidence only to the center of a city, State, or ZIP Code. 

 
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Using data from CMSs 2012 Outpatient Standard Analytic Filesthe 
most recent complete claims datawe calculated the amount Medicare 
and beneficiaries paid to RHCs that did not meet the location 
requirements.  
Finally, we reviewed Federal regulations and interviewed CMS staff to 
determine whether essential-provider criteria had been established or were 
in the process of being established. 
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General 
on Integrity and Efficiency. 
   
 
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FINDINGS 
Approximately 12 percent of RHCs no longer meet the 
location requirements 
Of the 3,521 RHCs included in our analysis, 434 no longer meet the 
location requirements.  Fifty-nine percent of these RHCs are located in 
areas not designated as shortage areas.  Another 39 percent of these RHCs 
are located in urbanized areas.  The final 2 percent were located in areas 
that were neither rural nor designated as shortage areas.  Medicare and 
beneficiaries paid approximately $132 million to these RHCs in 2012.  
Table 1 provides the number of RHCs that do not meet the location 
requirements and the amounts paid by Medicare and beneficiaries in 2012.   
Table 1: Number of RHCs that did not meet the location requirements and 
amounts paid to them by Medicare and beneficiaries  
Characteristics of RHCs that did not  Number of   Amount paid by Medicare and  
meet the location requirements   RHCs   beneficiaries to these RHCs  
Located in a rural area but not in a health 
257  $84.6 million 
care shortage area 
Located in a health care shortage area 
169  $46.7 million 
but not in a rural area 
Located in neither a health care shortage 
8  $0.8 million 
area nor a rural area 
 Total   434  $132.1 million 
Source:  OIG analysis of 2013 RHC locations and 2012 outpatient claims data, 2014. 
 
The number of RHCs that no longer meet the location requirements has 
increased by approximately 56 percent since 2003, when OIG found that 
279 RHCs did not meet the location requirements. 
RHCs may no longer meet location requirements because health care 
shortage areas and urbanized areas change periodically.  HPSAs are 
updated approximately every 4 years; urbanized areas are updated every 
10 years, following the decennial Census. 
Pursuant to the BBA, RHCs that no longer meet the location requirements 
should continue to qualify as RHCs only if they are determined to be 
essential providers.   
CMS has yet to issue final regulations that would allow 
RHCs that do not meet the location requirements to 
qualify as essential providers 
Sixteen years have passed since Congress directed CMS to issue 
regulations outlining the criteria that RHCs could use to qualify as 
essential providers, and CMS has not finalized such regulations.  CMS has 
 
CMS Has Yet To Enforce a Statutory Provision Related to Rural Health Clinics (OEI-05-13-00290)   6 
   
   
twice promulgated proposed rules, but neither rule was finalized by the 
Department of Health and Human Services.  There remains no final rule 
establishing essential-provider criteria for RHCs.  As such, RHCs continue 
to operate without the option to apply as essential providers.  
In addition, the CMS staff who are responsible for developing and 
overseeing RHC-related policies state that they are not currently planning 
to reissue the more recent of the two proposed rules or to develop a 
replacement.  Because CMS did not finalize the most recent proposed rule 
within 3 years of its publication date, the agency would need to reissue the 
proposed rule and go through the rulemaking process again. 
 
 
      
   
 
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CONCLUSION AND RECOMMENDATION 
More than 16 years have elapsed since Congress directed CMS to issue 
regulations to ensure that only RHCs determined to be essential providers 
remain certified as RHCs, and more than 8 years have elapsed since CMS 
told OIG that it planned to issue the regulations.  Although CMS has 
promulgated proposed rules regarding essential-provider criteria for 
RHCs, it has yet to publish a final rule establishing these criteria.  
Meanwhile, the number of RHCs that do not meet the location 
requirement has increased by 56 percent since 2003. 
To ensure that CMS can enforce the BBA provisions relating to RHCs, we 
recommend that CMS: 
Issue regulations to ensure that RHCs determined to be 
essential providers remain certified as RHCs.  
The BBA requires that RHCs that no longer meet the location 
requirements and that are not determined to be essential providers be 
terminated from the program.  However, CMS has yet to issue regulations 
defining essential-provider criteria for RHCs; consequently, all RHCs 
remain certified as RHCs and continue to receive enhanced Medicare and 
Medicaid reimbursements.  CMS should issue these regulations so that 
only RHCs determined to be essential providers continue to receive 
enhanced reimbursements. 
   
 
CMS Has Yet To Enforce a Statutory Provision Related to Rural Health Clinics (OEI-05-13-00290)   8 
   
   
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
CMS responded to the report but neither concurred nor nonconcurred with 
our recommendation. 
We continue to encourage CMS to issue regulations to ensure that RHCs 
determined to be essential providers remain certified as RHCs, as doing so 
will help protect Medicare and Medicaid dollars from going to providers  
that no longer qualify for the enhanced reimbursements that RHCs 
receive. Without regulations that define essential provider criteria, all 
RHCsincluding those that no longer meet the location requirements 
remain certified and continue to receive enhanced Medicare and Medicaid 
reimbursements.  We will routinely follow up with CMS about 
implementing this recommendation. 
For the full text of CMSs comments, see Appendix B. 
 
   
 
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APPENDIX A 
Definitions and Criteria for Health Care Shortage Areas  
1. 	  A Primary Care Geographic Health Professional Shortage Area 
(HPSA) must:   
o 	  Be a rational area for the delivery of primary care medical 
services; 
o 	  Meet one of the following conditions: 
  Have a population to full-time-equivalent primary care 
physician ratio of at least 3,500:1, or 
  Have a population to full-time-equivalent primary care 
physician ratio of less than 3,500:1 but greater than 
3,000:1 and have unusually high needs for primary 
health care services or insufficient capacity of existing 
primary care providers. 
o 	  Demonstrate that primary medical professionals in contiguous 
areas are overutilized, excessively distant, or inaccessible to the 
population under consideration.25  
2. 	  A Primary Care Population Group HPSA must:  
o 	  Reside in an area in that is rational for the delivery of primary 
medical care services as defined in the Federal code of 
regulations. 
o 	  Have access barriers that prevent the population group from  
use of the areas primary medical care providers. 
o 	  Have a ratio of persons in the population group to number of 
primary care physicians practicing in the area and serving the 
population group ratio of at least 3,000:1. 
   
 
25  Public  Health Services (PHS)  Act,  332(a)(1)(A); 42  CFR pt. 5, Appendix A, pt. 1;  
HRSA, Primary Medicare Care HPSA Designation Overview.  Accessed at  
http://bhpr.hrsa.gov/shortage/hpsas/designationcriteria/primarycarehpsaoverview.html on  
April 8, 2014. 
 
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o 	  Members of federally recognized Native American tribes are 
automatically designated. Other groups may be designated if 
the meet the basic criteria described above.26  
3. 	  A Medically Underserved Area (MUA) is:   
o   Defined by the Index of Medical Underservice (IMU). 
  The IMU scale is from 0 to 100, where 0 represents 
completely underserved and 100 represents best served 
or least underserved. 
  Under the established criteria, each service area found 
to have an IMU of 62.0 or less qualifies for designation 
as an MUA. 
o 	  The IMU involves four variablesratio of primary medical 
care physicians per 1,000 population, infant mortality rate, 
percentage of the population with incomes below the poverty 
level, and percentage of the population age 65 or over.  
  The value of each of these variables for the service area 
is converted to a weighted value, according to 
established criteria.  
  The four values are summed to obtain the areas IMU 
score.27  
4. 	  A Governor-designated and Secretary-certified shortage area is an area 
designated by the chief executive office of the State and certified by 
the Secretary as an area with a shortage of personal health services.28  
   
 
26  Public  Health Services (PHS)  Act,  332(a)(1)(B); 42  CFR pt. 5, Appendix A, pt. 2, 
 
HRSA, Primary Medicare Care HPSA Designation Overview.  Accessed at 
 
http://bhpr.hrsa.gov/shortage/hpsas/designationcriteria/primarycarehpsaoverview.html on 
 
April 8, 2014. 

27   PHS Act  330I(a)(4); 42  CFR   51c.102(e);  HRSA, Medically Underserved Areas/ 

Populations.  Accessed at http://www.hrsa.gov/shortage/mua/index.html on 
 
April 8, 2014. 

28 Omnibus Budget Reconciliation  Act of 1989 P. L. No. 101-239    6213(c); HRSA, 

Medically  Underserved Areas/ Populations.  Accessed at 

http://www.hrsa.gov/shortage/mua/index.html on April 8, 2014. 

 
CMS Has Yet To Enforce a Statutory Provision Related to Rural Health Clinics (OEI-05-13-00290)   11 
  APPENDIX 8 
Agency Comments 
DEPARTMENT OF HEALTH & HUMAN SERVICES  Center.s for Medh::are & Medicaid Services 
---
---~------------
Administrator 
Washington. DC 20201 
DATE:  AUG 08  2014 
TO:  Daniel R. Levinson 
In.spector General 
FROM:  Mai\lyn 1/avellller 
Administi'ulru-
SUBJECT:  Office oflnspector General (O!G) Draft Report: CMS Has Yet to Enforce a 
Statutory Provision Related to Rural Health Clinics, (OE!-05-J J-00290) 
Thank you for the opportunity to review and comment on the subject report.  Rural Health 
Clinics (RHCs) were created in 1997 to address the shortage of physicians in ntral areas.  RHCs 
must meet two location requirements: 1) they must be located in ntral areas. and 2) they must be 
located in areas that have a shortage of health care providers. RHCs receive enhanced Medicare 
and :V1edicaid payment for most services. 
The O!G found that approximately !2 percent of RHCs no longer met the location requirements 
in 20! 3.  Pursuant to the Balanced Budget Act of 1997, OIG indicates that these RHCs should 
only continue to qualify as RHCs and receive enhanced reimbursement if they are determined to 
be "essential providers"- However, OIG indicated that the Centers for Medicare & Medicaid 
Services (CMS) has yet to issue final regulations that would allow RHCs that do oot meet the 
!oc;Uion requirements to quality as essential providers. 
The OIG's recommendation and CMS' response to that recommendation arc discussed below. 
t;)TG Recommendation 
The O!G recommends that CMS issue regulations to ensure that RHCs determined to be essential 
providers remain certitied as RHCs_ 
CMS Response 
The CMS thanks OIG for their efforts on this issue, 
CMS Has Yet To Enforce a Statutory Provision Related to Rural Health Clinics (OEI-05-13-00290)  12   
   
ACKNOWLEDGMENTS 
This report was prepared under the direction of Ann Maxwell, Regional 
Inspector General for Evaluation and Inspections in the Chicago regional 
office, Thomas Komaniecki, Deputy Regional Inspector General, and 
Laura Kordish, Deputy Regional Inspector General. 
Lisa Minich served as the team leader for this study, and Hilary Slover 
served as the lead analyst.  Other Office of Evaluation and Inspections 
staff from the Chicago regional office who conducted the study include 
Elliot Curry.  Central office staff who provided support include 
Kevin Farber, Kevin Manley, and Christine Moritz.  
 
CMS Has Yet To Enforce a Statutory Provision Related to Rural Health Clinics (OEI-05-13-00290)   13 
   
Office of Inspector General
http://oig.hhs.gov  
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as  
amended, is  to protect the integrity of the Department of  Health and Human Services  
(HHS)  programs, as well as the health and welfare of beneficiaries  served by those 
programs.  This statutory mission  is  carried  out through  a nationwide network  of  audits, 
investigations, and inspections conducted by the  following operating components: 
Office of Audit Services 
The Office  of  Audit Services  (OAS) provides auditing services  for HHS, either by  conducting  
audits  with its own audit resources or by  overseeing  audit work done by others.  Audits  
examine the performance of HHS programs and/or its grantees and contractors in carrying  
out their respective responsibilities and are intended  to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and  
mismanagement and promote economy and efficiency  throughout  HHS. 
Office of Evaluation and Inspections 
The Office  of  Evaluation and Inspections (OEI)  conducts national evaluations to  provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud,  waste, or abuse  and promoting  
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations  
of  fraud and misconduct  related to HHS programs, operations, and beneficiaries.  With 
investigators working in all 50 States and the District of Columbia, OI  utilizes its resources 
by actively  coordinating with the Department  of Justice  and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to  criminal 
convictions, administrative sanctions,  and/or  civil monetary  penalties.  
Office of Counsel to the Inspector General  
The Office of Counsel to the  Inspector  General (OCIG) provides general legal services to 
OIG, rendering  advice and opinions on HHS programs and operations and  providing all  
legal support for OIGs  internal operations.  OCIG represents  OIG in all civil and 
administrative fraud and abuse cases involving HHS programs,  including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In  connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program  guidance, publishes fraud alerts, and provides other  
guidance  to  the health care industry concerning the anti-kickback statute and other  OIG  
enforcement authorities.