fMF Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
 
A Message From Christi A. Grimm, Inspector General 
I am pleased to submit this Semiannual Report to Congress summarizing 
the activities of the Department of Health and Human Services (HHS), 
Office of Inspector General (OIG), for the 6-month period ending on 
March 31, 2022.   
 
OIGs multidisciplinary workforcecomposed of more than 1,600 
auditors, attorneys, evaluators, investigators, and professionalsis 
dedicated to the mission of promoting the economy, efficiency, 
effectiveness, and integrity of HHSs programs.  We are steadfast in our 
commitment to conduct independent and objective oversight work to 
drive positive change in the HHS programs upon which all Americans rely.   
 
More than 2 years have passed since the emergence of COVID-19.  The pandemics toll is apparent as we 
surpass the tragic milestone of 1 million American lives lost due to the virus.  At the same time, we see 
increases in mental health conditions, including depression, anxiety, substance use disorder, drug 
overdoses, and suicide.  The pandemic created unprecedented strains on our health care system and 
exposed longstanding problems.  Hospitals, nursing facilities, and other health care providers have 
struggled with staffing, operational, and emergency response challenges.  Nursing home residents have 
been disproportionately affected by COVID-19, and many residents are experiencing the added pain of 
social isolation.  The disparate impacts exacted by this virus also highlight longstanding disparities and the 
need to promote health equity and better serve vulnerable populations.   
 
OIG offers pragmatic recommendations to drive sustained and meaningful change.  In our December 2021 
report Many Medicare Beneficiaries Are Not Receiving Medication To Treat Their Opioid Use Disorder, we 
found that only 16 percent of Medicare beneficiaries diagnosed with an opioid use disorder in 2020 
received medication treatment, and we recommended that CMS take steps to improve access.  In our 
January 2022 report CMS Should Take Further Action To Address States With Poor Performance in 
Conducting Nursing Home Surveys, we found that slightly more than half of States repeatedly failed to 
meet one or more performance measuresmost commonly, timeliness requirementsfor conducting 
nursing home surveys.  We recommended that CMS act to improve State oversight of nursing home care 
to better protect people residing in nursing homes.   
 
In this reporting period, OIG continued to drive a positive return on investment from enforcement and 
oversight.  Working with our law enforcement and agency partners, for every $1 dollar invested in the 
Health Care Fraud and Abuse Control Program, we recovered more than $4 for taxpayers.  We combated 
fraud through 320 criminal actions and $1.4 billion in expected investigative recoveries.  Throughout the 
pandemic, working with our Federal and State law enforcement partners, we have aggressively pursued 
bad actors who are exploiting the public health emergency.  OIGs work has resulted in numerous major 
nationwide law enforcement actions.  In April 2022, we participated in a coordinated law enforcement 
action against 21 defendants for their alleged participation in various COVID-19 health care fraud schemes 
that generated more than $149 million in false billings.  OIG also participated in a May 2022 enforcement 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
action targeting fraud schemes involving 5.1 million illegally prescribed controlled substance pills and 
roughly $7 million billed in opioid-related fraud loss.  As these law enforcement efforts demonstrate, OIG is 
uncompromising in finding and prosecuting criminals who steal for personal gain at the expense of all 
Americans.   
 
In addition to punishing fraudsters and recouping taxpayers money, we remain focused on preventing 
fraud.  We rigorously analyze data to detect concerning trends and outliers, issue compliance guidance for 
the health care industry, and make recommendations to HHS to improve program integrity.  We strive to 
ensure that programs are designed with integrity at the forefrontnot as an afterthoughtto prevent 
downstream issues with efficiency and effectiveness.  OIGs deep expertise in fraud, waste, and abuse 
enables us to offer HHS and its operating divisions technical assistance to design safeguards that mitigate 
risk in new and expanded programs. 
 
OIG employs modern technologies and tools to ensure good financial stewardship of American taxpayers 
$2.4 trillion investment in HHS.  We perform cutting-edge analyses in evolving and emergent areas, 
including telehealth and cybersecurity.  Our diligent and innovative workforce has experience in 
overseeing complex and consequential initiatives and produces outsized impact.  Our capacity to achieve 
high-impact results is limited only by our resources, which have not kept pace with the growing size of 
HHS programs in recent years.  OIG will continue to pursue the mission of providing independent, 
objective, standards-based oversight and enforcement to protect HHSs more than 100 programs and the 
people they serve.   
 
We appreciate the continued support of Congress and HHS for this important work. 
 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
 
Table of Contents     
A Message From Christi A. Grimm, Inspector General  2 
OIGs Approach to Driving Positive Change  4 
Highlights of OIG Accomplishments  5 
Selected Acronyms and Abbreviations   16 
Medicare and Medicaid Reports and Reviews  17 
Legal and Investigative Activities Related to Medicare and Medicaid  33 
Public Health and Human Service Agency Reports and Reviews   52 
Legal and Investigative Activities Related to Public Health and Human Service Agencies  57 
Other HHS-Related Reviews and Investigative Activities  59 
Appendix A: Questioned Costs and Funds To Be Put to Better Use  65 
Appendix B: Peer Review Results  70 
Appendix C: Summary of Sanction Authorities  73 
Appendix D: Reporting Requirements in the Inspector General Act of 1978  76 
Appendix E: Reporting Requirements in the Inspector General Empowerment Act of 2016  78 
Appendix F: Anti-Kickback StatuteSafe Harbors  86 
   
OIGs Approach to Driving Positive Change  
THE DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS), Office of Inspector General (OIG), provides 
independent and objective oversight that promotes economy, efficiency, and effectiveness in HHS 
programs and operations.  OIGs program integrity and oversight activities are shaped by legislative and 
budgetary requirements and adhere to professional standards established by the 
Government Accountability Office (GAO), Department of Justice (DOJ), and Inspector General community.  
Through a nationwide network of audits, investigations, and evaluations, OIG carries out its mission to 
protect the integrity of HHS programs and the health and welfare of the people served by those programs.  
OIGs work is conducted by the Office of Audit Services (OAS), Office of Evaluation and Inspections (OEI), 
Office of Investigations (OI), Office of Counsel to the Inspector General (OCIG), and Mission Support and 
Infrastructure (MSI).  
 
OIG Organization 
Office of Audit Services 
OAS conducts audits of HHS programs and operations either through its own resources or by 
overseeing audit work done by others.  Audits examine the performance of HHS programs and/or 
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Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
of HHSs grantees and contractors in carrying out their respective responsibilities and provide 
independent assessments of HHS programs and operations.  These audits help reduce waste, 
abuse, and mismanagement and promote the economy, efficiency, and effectiveness of programs 
and operations throughout HHS. 
 
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, 
and abuse and promoting economy, efficiency, and effectiveness in HHS programs.  OEI reports 
also present practical recommendations for improving program operations. 
 
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 almost every State, the 
District of Columbia, and Puerto Rico, OI coordinates with DOJ and other Federal, State, and local 
law enforcement authorities.  OI also coordinates with OAS and OEI when audits and evaluations 
uncover potential fraud.  OIs investigative efforts often lead to criminal convictions, administrative 
sanctions, or civil monetary penalties (CMPs). 
 
Office of Counsel to the Inspector General 
OCIG provides 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 the False Claims 
Act, program exclusion, self-disclosure, and CMP cases.  In connection with these cases, OCIG also 
negotiates and monitors corporate integrity agreements (CIAs).  OCIG renders advisory opinions, 
issues compliance program guidance, publishes fraud alerts, and provides other guidance to the 
health care industry about the anti-kickback statute and other OIG enforcement authorities.   
 
Mission Support and Infrastructure 
MSI is composed of the Immediate Office of the Inspector General and the Office of Management 
and Policy.  MSI is responsible for coordinating OIG activities and providing mission support, 
including setting vision and direction for OIGs priorities and strategic planning; ensuring effective 
management of budget, finance, human resource management, and other operations; and serving 
as a liaison with HHS, Congress, and other stakeholders.  MSI plans, conducts, and participates in a 
variety of cooperative projects within HHS and with other Government agencies.  MSI provides 
critical data analytics, data management, and information technology (IT) infrastructure that 
enables OIG components to conduct their work efficiently and effectively.  
 
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Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
OIG Strategic Publications
 
 
HHS-OIG Strategic Plan 
OIGs Strategic Plan outlines the approach to protecting the integrity of HHS programs.  The plan 
has three key goals: (1) to fight fraud, waste, and abuse; (2) to promote quality, safety, and value in 
HHS programs and for HHS beneficiaries; and (3) to advance excellence and innovation.  These 
goals drive OIGs work planning for audits and evaluations as well as OIGs approach to 
enforcement.  These goals also serve as a starting point for OIGs assessment of its own 
effectiveness. 
 
OIG Work Plan 
OIGs Work Plan sets forth projects that OIG plans to undertake during the fiscal year (FY) and 
beyond.  Projects listed in the Work Plan span HHSs operating divisions (OpDivs), which include 
the Centers for Medicare & Medicaid Services (CMS), public health agencies such as the Centers for 
Disease Control and Prevention (CDC) and the National Institutes of Health (NIH), and human 
services agencies such as the Administration for Children and Families (ACF) and the 
Administration for Community Living (ACL).  The Work Plan also includes oversight of State and 
local governments use of Federal funds as well as the administration of HHS.  Some of the projects 
described in the Work Plan are statutorily required. 
 
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  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
OIGs Top Recommendations 
OIG drives positive change by not only identifying risks, problems, abuses, and deficiencies, but 
also recommending solutions to address them.  OIG maintains a list of recommendations it has 
made to address vulnerabilities detected in its reviews, and it keeps track of whether these 
recommendations have been implemented.  OIG systematically follows up on its recommendations 
with the relevant HHS programs.  From among the recommendations that have not been 
implemented, OIG identifies the top recommendations that, if implemented, are likely to garner 
significant savings and improvements in quality, efficiency, and effectiveness.  OIG compiles these 
recommendations in the Solutions To Reduce Fraud, Waste, and Abuse in HHS Programs: OIGs Top 
Recommendations (previously known as the Compendium of Unimplemented Recommendations). 
 
Top Management and Performance Challenges Facing HHS 
To focus HHSs attention on the most pressing issues, each year OIG identifies the Top 
Management and Performance Challenges facing HHS.  These top challenges arise across HHS 
programs and cover critical HHS responsibilities, including delivering quality services and benefits, 
exercising sound fiscal management, safeguarding public health and safety, and enhancing 
cybersecurity. 
 
OIGs Semiannual Report to Congress  
OIGs Semiannual Report to Congress (Semiannual Report) describes OIGs work on identifying 
significant problems, abuses, deficiencies, remedies, and investigative outcomes relating to the 
administration of HHS programs and operations that were disclosed during the reporting period.  
In the report below, we present OIG expected recoveries, criminal and civil actions, and other 
statistics as a result of our work for the semiannual reporting period of April 1, 2021, through 
September 30, 2021.  We also provide data for accomplishments for FY 2021.  We also highlight 
some of our work completed during this semiannual reporting period. 
 
 
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  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
Highlights of OIG Accomplishments 
HHS-OIGS Semiannual Report describes OIGs work identifying significant risks, problems, abuses, 
deficiencies, remedies, and investigative outcomes relating to the administration of HHS programs and 
operations that were disclosed during the semiannual reporting period of October 1, 2021, through March 
31, 2022.  In this highlights section, we present data on OIG reports issued, expected recoveries, criminal 
and civil actions, and other statistics resulting from our work for the semiannual reporting period.  We then 
highlight significant results from selected audits, evaluations, and enforcement activities completed during 
the reporting period. 
 
At-a-Glance Highlights 
Statistic  Semiannual Reporting Period   
(10/1/20213/31/2022)   
 
Audit Reports Issued  47 
 
Evaluations Issued  14 
 
Expected Audit Recoveries  $1.14 billion 
 
Questioned Costs  $1.6 billion 
 
Potential Savings  $162.1 million 
 
New Audit and Evaluation  130 
 
Recommendations 
 
Recommendations Implemented by  265 
 
HHS OpDivs 
 
Expected Investigative Recoveries  $1.44 billion 
 
Criminal Actions  320 
 
Civil Actions  320 
Exclusions  1043 
 
Results for the Semiannual Reporting Period 
During this semiannual reporting period (October 1, 2021, through March 31, 2022), we issued 47 audit 
reports and 14 evaluation reports.  Our audit work identified $1.14 billion in expected recoveries, as well as 
$1.6 billion in questioned costs (costs questioned by OIG because of an alleged violation, costs not 
supported by adequate documentation, or the expenditure of funds where the intended purpose is 
unnecessary or unreasonable).  Our audit work also identified $162.1 million in potential savings for HHS
funds that could be saved if HHS implemented all of OIGs audit recommendations.  During this reporting 
period, OIG made 130 new audit and evaluation recommendations, which are crucial to encourage positive 
change in HHS programs.  Meanwhile, HHS OpDivs implemented 265 prior recommendations, leading to 
positive impact for HHS programs and beneficiaries. 
 
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  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
OIG also remains at the forefront of the Nations efforts to fight fraud in HHS programs and hold 
wrongdoers accountable for their actions.  Along with our partners DOJ, Medicaid Fraud Control Units 
(MFCUs or Units), and other Federal, State, and local law enforcement agencies, we detect, investigate, and 
prosecute fraud through a coordinated and data-driven approach.  OIGs investigative work led to 
$1.44 billion in expected investigative recoveries and 320 criminal actions during this reporting period.  OIG 
also took civil actions, such as assessing monetary penalties against 320 individuals and entities, and 
excluded 1,043 individuals and entities from Federal health care programs. 
 
OIG continues to focus on the most significant and high-risk issues in health care and human services.  Our 
mission is to provide objective oversight to promote the economy, efficiency, effectiveness, and integrity of 
HHS programs, as well as the health and welfare of the people they serve.  Below we highlight results from 
selected OIG oversight and enforcement activities from the semiannual reporting period of October 1, 
2021, through March 31, 2022, organized by subject area.  A comprehensive list of OIG work during the 
reporting period follows, and Appendices A through F provide data to meet the reporting requirements in 
the Inspector General Act of 1978. 
 
Responding to the COVID-19 Pandemic and Other Emergencies  
OIG continues to prioritize work related to COVID-19 response and recovery.  With 70 audits and 
evaluations underway, assessing a wide range of urgent issuesfrom health disparities to vaccine 
administration to nursing home oversight and preparedness, among othersand the issuance of fraud 
alerts, OIG continues to advance the four goals that drive OIGs strategic planning and mission execution 
with respect to HHSs COVID-19 response and recovery.  These goals are to: (1) protect people, (2) protect 
funds, (3) protect infrastructure, and (4) promote effectiveness of HHS programs, now and into the future.   
 
OIG is coordinating our COVID-19 work with key oversight and law enforcement partners, including the 
Pandemic Response Accountability Committee; Federal, State, local, and Tribal entities; and GAO, among 
others, to ensure adequate oversight, avoid duplication, and share insights.  Additional information about 
the OIG COVID-19 strategic plan, emerging fraud schemes, and work related to COVID-19 is available on 
our website, COVID-19 Portal.  
 
Significant OIG work completed during this semiannual reporting period related to the COVID-19 
pandemic includes the following: 
 
OIG found that COVID-19 tests drove an increase in total Medicare Part B spending on laboratory tests 
in 2020.  During the same time period, non-COVID-19 tests decreased significantly.  Medicare Part B 
spent $1.5 billion on COVID-19 tests in 2020, while non-COVID-19 tests declined by $1.2 billion.  In 
total, laboratory spending increased by 4 percent, but the decrease in utilization of non-COVID-19 
tests raises concerns about potential impacts on beneficiary health.  (See report OEI-09-21-00240.) 
 
OIGs survey of States found that most had implemented changes due to COVID-19 to ease restrictions 
on prior authorization and early refill requirements for prescription drugs.  Additionally, States made 
changes to their prescription quantity limits to allow pharmacies to dispense increased quantities of 
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  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
some prescription drugs and removed the requirement to obtain a signature upon receipt of a 
prescription.  All 24 States in our survey indicated that they are providing updated guidance to all 
stakeholders to ensure that beneficiaries can obtain their prescriptions.  (See report A-06-20-04007.) 
 
OIG found that the Assistant Secretary for Administration (ASA) awarded and managed five sole source 
contracts for COVID-19 testing in accordance with Federal and contract requirements.  ASA complied 
with sole source justification requirements when awarding the contracts and set reasonable payment 
rates for COVID-19 tests.  In addition, ASA appropriately managed the contracts by establishing and 
maintaining communications with contractors, verifying that laboratory result numbers matched the 
number of tests administered, and reviewing invoices to ensure that payment rates were in accordance 
with the contract terms and conditions.  (See report A-05-21-00014.)  
 
OIG found that, from March to the end of 2020, 84 percent of beneficiaries received telehealth services 
from providers with whom they had an established relationship.  On average, these beneficiaries 
tended to see their providers in person about 4 months prior to their first telehealth service.  
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.  (See 
report OEI-02-20-00521.) 
 
 
Leveraging Oversight To Better Protect Nursing Home Residents 
Improving nursing homes so that they work better for residents is a top priority for OIG.  We are deploying 
the PRO strategy: (1) Performanceunderstanding what makes poor performing nursing homes fail; (2) 
Residents Firstensuring that nursing homes prioritize quality of care and quality of life for residents; and 
(3) Oversightensuring that the entities responsible for nursing home oversightCMS and the States
detect problems quickly and insist on rapid remediation.  Past OIG work on nursing homes has uncovered 
widespread and persistent problems in providing quality care and reporting problems when they 
occur.  Nursing home residents have been among the hardest hit by the COVID-19 pandemic, in part 
because of their age, underlying medical conditions, and close living quarters.  According to CMS, as of 
April 10, 2022, more than 1,016,000 nursing home residents had confirmed COVID-19 and more than 
151,000 of those residents died from the virus.  Additionally, more than 1,072,000 nursing home staff had 
confirmed COVID-19 and 2,357 nursing home staff died. 
 
In March 2022, the Biden Administration launched an initiative to improve nursing home quality and 
safety.  The initiative focuses on several areas, including areas that align with OIG work such as: (1) 
improving nursing home staffing levels and training, (2) holding poorly performing nursing homes 
accountable for failures in quality of care, and (3) raising transparency about nursing home performance to 
enable for residents and families to find the best available options.   
 
Going forward, OIG plans to expand its nursing home oversight, continue to monitor identified areas of 
concern, push for implementation of unimplemented recommendations, and issue new recommendations 
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as problems and solutions are identified.  Information about ongoing nursing home work can be found on 
OIGs webpage.   
 
Significant OIG work completed during this semiannual reporting period related to protecting beneficiaries 
in nursing homes includes the following: 
 
OIG found that more than half of States failed to meet performance measures for their oversight of 
nursing homes in three or four consecutive years during FYs 20152018.  States most commonly 
missed performance measures related to survey timeliness.  State surveys of nursing homes are the 
primary safeguard for ensuring quality of care and resident safety.  The remedy that CMS 
consistently imposed on States for missing performance measures was requiring submission of 
corrective action plans.  However, 10 percent of plans were missing from CMS files and many 
others lacked substantive details.  In three States, CMS escalated concerns about performance to 
senior State officials, but it rarely imposed formal sanctions and never initiated action to terminate 
any of its agreements with States for conducting surveys.  (See report OEI-06-19-00460.) 
 
OIG found that the current extent of facility-initiated discharges remains unknown.  Inappropriate 
facility-initiated discharges can be unsafe and traumatic for nursing home residents.  However, 
neither ACL nor CMS collect data on the number of facility-initiated discharges.  Although nursing 
homes must send facility-initiated discharge notices to State Ombudsmen, many do not count or 
track the notices they receive.  Following CMSs 2018 initiative to review and take appropriate 
enforcement action in cases of noncompliance with requirements, State agencies cited more 
nursing homes for noncompliance, but CMS has not yet determined trends and outcomes of its 
initiative.  (See report OEI-01-18-00250.) 
 
Ensuring Health and Safety of Vulnerable Beneficiaries Served by HHS  
OIG has devoted substantial oversight efforts to protect vulnerable beneficiaries, including children and 
developmentally disabled adults, served by HHS programs such as Medicaid, the Unaccompanied Children 
(UC) Program, and the Child Care and Development Fund (CCDF). 
 
Significant OIG work completed during this semiannual reporting period related to ensuring health and 
safety of vulnerable beneficiaries includes the following: 
OIG found that more than one-third of Medicaid-enrolled children in five States did not receive 
required blood lead screening tests.  Of the 1 million children who were required to receive 12- and 
24-month blood lead screening tests, more than one-third received neither test.  Additionally, of 
the approximately 209,000 children continuously enrolled in Medicaid from birth through 3 years 
of age, 1 in 5 children in the selected States never received screening by age 3.  (See report OEI-07-
18-00371.) 
 
OIG found that Arkansas did not fully comply with requirements to report and monitor critical 
incidents in Medicaid beneficiaries with developmental disabilities residing in community-based 
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Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
settings.  Arkansas lacked internal controls to ensure that incidents of abuse, neglect, or death were 
reviewed and reported to the appropriate authority.  As a result, Arkansas did not ensure that 
community-based providers properly report all incidents of suspected adult or child abuse to the 
appropriate hotline; provide evidence of review and followup action on all incidents of adult or 
child abuse; and review all deaths of beneficiaries receiving waiver services.  (See report A-06-17-
01003.) 
OIG found that 1,178 children were separated from a parent or legal guardian and referred to 
ORRs care between June 27, 2018, and November 15, 2020.  Seventy percent of separated children 
referred to ORR care had been separated by immigration officials because of a parents criminal 
history.  Additionally, separated children spent longer in ORRs care and were less likely than non-
separated children to be released to a sponsor.  Of the 1,178 separated children referred to ORR 
during this time period, 182 children (15 percent) were reunified with the parent from whom the 
child was separated.  (See report OEI-BL-20-00680.)  
OIG found that the District of Columbias monitoring did not ensure compliance with criminal 
background check requirements for 7 of 30 sampled child care providers.  Errors occurred in the 
background check process because: (1) providers did not send the in-State child abuse and neglect 
check results to the District, (2) District law did not allow Child Protection Register check results to 
be sent directly to the District unless the individual was found not to be suitable for employment, 
and (3) processing delays resulted in incomplete Federal Bureau of Investigation (FBI) fingerprint 
checks and inter-State checks.  In response to our report, the District completed background 
checks for 52 of the 55 individuals, from the 7 sampled providers who did had not completed 
background checks.  (See report A-03-20-00252.) 
OIG found that Louisianas monitoring did not ensure compliance with criminal background check 
requirements for 8 of 30 sampled child care providers.  Providers did not initiate a timely 
background check request for 15 of the 264 individuals requiring background checks at the 8 
providers that did not complete background checks.  Because the State agency relies on child care 
providers to initiate the background check process, it was unaware that these individuals lacked 
required background checks, potentially endangering the safety and well-being of children at these 
facilities.  (See report A-06-19-02001.) 
 
Preventing and Treating Opioid Misuse  
OIG continued to prioritize oversight and enforcement activities to protect beneficiaries from prescription 
drug abuse and improve access to medication-assisted treatment.  
 
Significant OIG work completed during this semiannual reporting period related to preventing and treating 
opioid misuse includes the following: 
OIG found that of the roughly 1 million Medicare beneficiaries diagnosed with opioid use disorder 
in 2020, less than 16 percent received medication to treat their opioid use disorder.  Further raising 
concerns that beneficiaries face challenges accessing treatment, less than half of beneficiaries who 
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Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
received medication to treat opioid use disorder also received behavioral therapy.  We also found 
that beneficiaries in Florida, Texas, Nevada, and Kansas were less likely to receive medication to 
treat their opioid use disorder than beneficiaries nationwide; that Asian/Pacific Islander, Hispanic, 
and Black beneficiaries were less likely to receive medication than White beneficiaries; and that 
older beneficiaries and those who did not receive the Part D low-income subsidy were also less 
likely to receive medication to treat their opioid use disorder.  (See report OEI-02-20-00390.) 
OIG found that the Substance Abuse and Mental Health Services Administrations (SAMHSAs) 
oversight generally ensured that the commission on accreditation of rehabilitation facilities (CARFs) 
verified that opioid treatment programs (OTPs) met Federal opioid treatment standards.  
SAMHSAs oversight activities included: (1) reviewing CARFs renewal application, (2) inspecting a 
selected sample of OTPs that CARF accredited and surveyed, and (3) reviewing accreditation 
reports submitted by CARF.  SAMHSA also ensured that CARFs renewal application included a 
review of CARFs policies and procedures for hiring surveyors with required education and 
experience, training provided to surveyors, selecting surveyors for each survey, and avoiding 
conflicts of interest.  (See report A-09-20-01002.) 
A former doctor was sentenced to 20 years in prison for unlawful drug distribution and maintaining 
a drug-involved premises.  Patrick Titus unlawfully distributed or dispensed a variety of powerful 
opioidsincluding fentanyl, morphine, methadone, OxyContin, and oxycodoneoutside the usual 
scope of professional practice and for illegitimate medical purposes.   
A former doctor was sentenced to 24 months in Federal prison as a result of conspiring to violate 
the Federal anti-kickback statute.  Jeffrey Kesten conspired to take approximately $344,000 in 
bribes and kickbacks from a pharmaceutical company in exchange for prescribing a powerful 
fentanyl spray to his chronic pain patients.   
 
Reducing Costs to Beneficiaries for Part D Drugs 
OIG performs work to assess areas where beneficiaries may be paying more for Part D vital drugs than 
necessary.   
 
Significant OIG work completed during this semiannual reporting period related to Part D drug pricing 
includes the following: 
 
OIG found that biosimilars have the potential to significantly reduce costs for Medicare Part D and 
beneficiaries.  Biosimilars are lower cost, highly similar alternatives to existing biologic drugs approved by 
the Food and Drug Administration (FDA).  In 2019, Part D spending on biologics with available biosimilars 
could have decreased by $84 million, or 18 percent, if all biosimilars had been used as frequently as the 
most-used biosimilars. Additionally, beneficiaries out-of-pocket costs for these drugs could have 
decreased by $1.8 million, or 12 percent.  As currently designed, Part D formularies could limit wider 
utilization of and access to these biosimilar drugs for beneficiaries.  (See report OEI-05-20-00480.) 
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Promoting Good Financial Stewardship of Traditional Medicare  
OIG continues to devote resources to promote good financial stewardship, reduce improper payments, 
and protect the integrity of the Medicare program.  In the 2021 Medicare Trustees report, actuaries 
projected that assets in the Part A trust fund will be depleted by 2026, adding urgency to ensuring that 
funds are conserved and used appropriately to ensure that the Medicare program continues to operate. 
 
Significant OIG work completed during this semiannual reporting period related to Medicare oversight 
includes the following: 
 
OIG found that more than 40 percent of the health care providers did not comply with Medicare 
requirements when they billed for neurostimulator implantation surgeries.  We estimated that 
during 2016 and 2017, providers received $636 million in unallowable Medicare payments 
associated with neurostimulator implantation surgeries, and beneficiaries paid $54 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.  (See report A-01-18-00500.)  
 
OIG found that Medicare could have saved approximately $993 million in 2017 and 2018 if CMS 
had expanded its inpatient rehabilitation facility (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.  
(See report A-01-20-00501.) 
 
OIG found that Medicare and beneficiaries pay more for preadmission services at affiliated 
hospitals than at wholly owned settings.  Because the diagnosis-related group (DRG) window policy 
does not cover affiliated hospitals, Medicare and beneficiaries paid $168 million and $77 million, 
respectively, in 2019 for admission-related outpatient services thatif provided at wholly owned 
hospitalswould not have required separate outpatient payments.  These findings indicate that 
Medicare and beneficiaries may be overpaying for these services.  (See report OEI-05-19-00380.) 
 
OIG identified trends that indicate Medicare could be paying twice for items and services provided 
to beneficiaries in hospice care.  Nonhospice payments for Medicare Part A services and Part B 
items and services totaled $6.6 billion from 2010 through 2019 for beneficiaries in hospice care.  
Hospice beneficiaries should receive all of their medical care needs through the Medicare hospice 
benefit.  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.  (See report A-09-
20-03015.) 
 
 
11 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
Fighting Medicare Fraud 
OIG recognizes the importance of not only identifying and mitigating fraud risks in the Medicare program, 
but also holding accountable those who defraud Medicare, beneficiaries, and taxpayers. OIGs Office of 
Investigations conducts criminal, civil, and administrative investigations of fraud and misconduct related to 
HHS programs, operations, and beneficiaries.  
 
Significant OIG work completed during this semiannual reporting period related to Medicare enforcement 
includes the following: 
 
The former owner of a home health firm was extradited from the Republic of Cameroon to the 
United States after absconding to avoid an 80-year prison sentence.  Between 2006 and 2015, 
Ebong Aloysius Tilong, a top 10 most wanted fugitive; his wife, Marie Neba; and their co-
conspirators used their company, Fiango Home Healthcare Inc., to corruptly obtain more than 
$13 million by submitting false and fraudulent claims to Medicare for home health care services 
that Fiangos patients did not need or receive.  
 
A home health care worker 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.  Angelita 
Newton falsified patient visit records that were used to support claims billed to Medicare.  Between 
2011 and 2017, Care Specialists, a home health care company fraudulently billed Medicare at least 
$6.3 million.  At trial, the Government demonstrated that approximately 90 percent of Care 
Specialists patients were not homebound and did not qualify for the types of care that Care 
Specialists 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.   
 
Co-owners of a durable medical equipment (DME) company were sentenced to 151 months in 
prison and were ordered to pay more than $27 million in restitution for a Medicare kickback 
conspiracy.  Leah and Michael Hagen owned and operated two DME companies.  From March 2016 
to January 2019, the defendants paid kickbacks and bribes to their co-conspirators call center in 
the Philippines in exchange for signed doctors orders for DME that were used to submit false 
claims in excess of $59 million to Medicare.  As a result of those false claims, Medicare paid the 
defendants more than $27 million.   
 
A medical device company agreed to pay $16 million to resolve allegations that it violated the False 
Claims Act by paying kickbacks that caused the submission of false claims to the Medicare 
program.  The settlement resolves allegations that Arthrex agreed to provide remuneration to an 
orthopedic surgeon in the form of royalty payments purportedly for the surgeons contributions to 
Arthrexs products when the remuneration was in fact intended to induce the surgeons use and 
recommendation of Arthrexs products.  In connection with the settlement, Arthrex entered into a 
5-year CIA with HHS-OIG.  
 
12 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
Telemarketing executives 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.  Michael Nolan was sentenced to 78 months in Federal prison and 
Richard Epstein was sentenced to 63 months in Federal prison as a result of their scheme as 
executives of REMN Management that targeted the elderly to generate thousands of medically 
unnecessary physicians orders for DME and cancer genetic testing (CGx).  Epstein and Nolan also 
created and operated a telemedicine company through which they illegally bribed physicians to 
sign the orders regardless of medical necessity.  
 
A laboratory owner was sentenced to 82 months in Federal prison and ordered to pay more than 
$61 million in restitution for his role in a $73 million conspiracy to defraud Medicare.  Leonel 
Palatniks scheme exploited growing acceptance and use of telehealth  during the COVID-19 
pandemic.  Palatnik admitted that, as a co-owner of Panda Conservation Group, he conspired with 
other co-owners and with Michael Stein to pay kickbacks to Stein in exchange for his work 
arranging for telemedicine providers to authorize genetic testing orders for Pandas laboratories.   
 
Promoting Integrity and Effectiveness in Medicare Advantage 
In Medicare, more than 40 percent of beneficiaries are currently enrolled in Medicare Advantage 
Organizations (MAOs).  
 
Significant OIG work completed during this semiannual reporting period related to managed care includes 
the following: 
 
OIG found that most of the selected diagnosis codes that UPMC Health Plan, Inc. (UPMC) 
submitted to CMS for use in CMSs risk adjustment program did not comply with Federal 
requirements.  CMS relies on Medicare Advantage (MA) organizations to collect diagnosis codes 
from their providers and submit these codes to CMS.  Inaccurate diagnosis code submissions that 
portray an MAOs patient population as higher risk result in overpayments to MAOs.  These errors 
occurred because the policies and procedures that UPMC had to ensure compliance with CMSs 
program requirements, as mandated by Federal regulations, were not always effective.  (See report 
A-07-19-01188.) 
 
OIG found that SCAN Health Plan (SCAN) did not submit some diagnosis codes to CMS for use in 
the risk adjustment program in accordance with Federal requirements.  We estimated that SCAN 
received at least $54.3 million in net overpayments for 2015.  As demonstrated by the errors found 
in our sample, SCANs policies and procedures to prevent, detect, and correct noncompliance with 
CMSs program requirements, as mandated by Federal regulations, could be improved.  (See 
report A-07-17-01169.) 
 
Ensuring Medicaid Program Integrity  
Medicaid is the largest Federal health care program, with nearly 78 million individuals enrolled, and 
represents more than one-sixth of the national health economy.  Medicaid is administered by States in 
13 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
accordance with Federal requirements.  The program is funded jointly by the Federal Government and 
States.  CMS estimated Federal and State Medicaid expenditures of $671.2 billion in 2020.  
 
Significant OIG work completed during this semiannual reporting period related to Medicaid program 
integrity includes the following: 
 
OIG found that Tennessee did not comply with Federal requirements for claiming certified public 
expenditures (CPEs) for public hospital unreimbursed costs.  Of the $2 billion in expenditures 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.  (See report A-04-19-04070.)  
 
Counselor sentenced to Federal prison for wide-ranging Medicaid fraud scheme.  In a case 
investigated by OIG, Courtney Dunlap was sentenced to 57 months of imprisonment, followed by 3 
years of supervised release, for operating a wide-ranging scheme that defrauded the Connecticut 
Medicaid Program of more than $1.3 million.  Dunlap submitted claims for psychotherapy services 
that were purportedly provided to Medicaid clients.  The vast majority of the claims were for 
occasions and dates of service when no psychotherapy services of any kind had been provided to 
the Medicaid clients identified in the claims.   
 
Promoting Proper Departmental Management and Operations  
OIG reviews programs across the breadth of the department to ensure that programs are being 
administered correctly, efficiently, and without waste.   
 
Significant OIG work completed during this semiannual reporting period related to proper departmental 
management includes the following: 
 
OIG found that FDA did not always identify contracts eligible for closeout and did not always follow 
Federal Acquisition Regulations (FAR) requirements for closing contracts timely but otherwise 
generally closed contracts in accordance with acquisition policies and procedures.  FDA did not 
always identify and close contracts timely because FDA utilized manual processes for some 
contract closeout review functions when an automated process may have been more efficient.  
Because contracts were not always closed timely, FDA may not have identified unused funds that 
could be deobligated and released to another appropriate need.  (See report A-03-20-03004.)  
 
OIG found that the National Cancer Institutes (NCIs) post-award process for providing oversight 
and monitoring of grants was generally effective in ensuring that grantees met the program 
objectives and that NCI was able to identify potential problems.  However, for 12 of the 20 grants in 
our sample that were closed in FY 2019, the grantee did not submit final reports within 120 days of 
the end of the period of performance as required.  If grantees submit final reports late, it could 
14 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
indicate an issue with the grantees ability to comply with grant requirements, including accounting 
for grant funds and tracking the progress and outcomes of the grant.  (See report A-03-20-03001.) 
 
OIG found that the Office of Intergovernmental and External Affairs (IEAs) travel card program did 
not always comply with Federal requirements.  These deficiencies occurred because IEA had a high 
staff turnover rate, and IEAs internal controls were not adequate to ensure that staff, approving 
officials, and travel card program coordinators understood and executed their responsibilities.  (See 
report A-03-19-00501.) 
 
Protecting Cybersecurity  
OIG continues to recognize cybervulnerabilities as major risks to effectively managing and safeguarding 
the Departments programs and is prioritizing oversight of the Departments cybersecurity.  Repeated 
cyberintrusions focused on accessing critical information found in HHS systems has added urgency to 
developing departmental cybersafeguards over the course of the COVID-19 pandemic in addition to 
normal operations. 
 
During this reporting period, OIG continued to conduct work looking at HHSs cybersecurity controls to 
strengthen HHSs cybersecurity posture. 
 
 
 
 
 
 
 
15 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
Selected Acronyms and Abbreviations  
 
ACA  Patient Protection and Affordable Care Act 
ACF  Administration for Children and Families 
ACL  Administration for Community Living 
CDC  Centers for Disease Control and Prevention 
CIA  corporate integrity agreement 
CMP  civil monetary penalty 
CMS  Centers for Medicare & Medicaid Services 
DOJ  Department of Justice 
DME  durable medical equipment 
EMTALA  Emergency Medical Treatment and Labor Act 
FDA  Food and Drug Administration 
GAO  Government Accountability Office 
HHS  Department of Health and Human Services 
HIPAA  Health Insurance Portability and Accountability Act of 1996 
HRSA  Health Resources and Services Administration 
IHS  Indian Health Service 
MCO  managed care organization 
MFCU  Medicaid Fraud Control Unit 
NIH  National Institutes of Health 
OAS  Office of Audit Services 
OASH  Office of Safety and Health 
OCIG  Office of Counsel to the Inspector General 
OEI  Office of Evaluation and Inspections 
OI  Office of Investigations 
OIG  Office of Inspector General 
OMB  Office of Management and Budget 
OS  Office of the Secretary 
SAMHSA   Substance Abuse and Mental Health Services Administration 
16 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
Medicare and Medicaid Reports and Reviews 
Medicare Program Reports and Reviews 
Financial Management and Improper Payments 
Medicare Overpaid $636 Million for Neurostimulator Implantation Surgeries (A-01-18-00500), 
 
October 2021 
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 million in unallowable Medicare payments associated with neurostimulator 
implantation surgeries, and that beneficiaries paid $54 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.   
 
CMS concurred with our recommendations that it instruct the Medicare contractors to: (1) recover 
the portion of the identified Medicare potential overpayments for the 54 incorrectly billed claims 
that are within the 4-year reopening period; (2) instruct the providers identified with the incorrectly 
billed claims to refund coinsurance amounts that have been collected from the sampled 
beneficiaries for claims within the 4-year reopening period; (3) determine which of the remaining 
claims in our sampling frame were incorrectly billed, recover Medicare overpayments that are 
within the reopening period, and instruct the providers to refund beneficiary coinsurance amounts; 
and (4) notify the providers with potential overpayments, so they can exercise reasonable diligence 
to identify, report, and return any overpayments in accordance with the 60-day rule.  We also 
recommended that CMS: (1) conduct provider outreach and education regarding the Medicare 
coverage requirements for neurostimulator implantation surgeries and (2) require prior 
authorization for neurostimulator implantation surgeries for Parkinsons disease and seizure 
disorders. 
 
Medicare Advantage Diagnosis Codes 
To determine the health status of enrollees, CMS relies on MA organizations to collect diagnosis 
codes from their providers and submit these codes to CMS.  Some diagnoses are at higher risk for 
being miscoded, which may result in overpayments from CMS.  During this reporting period, OIG 
conducted four audits that were designed to assess whether selected diagnosis codes that MA 
organizations submitted to CMS for use in CMSs risk adjustment program complied with Federal 
requirements.  Complete recommendations and providers responses can be found in the final 
reports, which are summarized below. 
 
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  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Coventry Health Care of 
Missouri, Inc. (Contract H2663) Submitted to CMS (A-07-17-01173), October 2021  
With respect to the six high-risk groups covered by our audit, most of the selected diagnosis codes 
that Coventry Health Care of Missouri, Inc. (Coventry), submitted to CMS for use in CMSs risk 
adjustment program did not comply with Federal requirements.  These errors occurred because 
the policies and procedures that Coventry had to detect and correct noncompliance with CMSs 
program requirements, as mandated by Federal regulations, were not always effective.  As a result, 
Coventry received $548,852 of net overpayments for 2014 through 2016. 
 
Medicare Advantage Compliance Audit of Specific Diagnosis Codes That UPMC Health Plan, Inc. 
(Contract H3907) Submitted to CMS (A-07-19-01188), November 2021  
With respect to the 10 high-risk groups covered by our audit, most of the selected diagnosis codes 
that UPMC submitted to CMS for use in CMSs risk adjustment program did not comply with 
Federal requirements.  These errors occurred because the policies and procedures that UPMC had 
to ensure compliance with CMSs program requirements, as mandated by Federal regulations, were 
not always effective.  On the basis of our sample results, we estimated that UPMC received at least 
$6.4 million of net overpayments for these high-risk diagnosis codes for 2015 and 2016. 
 
Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Healthfirst Health Plan, Inc., 
(Contract H3359) Submitted to CMS (A-02-18-01029), January 2022 
With respect to the seven high-risk groups covered by our audit, most of the selected diagnosis 
codes that Healthfirst Health Plan, Inc. (Healthfirst), submitted to CMS for use in CMSs risk 
adjustment program did not comply with Federal requirements.  These errors occurred because 
the policies and procedures that Healthfirst had to detect and correct noncompliance with CMSs 
program requirements, as mandated by Federal regulations, were not always effective.  On the 
basis of our sample results, we estimated that Healthfirst received at least $5.2 million in net 
overpayments for these high-risk diagnosis codes in 2015 and 2016. 
 
Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Tufts Health Plan (Contract 
H2256) Submitted to CMS (A-01-19-00500), February 2022  
With respect to the seven high-risk groups covered by our audit, most of the selected diagnosis 
codes that Tufts Health Plan (Tufts) submitted to CMS for use in CMSs risk adjustment program 
did not comply with Federal requirements.  These errors occurred because the policies and 
procedures that Tufts had to ensure compliance with CMSs program requirements, as mandated 
by Federal regulations, could be improved.  On the basis of our sample results, we estimated that 
Tufts received at least $3.7 million of net overpayments for these high-risk diagnosis codes in 2015 
and 2016. 
 
18 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
Medicare Improperly Paid Suppliers an Estimated $117 Million Over 4 Years for Durable Medical 
Equipment, Prosthetics, Orthotics, and Supplies Provided to Hospice Beneficiaries (A-09-20-03026), 
November 2021  
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 modifierwhich indicates that the service is unrelated to the patients 
terminal diagnosis.  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.  
 
CMS concurred with our recommendations that it improve the prepayment edit process by 
instructing the DME Medicare contractors to deny DMEPOS claims submitted by suppliers without 
the GW modifier for DMEPOS items provided to hospice beneficiaries; and direct the DME and 
hospice Medicare contractors, or other contractors as appropriate, to conduct prepayment or 
postpayment reviews of supplier claims billed with the GW modifier.  CMS did not concur with our 
recommendations that it implement a postpayment edit process and study the feasibility of 
including palliative items and services not related to a beneficiarys terminal illness and related 
conditions within the hospice per diem. 
 
Medicare and Beneficiaries Pay More for Preadmission Services at Affiliated Hospitals Than at Wholly 
Owned Settings (OEI-05-19-00380), December 2021  
Because the DRG window policy does not cover affiliated hospitals, Medicare and beneficiaries paid 
$168 million and $77 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.   
 
19 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
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 (OEI-09-21-00240), December 2021  
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 4 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. 
 
Medicare Could Have Saved Approximately $993 Million in 2017 and 2018 if It Had Implemented an 
Inpatient Rehabilitation Facility Transfer Payment Policy for Early Discharges to Home Health 
Agencies (A-01-20-00501), December 2021   
Medicare could have saved approximately $993 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 claim 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. 
 
CMS stated that it would consider our recommendation that it take the necessary steps to establish 
an IRF transfer payment policy for early discharges to home health care.  If this expanded policy 
had been in place, Medicare could have saved $993,134,059 in 2017 and 2018. 
 
Medicare Hospital Provider Compliance Audit: St. Josephs Hospital Health Center (A-02-20-01004), 
December 2021 
St. Josephs Hospital Health Center (the Hospital) complied with Medicare billing requirements for 
94 of the 100 inpatient and outpatient claims we audited.  However, the Hospital did not fully 
comply with Medicare billing requirements for the remaining six claims, resulting in overpayments 
of $68,897 for the audit period.  Specifically, five inpatient claims and one outpatient claim had 
billing errors. 
 
On the basis of our sample results, we estimated that the Hospital received overpayments of at 
least $389,000 for the audit period.  As of the publication of this report, this amount included 
claims outside of the Medicare 4-year claim-reopening period.  
 
We recommend that the Hospital: (1) refund to the Medicare contractor $389,000 in estimated 
overpayments for the audit period for the claims that it incorrectly billed that are within the 4-year 
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  Department of Health and Human Services, Office of Inspector General 
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claim reopening period; (2) based on the results of this audit, exercise reasonable diligence to 
identify, report, and return any overpayments in accordance with the 60-day rule and identify any 
of those returned overpayments as having been made in accordance with this recommendation; 
and (3) strengthen controls to ensure full compliance with Medicare requirements.  The Hospital 
partially disagreed with our first recommendation, stated that it complied with our second 
recommendation, and contended that it did not need to implement our third recommendation. 
 
Medicare Advantage Compliance Audit of Diagnosis Codes That SCAN Health Plan (Contract H5425) 
Submitted to CMS (A-07-17-01169), February 2022  
SCAN did not submit some diagnosis codes to CMS for use in the risk adjustment program in 
accordance with Federal requirements.  First, although most of the diagnosis codes that SCAN 
submitted were supported in the medical records and therefore validated 1,413 of the 1,577 
sampled enrollees hierarchical condition categories (HCCs), the remaining 164 HCCs were not 
validated and resulted in overpayments.  These 164 unvalidated HCCs included 20 HCCs for which 
we identified 20 other HCCs for more and less severe manifestations of the diseases.  Second, 
there were an additional 21 HCCs for which the medical records supported diagnosis codes that 
SCAN should have submitted to CMS but did not. 
 
Thus, the risk scores for the 200 sampled enrollees should not have been based on the 1,577 HCCs.  
Rather, the risk scores should have been based on 1,454 HCCs (1,413 validated HCCs plus 20 other 
HCCs plus 21 additional HCCs).  As a result, we estimated that SCAN received at least  
$54.3 million in net overpayments for 2015.  As demonstrated by the errors found in our sample, 
SCANs policies and procedures to prevent, detect, and correct noncompliance with CMSs 
program requirements, as mandated by Federal regulations, could be improved. 
 
SCAN disagreed with our recommendations that it refund to the Federal Government the 
$54.3 million of net overpayments and continue to improve its policies and procedures to prevent, 
detect, and correct noncompliance with Federal requirements for diagnosis codes that are used to 
calculate risk-adjusted payments. 
 
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 (A-09-20-03015), 
February 2022  
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.  
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  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
 
Psychotherapy Services Billed by a New York City Provider Did Not Comply With Medicare                 
Requirements (A-02-21-01006), March 2022 
  
A New York City provider did not comply with Medicare requirements when billing for 
psychotherapy services for all 100 sampled beneficiary-days.  Specifically, 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 who was not licensed or registered in New York State.  Also, time spent 
on psychotherapy services was not documented, and treatment notes were not maintained to 
support the services billed.  In addition, for psychotherapy services provided during 96 sampled 
beneficiary-days, there was no evidence that beneficiaries treatment plans were signed by the 
treating physician.  
  
The provider disagreed with our recommendation that it refund to the Medicare program the 
estimated $1.1 million overpayment and partly agreed with our recommendation to exercise 
reasonable diligence to identify, report, and return any overpayments in accordance with the 60-
day rule and identify any of those returned overpayments as having been made in accordance with 
this recommendation.  The provider agreed with our recommendation that it develop policies and 
procedures and provide training to its therapists to ensure that psychotherapy services comply with 
Medicare requirements. 
 
Medicare Improperly Paid Physicians for Spinal Facet-Joint Denervation Sessions (A-09-21-03002), 
December 2021 
Medicare did not pay physicians for selected facet-joint denervation sessions in accordance with 
Medicare requirements.  Specifically, for our audit period, the Medicare Administrative Contractors 
(MACs) for the 11 jurisdictions with a coverage limitation of 2 facet-joint denervation sessions per 
beneficiary for each covered spinal region during a 12-month period made improper payments of 
$7.2 million.  In addition, the MACs for the 9 jurisdictions with a coverage limitation of 4 facet joints 
per denervation session and the MACs for the remaining 3 jurisdictions with a coverage limitation 
of 10 facet joints per denervation session made improper payments of $2.3 million.  In total, 
Medicare improperly paid physicians $9.5 million.  These improper payments occurred because 
CMSs oversight was not adequate to prevent or detect improper payments for selected facet-joint 
denervation sessions. 
 
CMS concurred with our recommendations that it: (1) direct the MACs to recover $9.5 million in 
improper payments made to physicians for selected facet-joint denervation sessions; (2) instruct 
the MACs to, based upon the results of this audit, notify appropriate physicians (i.e., those for 
whom CMS determines this audit constitutes credible information of potential overpayments) so 
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  Department of Health and Human Services, Office of Inspector General 
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that the physicians can exercise reasonable diligence to identify, report, and return any 
overpayments in accordance with the 60-day rule and identify any of those returned overpayments 
as having been made in accordance with this recommendation; (3) assess the effectiveness of 
oversight mechanisms specific to preventing or detecting improper payments to physicians for 
facet-joint denervation sessions, and modify the oversight mechanisms based on that assessment; 
and (4) direct the MACs to review claims for denervation sessions after our audit period to recover 
any improper payments. 
 
Quality of Care, Safety, and Access 
Most Medicare Beneficiaries Received Telehealth Services Only From Providers With Whom They Had 
an Established Relationship (OEI-02-20-00521), October 2021  
From March 2020 to the end of 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 4 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.   
 
Many Medicare Beneficiaries Are Not Receiving Medication to Treat Their Opioid Use Disorder (OEI-
02-20-00390), December 2021  
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 SAMHSA 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. 
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  Department of Health and Human Services, Office of Inspector General 
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Program Integrity 
Trends in Genetic Tests Provided Under Medicare Part B Indicate Areas of Possible Concern (A-09-
20-03027), December 2021  
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 received 
more than $1 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 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.  This report contains no recommendations. 
 
Hospitals Did Not Always Meet Differing Medicare Contractor Specifications for Bariatric Surgery (A-
09-20-03007), February 2022  
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 more 
specifications that were not met.  The Medicare contractors may have issued differing eligibility 
specifications because CMSs national coverage determination (NCD) 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. 
 
CMS did not concur with our recommendations that it: (1) determine whether any eligibility 
specifications in the Medicare contractors local coverage determinations (LCDs) and local 
coverage articles (LCAs) should be added to the NCD for bariatric surgery and, if so, take the 
necessary steps to update the NCD; (2) work with the Medicare contractors to review the eligibility 
specifications in the applicable Medicare contractors bariatric surgery LCDs and LCAs and 
determine which, if any, of those additional specifications should be requirements rather than 
guidance; and (3) educate hospitals on the NCD requirements for bariatric surgeries if the NCD has 
been updated in response to our first recommendation. 
 
24 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
Drug Pricing and Reimbursement 
CMS Should Strengthen Its Prescription Drug Event Guidance To Clarify Reporting of Sponsor Margin 
for Medicare Part D Bids (A-03-17-00001), November 2021  
A Part D sponsor (Sponsor) complied with CMSs prescription drug event (PDE) reporting 
requirements.  However, we also found that CMSs PDE reporting guidance does not adequately 
address a sponsor service delivery model in which a sponsor owns the pharmacy it uses and does 
not have a negotiated contract with the pharmacy.  CMS clarified that it does not consider 
pharmacy margin to be sponsor margin, and CMSs current guidance allows pharmacy margin but 
not sponsor margin to be included in the PDE record.  Any sponsor margin included in the PDE 
record cannot be identified and separated from pharmacy costs.  In sponsors Part D bid 
submissions, sponsor margin is reported separately from ingredient costs.  Any sponsor margin 
included in PDE records may not be evaluated during the bid review. 
 
Because of the lack of clarity about margin in the PDE records for sponsors with an integrated 
service delivery model, the inclusion of margin in ingredient costs prevents CMS from being able to 
readily identify and evaluate all margin that accrues to such sponsors in future years Part D bids.  
Therefore, CMS cannot readily determine whether the amounts included in those Part D bids are 
reasonable.  
 
CMS did not concur with our recommendation that it update its PDE guidance to address margin 
under sponsor delivery models in which a sponsor owns a pharmacy.  We did not make any 
recommendations to the Sponsor because it followed PDE guidance for the period we audited. 
 
Comparison of Average Sales Prices and Average Manufacturer Prices: Results for the Second 
Quarter of 2021 (OEI-03-22-00060), November 2021; and Comparison of Average Sales Prices and 
Average Manufacturer Prices: Results for the Third Quarter of 2021 (OEI-03-22-00190), February 
2022 
OIG identified seven drug codes in the second quarter of 2021 and eight drug codes in the third 
quarter of 2021 that met CMSs criteria for price substitution.  OIG compares average sales prices 
(ASPs) to average manufacturer prices (AMPs) every quarter and identifies Part B-covered drug 
codes eligible for price substitutions.  If OIG finds that the ASP for a drug exceeds the AMP by a 
certain percentagecurrently, 5 percentthe ASP-based payment amount is substituted with a 
lower calculated rate.  This difference, between the ASP and AMP prices, serves as a mechanism for 
monitoring market prices and limiting potentially excessive payment amounts.  OIG provides these 
drug codes to CMS for its review.  CMS reviews this information and determines whether to 
implement price substitutions that would limit excessive payments for Part B drugs. 
 
25 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
Medicare Part D and Beneficiaries Would Realize Significant Spending Reductions With Increased 
Biosimilar Use (OEI-05-20-00480), March 2022  
Biosimilarslower cost, highly similar alternatives to existing biologic drugs approved by FDA
have 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 noncurred 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. 
 
 
Medicaid Program Reports and Reviews 
Financial Management and Improper Payments 
Tennessee Medicaid Claimed Hundreds of Millions of Federal Funds for Certified Public Expenditures 
That Were Not in Compliance With Federal Requirements (A-04-19-04070), October 2021  
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 (IMDs) uninsured patients, $53.6 million ($37.9 million Federal share) of 
unallowable net costs of caring for TennCare IMD patients between ages 21 and 64, and 
$33.5 million ($22 million Federal share) of overstated costs because of incorrect calculations. 
 
Tennessee generally disagreed with our recommendations that it: (1) refund $397.4 million in 
overpayments to the Federal Government for CPEs that it claimed in excess of the allowable 
amount, (2) provide support for or refund to the Federal Government $370.1 million for the net 
costs of caring for uninsured IMD patients for which it did not provide detailed supporting 
documentation, and (3) establish additional policies and procedures to ensure compliance with 
Federal requirements. 
 
26 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
Kentucky Made Almost $2 Million in Unallowable Capitation Payments for Beneficiaries With Multiple 
Medicaid ID Numbers (A-04-20-07094), December 2021  
Kentucky made unallowable capitation payments on behalf of beneficiaries with multiple Medicaid 
ID numbers.  Of the 100 beneficiary matches in our sample, Kentucky correctly made capitation 
payments on behalf of 3.  However, it incorrectly made capitation payments that totaled $455,296 
($323,126 Federal share) on behalf of the remaining 97.  
 
The unallowable capitation payments occurred because the beneficiaries had multiple Medicaid ID 
numbers.  According to Kentucky, the beneficiaries had multiple ID numbers because either the 
beneficiaries or the caseworkers entered demographic data incorrectly during the application 
process.  
 
On the basis of our sample results, we estimated that Kentucky made unallowable capitation 
payments totaling approximately $2.7 million ($1.9 million Federal share) on behalf of beneficiaries 
with multiple Medicaid ID numbers during our audit period. 
 
We recommended that Kentucky: (1) refund to the Federal Government approximately $1.9 million 
(Federal share) in unallowable payments, (2) review capitation payments that fell outside of our 
audit period and refund any unallowable payments, and (3) enhance or establish new controls to 
ensure that no beneficiary is issued multiple Medicaid ID numbers.  Kentucky agreed with our 
findings but disagreed with refunding the extrapolated amount. 
 
New Jerseys Medicaid School-Based Cost Settlement Process Could Result in Claims That Do Not 
Meet Federal Requirements (A-02-20-01012), March 2022 
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. 
  
CMS concurred with our recommendation that it direct New Jersey to revise the Process Guide to 
ensure that New Jerseys methodology for claiming Medicaid school-based health care services 
27 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
costs complies with Federal requirements.  The detailed recommendations are listed in the body of 
the report. 
 
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 
(A-06-19-09005), March 2022 
New Mexico claimed $209.4 million of $222.6 million in Indian Health Service (IHS) expenditures in 
accordance with Federal and State requirements.  However, 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 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 that managed care organizations (MCOs) submitted beyond the 2-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.  
  
New Mexico concurred with our recommendation that it use the entered date to determine 
whether the MCO submitted an encounter within the 2-year limit.  New Mexico did not address 
our recommendations that it: (1) refund $12.4 million to the Federal Government, (2) work with 
CMS to determine the appropriate amount of the additional $750,811 that it should have claimed 
and refund the Federal share difference, and (3) establish policies and procedures to account for 
adjustments MCOs make to IHS encounter data after reconciliations are completed.  We made 
additional recommendations in the audit report. 
 
Quality of Care, Safety, and Access 
More Than One-Third of Medicaid-Enrolled Children in Five States Did Not Receive Required Blood 
Lead Screening Tests (OEI-07-18-00371), October 2021  
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 followup, 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 
28 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
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.  
 
Changes Made to States Medicaid Programs To Ensure Beneficiary Access to Prescriptions During the 
COVID-19 Pandemic (A-06-20-04007), October 2021  
Most States from which we obtained information responded that, as a result of the pandemic, they 
had implemented changes to ease restrictions on prior authorizations and early refill requirements, 
made changes to their prescription quantity limits to allow pharmacies to dispense increased 
quantities of some prescription drugs, and removed the requirement of obtaining a signature upon 
receipt of a prescription.  
 
In addition, most States from which we obtained information responded that they have 
implemented changes that give physicians greater flexibility to prescribe drugs to both new and 
established patients following telehealth episodes during the COVID-19 pandemic.  All 24 States in 
our survey indicated that they are providing updated guidance to all stakeholders to ensure that 
beneficiaries can obtain their prescriptions. 
 
We summarized the selected States actions to share the information with CMS and States for their 
use.  This report contains no recommendations. 
 
Arkansas Did Not Fully Comply With Federal and State Requirements for Reporting and Monitoring 
Critical Incidents Involving Medicaid Beneficiaries With Developmental Disabilities (A-06-17-01003), 
 
December 2021
Arkansas did not fully comply with Federal Medicaid waiver and State requirements for reporting 
and monitoring critical incidents involving Medicaid beneficiaries with developmental disabilities 
residing in community-based settings.  These issues occurred because Arkansas did not have 
controls in place to ensure that incidents of abuse, neglect, or death were investigated and 
reported to the appropriate authority.  Additionally, Arkansas did not ensure that all incidents 
involving Medicaid beneficiaries, including incidents of death, were reported because it did not 
have waiver requirements to report incidents that occurred outside of State custody or State 
facilities.  Also, Arkansas did not have adequate internal controls in place to detect unreported 
incidents.  
 
Arkansas generally concurred with our recommendations that it: (1) ensure that community-based 
providers report all suspected adult or child abuse and neglect to the appropriate adult or child 
abuse hotline; (2) follow waiver guidance for incidents that appear to be abuse that require review 
and followup; (3) follow waiver guidance to conduct reviews of the deaths of beneficiaries receiving 
waiver services; (4) consider amending critical incident reporting requirements, including those 
29 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
related to incidents of death, to clearly apply to circumstances in which Arkansas employees or 
contractors are providing waiver services at a non-State facility, such as a private home, and a 
critical incident occurs; and (5) perform analytical procedures, such as data matches, on Medicaid 
claims data to identify potential critical incidents that have not been reported and investigate as 
needed. 
 
New York Verified That Medicaid Assisted Living Program Providers Met Life Safety and Emergency 
Planning Requirements But Did Not Always Ensure That Assisted Living Program Services Met 
Federal and State Requirements (A-02-19-01017), March 2022 
  
New York verified that life safety and emergency planning requirements were met at the five 
judgmentally selected assisted living program (ALP) providers we visited.  However, it claimed 
reimbursement for some unallowable ALP services during our random sample of 100 beneficiary-
months.  Despite New Yorks efforts, some ALP providers did not comply with the requirements for: 
(1) documenting beneficiary assessments and care plans and (2) claiming reimbursement only for 
services in accordance with Medicaid billing requirements and beneficiary care plans.  
  
On the basis of our sample results, we estimated that New York improperly claimed at least 
$1.9 million in Federal Medicaid reimbursement for ALP services during our audit period.  In 
addition, the health and safety of some Medicaid beneficiaries may have been put at risk because 
their assessments and care plans were not valid or were missing, and some nurses aides 
qualifications were not documented.  As a result, beneficiaries may have: (1) not received ALP 
services that they were entitled to, (2) received services that were not needed, or (3) received 
services from some nurses aides that were not qualified to perform the services furnished.  
  
New York did not indicate concurrence or nonconcurrence with our recommendations that it 
refund $1.9 million to the Federal Government and that it strengthen its oversight and monitoring 
of its ALP to ensure that providers comply with Federal and State requirements. 
 
Program Integrity 
Michigan Did Not Report Calendar Year 2019 Medicaid Third-Party Liability Cost Avoidance Data to 
the Centers for Medicare & Medicaid Services (A-05-20-00058), October 2021  
CMS requires States to identify Medicaid beneficiaries third-party health coverage and determine 
the third-party liability (TPL) for the services.  Michigan did not report Medicaid TPL Medicare cost 
avoidance for all four quarters in CY 2019, totaling $3.4 billion.  Inaccurate amounts reported on 
the CMS-64 could impact CMSs monitoring and evaluation of the effectiveness of the States TPL 
activity.  
 
Michigan said the TPL Medicare cost avoidance was omitted in error because there was no process 
in place to ensure that the amounts were reported on the CMS-64.  This error was corrected, and 
30 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
the full amount was reported on the CMS-64 for the third quarter of Federal FY 2020.  Michigan 
said it added steps for entering TPL cost avoidance as part of its quarterly preparation checklist 
that must be completed and reviewed prior to certifying the CMS-64 quarterly reports.  This report 
contains no recommendations.  
 
Missouri Properly Converted Provisionally Enrolled Medicaid Providers to Permanent Providers (A-07-
21-03248), November 2021 
Missouri correctly followed up with the provisionally enrolled Medicaid providers to ensure that all 
documentation was obtained in accordance with applicable provider screening and enrollment 
requirements, or that the Medicaid provider was terminated, after the regular enrollment practices 
resumed for all 100 sampled provisionally enrolled Medicaid providers.  Missouris provisional 
enrollment process involved tracking provisionally enrolled providers on a spreadsheet and 
terminating them if they did not provide the necessary documents required for a regular 
enrollment.  Because we identified no errors in our sample review, we concluded that Missouris 
controls over the provisional enrollment process were effective. 
 
Prior Audits of Medicaid Eligibility Determinations in Four States Identified Millions of Beneficiaries 
Who Did Not or May Not Have Met Eligibility Requirements (A-02-20-01018), February 2022  
Our previous audits of 4 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 4 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 4 States made 
Federal Medicaid payments on behalf of non-newly eligible beneficiaries totaling more than 
$5 billion for almost 5 million ineligible or potentially ineligible beneficiaries. 
 
CMS disagreed with our recommendation that it work with States to implement all of the 
recommendations made in OIGs prior audits.  CMS agreed with our recommendations that it: (1) 
maintain its efforts to provide training, technical advice, and guidance to States to address the 
causes identified in OIGs prior audits and (2) use all available remedies to prevent and reduce the 
amount of improper payments made on behalf of ineligible beneficiaries.  
 
31 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
Minnesota MMIS and E&E Systems Controls Were Generally Effective, but Some Improvements Are 
Needed (A-18-20-08002), February 2022 
Due to the current public health emergency and increased cyberactivity, we are only posting the 
title of our cybersecurity audits. 
 
The Centers for Medicare & Medicaid Services Eligibility Review Contractor Adequately Determined 
Medicaid Eligibility for Selected States Under the Payment Error Rate Measurement Program (A-02-
20-01006), March 2022 
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 Payment Error Rate 
Measurement program in accordance with Federal and State requirements.  This report contains 
no recommendations. 
 
Two HHS Systems Were Launched Without Foundational Cybersecurity Controls (A-18-20-06800), 
November 2021.  
Due to the current public health emergency and increased cyberactivity, we are only posting the 
title of our cybersecurity audits. 
 
Nursing Home Reports and Reviews 
CMS Should Take Further Action To Address States With Poor Performance in Conducting Nursing 
Home Surveys (OEI-06-19-00460), January 2022 
Slightly more than half of State survey agencies (States) repeatedly failed to meet requirements for 
conducting nursing home surveys during FYs 20152018, 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. 
 
32 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
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. 
 
Facility-Initiated Discharges in Nursing Homes Require Further Attention (OEI-01-18-
00250), November 2021  
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. 
 
 
Legal and Investigative Activities Related to 
Medicare and Medicaid  
OIG investigates allegations of fraud, waste, and abuse in all HHS programs.  Our largest body of work 
involves investigating matters related to the Medicare and Medicaid programs, such as patient harm; 
billing for services not rendered, medically unnecessary services, or upcoded services (i.e., services billed 
for at a level higher than warranted); illegal billing, sale, and diversion of prescription drugs; the marketing 
of off-label uses for prescription drugs; and solicitation and receipt of kickbacks, including illegal payments 
33 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
to patients for involvement in fraud schemes and illegal referral arrangements between physicians and 
medical companies. 
 
OIG also conducts investigations regarding organized criminal activity, including medical identity theft and 
fraudulent medical schemes established for the sole purpose of stealing Medicare dollars.  Investigators 
are opening an increasing number of cases against health care providers who engage in these health care 
fraud schemes.  Those who participate in the schemes may face heavy fines, jail time, and exclusion from 
participation in Federal health care programs. 
 
One of the most common types of fraud perpetrated against Medicare, Medicaid, and other Federal health 
care programs involves filing false claims for reimbursement.  False claims may be pursued under Federal 
and State criminal statutes and, when appropriate, under the False Claims Act.  Depending on the types of 
fraud or other violations involved, OIG investigations may culminate in criminal or civil court judgments 
and decisions, administrative sanctions and decisions, and/or negotiated settlement agreements.  
Investigative outcomes take many forms, including incarceration, restitution, fines, penalties, forfeitures, 
assessments, and exclusion of individuals or entities from participation in all Federal health care programs.  
Frequently used exclusion and penalty authorities are described on our website at 
http://oig.hhs.gov/fraud/enforcement/cmp/. 
 
During this semiannual reporting period, we reported 307 criminal and 313 civil actions against individuals 
or entities that engaged in offenses related to health care.  We also reported more than $1.18 billion in 
investigative receivables due to HHS and more than $262.0 million in non-HHS investigative receivables, 
including civil and administrative settlements or civil judgments related to Medicare, Medicaid, and other 
Federal, State, and private health care programs.   
 
Criminal and Civil Enforcement Activities Related to Medicare and Medicaid 
The following recently completed actions and settlements are organized by the type of provider or entity 
involved.  Additional cases appear in the Medicare Fraud Strike Force Activities section below. 
 
Psychotherapy 
The following case example involves psychotherapy:  
  
ConnecticutOn March 11, 2022, Courtney Dunlap was sentenced to 57 months of 
imprisonment, followed by 3 years of supervised release, for operating a wide-ranging 
scheme that defrauded the Connecticut Medicaid Program of more than $1.3 million.  
According to court documents and statements in court, from 2014 to 2020, Dunlap was a 
Licensed Professional Counselor with offices located on Brainard Road in Hartford.  Dunlap 
also owned two entities, Inspirational Care, and KEYS Program Inc., through which he 
managed group homes in Hartford, Bristol, Cromwell, and Waterbury, including residences 
for women and children who were victims of domestic abuse. 
34 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
From August 2018 through October 2020, Dunlap engaged in a scheme to defraud the 
Connecticut Medicaid Program by submitting claims for psychotherapy services that were 
purportedly provided to Medicaid clients.  The vast majority of the claims were for 
occasions and dates of service when no psychotherapy services of any kind had been 
provided to the Medicaid clients identified in the claims.  On a limited number of occasions, 
some of the services were rendered by unlicensed individuals who were not qualified or 
licensed to provide psychotherapy. 
Genetic Testing 
The following case example involves genetic testing fraud and kickback schemes related to a 
telemedicine company:  
  
FloridaOn November 9, 2021, Leonel Palatnik was sentenced to 82 months in Federal 
prison and ordered to pay more than $61 million in restitution for his role in a $73 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, Leonel Palatnik admitted that, as a co-owner of Panda Conservation Group 
LLC, he conspired with other co-owners and with Michael Stein, the owner of 1523 Holdings 
LLC, to pay kickbacks to Stein in exchange for his work arranging for telemedicine providers 
to authorize genetic testing orders for Pandas laboratories.  Pandas owners and Stein 
entered into a sham contract for purported IT and consultation services to disguise the true 
purpose of these payments.  Then 1523 Holdings exploited temporary amendments to 
telehealth restrictions enacted during the pandemic 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 Pandas laboratories for 
expensive and medically unnecessary CGx.  
 
Pharmaceutical Companies 
The following case example involves a pharmaceutical company:  
  
MassachusettsOn November 9, 2021, kaleo Inc., a Virginia-based pharmaceutical 
manufacturer, agreed to pay the United States $12.7 million to resolve 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.  Between March 14, 
2017, and April 30, 2020, kaleo directed prescribing doctors to send Evzio prescriptions to 
35 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
certain preferred pharmacies that in turn submitted false prior authorization requests to 
insurers.  The prior authorization requests 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 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 to induce and 
reward their prescribing of Evzio. 
  
DME Companies 
The following case examples involve DME companies:  
 
AlabamaOn December 2, 2021, Phillip Minga was sentenced to 78 months in prison for 
health care fraud and conspiracy to commit health care fraud.  The court also ordered 
Minga 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, Minga 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 Minga in a management or administrative role.  Nevertheless, from 
2016 until 2021, Minga committed health care fraud by continuing to manage and control 
pharmacies that submitted claims for payment to Medicare.  To avoid detection, Minga 
ensured that those submitting Medicare enrollment or revalidation paperwork for these 
pharmacies would not disclose Mingas ownership interest or managerial role in these 
pharmacies.  From October 17, 2016, to August 16, 2021, Medicare paid more than 
$16 million to the pharmacies in which Minga had an ownership interest or managerial role. 
 
FloridaOn November 5, 2021, Michael Nolan and Richard Epstein 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).  Nolan was sentenced to 78 months in Federal prison and Epstein 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 million, respectively, which were proceeds of the conspiracy.  Nolan and Epstein 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, Epstein and Nolan ran a telemarketing company in Tampa 
called REMN Management LLC that targeted the elderly to generate thousands of 
medically unnecessary physicians orders for DME and CGx.  Epstein and Nolan also created 
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and operated Comprehensive Telcare, LLC, a telemedicine company through which they 
illegally bribed physicians to sign the orders regardless of medical necessity.  Epstein and 
Nolan then illegally sold the signed physicians 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 million in fraudulent claims to the 
Federal health benefit programs, resulting in approximately $29 million in payments. 
 
 
Pharmacies 
The following case example involves  a pharmacy: 
  
OregonOn December 10, 2021, Matthew Hogan Peters, who owned and operated two 
compounding pharmacies, was sentenced to 3 years in Federal prison and ordered to pay 
more than $3 million in restitution to the Internal Revenue Service (IRS) for evading the 
payment of approximately $5.5 million in personal income 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 multiyear investigation into alleged illegal kickback 
arrangements at compounding pharmacies owned by Peters and members of his family in 
several states.  Two such pharmacies, Professional Center Pharmacy and Professional 
Center 205 Pharmacy, were located in Southeast Portland.  The investigation ultimately 
revealed that Peters 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 Peters pharmacies.  Peters health care 
fraud conviction stemmed from his requests for approximately $3.4 million in 
reimbursement from CVS Caremark for medication his pharmacies had purportedly 
dispensed.  In mid-2015, CVS Caremark audited Peters reimbursement claims and 
identified nearly a quarter-million dollars in potentially unwarranted reimbursement.  Many 
of the reviewed claims lacked records proving customers receipt of medications. 
 
In October 2015, seeking to resolve these discrepancies and avoid possible suspension from 
CVS Caremarks network, Peters submitted to CVS Caremark a total of 41 forged patient 
attestations, purportedly confirming individual patients receipt of prescriptions.  CVS 
Caremark auditors noticed that the patient attestations all bore the same unique digital 
code and, after further investigation, suspended Peters pharmacies from their network.  A 
subsequent Federal investigation confirmed that Peters had used DocuSign, an electronic 
signature application, from his personal computer to sign the attestations. 
 
 
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  Department of Health and Human Services, Office of Inspector General 
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Prescription Drugs 
The following case examples involve prescription drugs: 
 
DelawareOn March 1, 2022, Patrick Titus, a former doctor, was sentenced to 20 years in 
prison for unlawful drug distribution and maintaining drug-involved premises.  According 
to court documents and evidence presented at trial, Titus unlawfully distributed or 
dispensed a variety of powerful opioidsincluding fentanyl, morphine, methadone, 
OxyContin, and oxycodoneoutside the usual scope of professional practice and for 
illegitimate medical purposes.  Titus 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 Titus distributed more than 1 million opioid pills.  
Although these Schedule II drugs are approved for pain management treatment, Titus 
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. 
 
South DakotaOn November 2, 2021, Frenchone One Horn (also known as Frenchone Kills 
In Water) was sentenced to 60 months in Federal prison to be served consecutively on each 
count of assault resulting in serious bodily injury.  One Horn was sentenced to 24 months in 
Federal prison on the charge of health care fraud, to be served consecutively to the assault 
charges.  As to the charge of obtaining controlled substances by fraud, One Horn was 
sentenced to 12 months in Federal prison.  In total, One Horn was sentenced to 12 years in 
Federal prison, followed by 3 years of supervised release, and ordered to pay $400 in 
special assessments to the Federal Crime Victims Fund.  One Horn assaulted others, 
including her minor children, to obtain prescriptions from medical providers for the injuries 
she intentionally inflicted.  As a result of One Horns actions, three victims lost four fingers 
to amputation.  One Horn fabricated stories as to how the individuals received their injuries, 
and also provided false statements to health care providers to obtain controlled substances 
and health care benefits.  Once the individuals received controlled substances, One Horn 
took the controlled substances, despite the individuals having significant bodily injuries. 
 
 
Kickbacks 
The following case examples involve kickbacks: 
 
ColoradoOn March 1, 2022, Jeffrey Kesten was sentenced to 24 months in Federal prison, 
to be followed by 3 years of supervised release for conspiring to violate the anti-kickback 
statute 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.  
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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 Insys Therapeutics, Inc., 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 more than $40,000 from Insys for 17 programs he allegedly delivered 
to his own staff at his medical clinic.  As part of the plea agreement, the defendant 
admitted that he entered into a quid pro quo relationship with Insys, 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 Insyss 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 Dr. Kesten.  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 Transmucosal Immediate Release Fentanyl 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. 
 
MissouriOn January 18, 2022, Brandy McKay, was sentenced to 36 months in Federal 
prison, to be followed by 3 years of supervised release and ordered to pay more than 
$7.5 million in restitution.  On October 6, 2021, Brandy McKay pleaded guilty to one count 
health care fraud, one count of making false statements concerning health care matters 
and one count of illegal kickbacks for health care program referrals.  According to the plea 
agreement, between 2017 and 2019, McKay owned or managed multiple DME companies, 
including three located in Cape Girardeau, Missouri.  The DME companies paid kickbacks 
for orders and prescriptions signed by telemedicine doctors and nurse practitioners, who in 
almost all cases did not examine the patients, had no contact with the patients, and did not 
otherwise determine that the patients needed DME.  The DME companies then submitted 
reimbursement claims to Medicare and Medicaid.  Based on the fraudulent claims 
submitted by McKay and her co-conspirators, Medicare and Medicaid reimbursed the DME 
companies for the medically unnecessary equipment.  In many cases, patients received 
DME equipment from several DME companies, which they had neither requested nor 
needed. 
 
Patient Harm 
The following case example involves patient harm: 
 
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South DakotaOn December 21, 2021, Pedro Ibarra-Perocier, a physician at the Wagner 
Indian Health Service Clinic, was sentenced to 120 months in Federal prison, followed by 5 
years of supervised release, a $35,000 fine, after he pled guilty to five counts of abusive sexual 
contact.  The conviction stemmed from several incidents that occurred between approximately 
February 2007 and August 2018, when Ibarra-Perocier was a licensed physician practicing at 
the Wagner Indian Health Service Clinic and sexually abused five Native American women who 
came to see him at the clinic for medical appointments.  Ibarra-Perocier frequently locked the 
door to the examination room before he sexually abused those women.  Ibarra-Perocier 
threatened or placed some of them in fear that they would not receive the medications or 
medical care they needed unless they complied with his sexual demands in the clinic 
examination rooms.. 
 
Home Health 
The following case example involves home health: 
 
IllinoisOn November 30, 2021, Angelita Newton 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, Angelita Newton worked at Care Specialists, a home health care 
company owned by Ferdinand Echavia and later his wife, Ma Luisa Echavia.  Ferdinand 
Echavia and Ma Luisa Echavia were previously sentenced to 84 months and 60 months in 
prison, respectively, for their role in the conspiracy.  Between 2011 and 2017, Care Specialists 
fraudulently billed Medicare at least $6.3 million.  At trial, the Government demonstrated 
that around 90 percent of Care Specialists patients were not homebound and did not 
qualify for the types of care that Care Specialists had billed to Medicare.  Furthermore, 
many patients received cash bribes to receive home health visits, some of which were 
performed in the visiting nurses car.  Newton facilitated the conspiracy by falsifying patient 
visit records that were used to support claims billed to Medicare, and she was convicted by 
a federal jury on February 14, 2020.  Another participant in the conspiracy, Reginald Onate, 
who pleaded guilty and cooperated with the Government throughout the investigation, 
was sentenced to 3 years probation. 
 
Medical Device Company 
The following case example involves a medical device company: 
 
MassachusettsOn November 8, 2021, Arthrex Inc., a Florida-based medical device 
company, agreed to resolve allegations that it violated the False Claims Act by paying 
kickbacks that caused the submission of false claims to the Medicare program.  According 
to the settlement, Arthrex Inc., which specializes in orthopedic products, has agreed to pay 
$16 million for allegedly paying kickbacks to a Colorado-based orthopedic surgeon.  The 
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  Department of Health and Human Services, Office of Inspector General 
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settlement resolves allegations that Arthrex agreed to provide remuneration to the surgeon 
in the form of royalty payments purportedly for the surgeons contributions to Arthrex Inc.s 
SutureBridge and SpeedBridge products when the remuneration was in fact intended to 
induce the surgeons use and recommendation of Arthrex Inc.s products.  The United 
States contended that Arthrex Inc.s participation in this arrangement violated the Federal 
anti-kickback statute and, in turn, the False Claims Act, by causing the submission of false 
or fraudulent Medicare claims.  In connection with the settlement, Arthrex, Inc. entered into 
a 5-year CIA with HHS-OIG.  
 
Medicare Fraud Strike Force Activities 
In 2007, Medicare Fraud Strike Force teams began an effort to combine resources of Federal, State, and 
local law enforcement entities to prevent and combat health care fraud, waste, and abuse.  These 
partnerships among OIG and HHS, DOJ, U.S. Attorneys Offices, FBI, and State and local law enforcement 
have a common goal: to analyze health care fraud data and investigative intelligence to quickly identify 
fraud and bring prosecutions.  Strike Force teams operate in 11 areas: Miami and Tampa/Orlando, Florida; 
Dallas and Houston, Texas; Los Angeles, California; Detroit, Michigan; Brooklyn, New York; Baton Rouge 
and New Orleans, Louisiana; Chicago, Illinois; and Newark, New Jersey/Philadelphia, Pennsylvania; along 
with a Corporate Strike Force located in Washington, DC.  During this semiannual reporting period, Strike 
Force efforts resulted in the filing of charges against 72 individuals or entities, 91 criminal actions, and 
more than $227.6 million in investigative receivables. 
In October 2018, DOJ announced the creation of a new initiative to combat the Nations opioid 
epidemic.  The Appalachian Regional Prescription Opioid Strike Force covers 10 Federal judicial districts 
in Alabama, Kentucky, Ohio, Tennessee, Virginia, and West Virginia.  OIGs Office of Investigations is 
working closely with its law enforcement partners at the Drug Enforcement Administration (DEA), FBI, 
and the MFCUs to provide investigative support.  Cases involve physicians and pharmacies that are 
responsible for medically unnecessary opioid prescriptions and dangerous drug combinations that are 
being paid for by Medicare and Medicaid.  In many instances, there are other allegations of 
wrongdoing relating to kickbacks, health care fraud, and quality of care, including patient overdoses 
and deaths. 
 
The following case example involves a Strike Force case: 
 
TexasOn December 16, 2021, Leah Hagen and Michael Hagen were sentenced to 151 months in 
prison and were ordered to pay more than $27 million in restitution for a Medicare kickback 
conspiracy.  According to the evidence presented at trial, Leah and Michael Hagen owned and 
operated two DME companies, Metro DME Supply LLC and Ortho Pain Solutions LLC.  From March 
2016 to January 2019, the defendants paid kickbacks and bribes to their co-conspirators call center 
in the Philippines in exchange for signed doctors orders for DME that were used to submit false 
claims in excess of $59 million to Medicare.  As a result of those claims, Medicare paid the 
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  Department of Health and Human Services, Office of Inspector General 
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defendants more than $27 million.  The defendants transferred millions of dollars overseas to 
purchase a home in Spain, among other things.  To conceal the payments of kickbacks and bribes 
from the authorities, the defendants, through their DME companies, signed sham contracts that 
disguised payments as marketing and business process outsourcing.  The DME claims submitted by 
the defendants to Medicare were for services that were medically unnecessary and not provided as 
represented.  In some cases, beneficiaries were convinced to accept braces they did not need or 
want and were offered gift cards in exchange for accepting those braces.  
 
Most Wanted Fugitives List 
OIGs Most Wanted Fugitives website continues to garner national and international attention and has 
greatly assisted in helping to capture fugitives charged with defrauding Federal health care programs and 
stealing millions of taxpayer dollars.  The Most Wanted Fugitives website is continually updated and 
features a profile for each fugitive as well as an online tip form and a hotline number for individuals to 
report fugitive-related information to OIG, in English or Spanish, 24 hours a day, 365 days a year.  The 
Most Wanted Fugitives list is available at https://oig.hhs.gov/fraud/fugitives/.  During this semiannual 
reporting period, four fugitives were captured. 
 
The following case example involves a captured fugitive:  
 
TexasOn December 10, 2021, Ebong Aloysius Tilong (Tilong ) was extradited from the Republic of 
Cameroon to the United States to serve an 80-year prison sentence he received in absentia 4 years 
ago after he pleaded guilty in two separate cases to conspiracy, health care fraud, money 
laundering, and tax offenses.  The trial evidence and court documents showed that between 2006 
and 2015, Tilong, Neba, and their co-conspirators used Tilong and Nebas company, Fiango Home 
Healthcare Inc. (Fiango), to corruptly obtain more than $13 million by submitting false and 
fraudulent claims to Medicare for home health care services that Fiangos patients did not need or 
receive.  Additional evidence demonstrated that Tilong attempted to destroy evidence and to 
blackmail and induce witnesses to commit perjury.  After the first week of trial, Tilong pleaded 
guilty to one count of conspiracy to commit health care fraud, three counts of health care fraud, 
one count of conspiracy to pay and receive health care kickbacks, three counts of payment and 
receipt of health care kickbacks, and one count of conspiracy to launder monetary instruments.   
In August 2017, Neba was sentenced to 75 years in prison for the Medicare fraud scheme at 
Fiango.  The U.S. District Court scheduled Tilongs sentencing for October 13, 2017, but court 
records show that on the morning of his sentencing hearing, Tilong removed an ankle bracelet 
monitoring his location and failed to respond to phone calls from, or appear in, the U.S. District 
Court for his sentencing.  On December 8, 2017, the U.S. District Court sentenced Tilong in absentia 
to 80 years in prison for his role in the Medicare and tax fraud schemes.   
After Tilong absconded, the FBI Houston Field Office located Tilong in Cameroon, and worked 
collaboratively with the FBI Legal Attache in Abuja, Nigeria, HHS-OIG, IRS Criminal Investigation 
(IRS-CI) Fraud Section, and the Office of the President of the Republic of Cameroon to ensure 
Tilongs capture.  The National Police Force of Cameroon arrested Tilong in January 2019.  Prior to 
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  Department of Health and Human Services, Office of Inspector General 
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his extradition from Cameroon, Tilong was wanted by the FBI and was listed among HHS-OIGs 
Top 10 Most Wanted Fugitives. 
HHS-OIG Hotline 
As part of OIGs Office of Investigations, the hotline is the public-facing division for OIGs intake and 
evaluation of fraud tips.  The mission of the HHS-OIG Hotline is to support OIGs oversight responsibilities 
in safeguarding the integrity of all programs and personnel under HHSs purview and protecting them 
from fraud, waste, and abuse.  The hotline achieves its mission through its staffs dedication to timely 
intake and analysis of information received from various sources, such as the Submit a Complaint link on 
the HHS-OIG website.  During this semiannual reporting period, the OIG Hotline reported expected 
recoveries of $97,002,239 as a direct result of cases originating from hotline complaints. 
 
OIG Hotline Activity (4/1/20219/30/2021) 
Contacts to 1-800-HHS-TIPS phone line, including  53,782 
callers seeking information 
Total tips evaluated  20,391 
Tips referred for action  12,110 
Closed; no basis provided for further action  1,514 
Closed; no HHS violation1  933 
Closed; other administrative reason  5,834 
 
Sources of tips referred for action 
Phone  3,607 
OIG website  6,848 
Letters or faxes  603 
Other  1,052 
 
 
Medicaid Fraud Control Units 
OIG Oversight of Medicaid Fraud Control Units 
MFCUs are key partners with OIG in the fight against fraud, waste, and abuse in State Medicaid 
programs.  OIG has oversight responsibility for MFCUs and administers grants that provide Federal 
funding for their operations.  Currently, all 50 States, the District of Columbia, Puerto Rico, and the 
U.S. Virgin Islands operate MFCUs.  The Federal Government reimburses 90 percent of a MFCUs 
total expenditures during the first 3 years of operation and 75 percent thereafter.  MFCUs 
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  Department of Health and Human Services, Office of Inspector General 
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investigate and prosecute Medicaid provider fraud as well as abuse or neglect of residents in 
health care facilities and board and care facilities and of Medicaid beneficiaries in noninstitutional 
or other settings. 
 
Medicaid Fraud Control Units Fiscal Year 2021 Annual Report (OEI-09-22-00020), March 2022 
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, OIG summarizes beneficial practices identified by 
OIG in its reviews or inspections that may be useful to other MFCUs.  
 
OIG Joint Casework With MFCUs 
The following case example involves OIGs joint efforts with MFCUs: 
 
PennsylvaniaOn December 7, 2021, Thomas Whitten was sentenced to 57 months in 
prison and ordered to pay $8 million in restitution for conspiracy to violate the Federal anti-
kickback statute, health care fraud, and conspiracy to distribute Schedule IV controlled 
substances.  Whitten pled guilty on July 22, 2021.  During the change of plea hearing, 
Whitten admitted that, from May 2013 to November 2015, he conspired to receive 
kickbacks from pharmaceutical company Insys Therapeutics in exchange for prescribing 
Subsys, a powerful painkiller that is approximately 50 to 100 times more potent than 
morphine.  The FDA approved Subsys only for the management of breakthrough pain in 
cancer patients.  Whitten prescribed Subsys to patients for whom the drug was not 
medically indicated and received more than $100,000 as well as other benefits from Insys in 
exchange for writing those prescriptions.  Prescriptions for Subsys typically cost thousands 
of dollars each month, and Medicare and Medicaid, as well as commercial insurers, 
including Highmark, paid millions of dollars to cover illegitimate Subsys prescriptions 
written by Whitten.  In addition, from November 2017 through December 12, 2019, Whitten 
conspired to unlawfully distribute Schedule IV controlled substances, phentermine 
hydrochloride and diethylpropion, to patients at five weight loss clinics.  Based on an 
agreement between Whitten and the owner of those clinics, Schedule IV controlled 
substances were dispensed to patients under Whittens DEA registration numbers, including 
to new patients and patients who had not been seen at the clinics for years, without any 
physical examination by Whitten or another appropriately trained licensed medical 
professional. 
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  Department of Health and Human Services, Office of Inspector General 
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The investigation leading to the filing of charges in this case was conducted by the Western 
Pennsylvania Opioid Fraud and Abuse Detection Unit, a collaborative effort including HHS-
OIG; FBI; DEA; IRS-Criminal Investigations; Pennsylvania Office of Attorney GeneralMFCU; 
Pennsylvania Office of Attorney GeneraBureau of Narcotic Investigations; United States 
Postal Inspection Service; U.S. Attorneys OfficeCriminal Division, Civil Division and Asset 
Forfeiture Unit; VA-OIG; OPM-OIG; and the Pennsylvania Bureau of Licensing. 
 
Advisory Opinions and Other Industry Guidance  
Advisory opinions, which are developed in consultation with DOJ, are issued to requesting parties 
regarding the interpretation and applicability of certain statutes relating to Federal health care programs.  
The Health Insurance Portability and Accountability Act of 1996 (HIPAA),  205, allows OIG to provide case-
specific formal guidance on the application of the anti-kickback statute and safe harbor provisions and 
other OIG health care fraud and abuse sanctions.  During this semiannual reporting period, OIG received 
24 requests for advisory opinions and issued 11 advisory opinions. 
 
Sanction Authorities and Other Administrative Actions  
Various Federal laws provide authorities the ability to impose administrative sanctions for fraud and abuse 
as well as other activities that pose a risk to Federal health care programs and their beneficiaries.  
Sanctions include the exclusion of individuals and entities from Federal health care programs and the 
imposition of CMPs for submitting false and fraudulent claims to a Federal health care program or for 
violating the anti-kickback statute, the physician self-referral law (commonly referred to as the Stark Law), 
or the Emergency Medical Treatment and Labor Act (EMTALA), also known as the patient dumping 
statute.  Sanctions also include referrals for suspension and debarment in cases of grant and contract 
fraud. 
 
During this semiannual reporting period, OIG imposed 1,122 administrative sanctions in the form of 
program exclusions or administrative actions for alleged fraud or abuse or other activities that posed a risk 
to Federal health care programs and their beneficiaries.  
 
Exclusion and penalty authorities are described in Appendix C and on our website at 
http://oig.hhs.gov/fraud/enforcement/cmp/index.asp. 
 
Program Exclusions 
During this semiannual reporting period, OIG excluded 1043 individuals and entities from 
Medicare, Medicaid, and other Federal health care programs.  Most of the exclusions resulted from 
convictions for crimes relating to Medicare or Medicaid, patient abuse or neglect, financial 
misconduct, controlled substances, or as a result of license revocation.  OIG completed the 
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deployment of a new service for MFCUs to report convictions through a central web-based portal 
for exclusions.  OIG is also responsible for reinstating providers who apply and have met the 
requirements of their exclusions.  For a list of excluded individuals and entities, see 
https://exclusions.oig.hhs.gov/. 
 
The following are case examples of program exclusions:  
 
New YorkOn November 18, 2021, a medical doctor was excluded for a minimum period of 30 
years based on convictions for Health Care Fraud and Conspiracy to Unlawfully Distribute 
Controlled Substances.  From about 2007 to about September 2014, this physician issued 
prescriptions for controlled substances without conducting exams, issued prescriptions 
knowing patients had overdosed and were hospitalized, and continued to prescribe controlled 
substances that resulted in drug-seeking behavior and patient death.  The individual was 
sentenced to 70 months of incarceration and ordered to pay approximately $344,500 in 
restitution.  In addition, the New York Department of Health, State Board of Professional 
Medical Conduct revoked the individuals license to practice as a medical doctor. 
 
TexasOn November, 18, 2021, a co-owner of a pharmaceutical marketing company was 
excluded for a minimum period of 50 years based on the individuals convictions of conspiracy 
to commit health care fraud and receipt of illegal kickbacks.  From about May 2014 to about 
February 2016, the individual conspired with others to defraud TRICARE with a scheme that 
involved a sham medical study, a bogus charity, and kickbacks to incentivize patients to obtain 
expensive pain and scar cream prescriptions.  The individual was sentenced to 120 months of 
incarceration and ordered to pay approximately $70,417,800 in restitution. 
 
Washington StateOn January 19, 2022, a massage therapist was excluded for a minimum 
period of 55 years based on convictions for one count of rape and three counts of indecent 
liberties.  From about January 2011 to about June 2020, this individual engaged in sexual 
intercourse with a client/patient during treatment sessions.  The individual was sentenced to 
132 months of incarceration.  In addition, the Washington Department of Health, Massage, 
Therapist Program accepted the surrender of the individuals license to practice as a massage 
therapist. 
 
West VirginiaOn February 20, 2022, a nursing assistant was excluded for a minimum period 
of 97 years based on a conviction of seven counts of second degree murder and one count of 
assault with intent to commit murder.  Specifically, this individual deliberately and without 
authorization administered lethal doses of insulin to patients under the individuals care at the 
Veterans Affairs Medical Center.  The nursing assistant was sentenced to pay restitution and 
serve seven life terms plus 240 months in prison.     
 
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  Department of Health and Human Services, Office of Inspector General 
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MississippiOn March 20, 2022, a pharmacist was excluded for a minimum period of 80 years 
based on a conviction of conspiracy to commit health care fraud and money laundering.  From 
about January 2012 to about December 2015, this individual defrauded TRICARE and other 
health care benefit programs by producing compound medications to maximize 
reimbursement, submitting false and fraudulent claims for reimbursement, and diverting the 
proceeds for personal use and benefit.  The pharmacist was sentenced to 12 months and 1 day 
of incarceration and ordered to pay approximately $182,503,900 in restitution.   
 
Suspensions and Debarments  
Suspensions and debarments are administrative tools used by HHS and other Federal agencies to 
protect the Government from individuals and entities that have engaged in contract fraud, have 
misused grant funds, or are otherwise not presently responsible.  Because these are 
Governmentwide sanctions, an individual or entity that has been suspended or debarred by HHS or 
any other agency is ineligible to participate in any future funding opportunities across the Federal 
Government for a specified period of time. 
 
OIG refers individuals and entities that have potentially engaged in grant or contract fraud or 
misconduct to the HHS suspension and debarment official, who is responsible for determining 
whether to impose a suspension or debarment.  OIG continues to develop a robust suspension and 
debarment program and uses this tool to protect Government programs against fraud, waste, poor 
performance, and noncompliance with contract provisions or applicable law.  
 
The following case example involves debarment:  
 
NebraskaOn January 8, 2022, the HHS Suspension and Debarment Official (SDO) 
debarred the director of a grant recipient that OIG had referred to the Office of Recipient 
Integrity Coordination.  The grant recipient received reimbursement payments in the form 
of grants through the Child Care Bureau in the Office of Family Assistance of the 
Administration for Children and Families.  These grants provided childcare subsidies to low-
income families where the parents were employed or engaged in job training.  After a 
review of timesheets demonstrated that families were being billed that did not attend 
daycare during the recorded days and times, the director was convicted of stealing money 
and property of the United States and sentenced to serve 5 years of probation and pay 
$143,099.84 in restitution.  In addition to the SDOs 3-year debarment, OIG excluded the 
director from participating in the Federal health care programs for 6 years. 
 
Civil Monetary Penalties Law 
The Civil Monetary Penalties Law (CMPL) authorizes OIG to impose administrative penalties, 
assessments, and exclusions against a person who, among other things, submits, or causes to be 
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submitted, claims to a Federal health care program that the person knows, or should know, are 
false or fraudulent.  The exclusions statute also authorizes OIG to exclude a person who violates 
the CMPL.  During this semiannual reporting period, OIG concluded cases involving more than $32 
million in CMPs and assessments. 
 
Affirmative Litigation 
The CMPL authorizes OIG to use its administrative remedies to affirmatively pursue cases.  OIG 
may also exclude under the exclusions statute for engaging in conduct that violates the CMPL.  
When OIG excludes under the exclusions statute for engaging in conduct that violates the CMPL, it 
is known as an affirmative exclusion. 
 
The following case examples involve affirmative litigation under the CMPL:  
  
TexasDr. Steven Lane Casey and Metroplex Pain Consultants, LLC (collectively, Casey) 
entered into a $110,748.12 settlement agreement with OIG.  The settlement agreement 
resolves allegations that Casey submitted claims to Medicare while Dr. Casey neither 
performed the services himself, nor supervised them.  This settlement also resolved 
allegations that Casey billed Medicare for medically unreasonable or unnecessary spinal 
facet joint injections.   
 
FloridaMeir Daller, M.D., entered a settlement agreement with OIG in which he agreed to 
pay $455,400 and be excluded from participation in all Federal health care programs for 3 
years under 42 U.S.C. 1320a-7a and 42 U.S.C. 1320a-7(b)(7).  The settlement agreement 
resolves allegations that Dr. Daller submitted or caused to be submitted the following: (1) 
claims for cystourethroscopy with dilation of urethral stricture where no stricture was 
present that necessitated urethral dilation; (2) claims for urodynamics testing that was 
ordered on a routine periodic basis, not out of medical necessity; and (3) claims for 
evaluation and management (E&M) services related to in-office testosterone injections that 
were: (i) submitted in conjunction with claims for the testosterone injections, using modifier 
25, where no significant and separately identifiable service other than the testosterone 
injection took place; and (ii) submitted alone where the patient received an in-office 
testosterone injection but no evaluation or management of the patient took place that 
justified the billing of an E&M code.  
  
CaliforniaOcean Mind and Body (Ocean) and Laura Rausa (Rausa) entered a $62,528.73 
settlement agreement with OIG, resolving allegations that Ocean and Rausa knowingly 
made, used, or caused to be made a false statement in a document that is required to be 
submitted to directly or indirectly receive or retain funds provided in whole or in part by 
the Secretary of HHS.  Specifically, OIG contends that in April 2020, Ocean, a medical 
supply company, received a Provider Relief Fund payment pursuant to the CARES Act.  On 
April 28, 2020, Rausa, the Chief Executive Officer and owner of Ocean, attested in the HHS 
48 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
Provider Relief Fund Portal that Ocean was eligible to receive this payment because, among 
other things, it provides or provided after January 31, 2020, diagnoses, testing, or care for 
individuals with possible or actual cases of COVID-19.  However, Ocean and Rausa did not 
provide diagnoses, testing, or care for any individuals after January 31, 2020.   
 
TexasOIG excluded the Woodlands Pain Institute, PLLC, and its owner, Emad Bishai, M.D. 
for 7 years each under 42 U.S.C. 1320a-7(b)(7) as part of a $523,331 False Claims Act 
settlement.  The exclusions and settlement resolve allegations that Dr. Bishai, an 
anesthesiologist, and Woodlands Pain Institute knowingly submitted, or caused to be 
submitted, claims to Medicare under Healthcare Common Procedure Coding System code 
L8679, which is designed for implantable neurostimulator, pulse generator devices that a 
surgeon implants into a patient typically in an operating room.  Dr. Bishai did not perform 
surgery and did not implant anything into patients bodies.  Instead, the underlying services 
for which the L8679 claims were submitted involved the application of a device used for 
electroacupuncture.  To apply the electroacupuncture device, needles were inserted into 
patients ears and the neurostimulator was taped behind their ears with an adhesive.  
Medicare does not reimburse for electroacupuncture devices as neurostimulators. 
 
Patient Dumping  
Some of the CMPL cases that OIG resolved during this semiannual reporting period were pursued 
under the Emergency Medical Treatment and Labor Act (EMTALA), a statute designed to prevent 
hospitals from denying emergency care to patients and to ensure patient access to appropriate 
emergency medical services. 
 
The following case examples involve EMTALA:  
  
TennesseeOIG entered a settlement agreement for $725,000 with Tristar Centennial 
Medical Center (Centennial), a 741-bed acute care hospital located in Nashville, Tennessee.  
OIG identified 29 incidents in which Centennial violated EMTALA, 42 U.S.C.  1395dd(g).  In 
each of these incidents, a patient presented to Centennials Emergency Department (ED) 
with an unstable psychiatric emergency medical condition.  In each incident, Centennial 
failed to provide, with the staff and facilities available at Centennial, further medical 
examination and treatment required to stabilize the patients emergency medical condition.  
In two of these incidents, rather than admitting the patient to Parthenon Pavilion, 
Centennial's inpatient psychiatric unit, which had the capability and capacity to treat the 
patient, Centennial discharged the patient home with an unstable emergency medical 
condition.  For other presentments, rather than admitting the patient to Parthenon Pavilion, 
Centennial 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 Centennial and the Tristar Behavioral 
Health Transfer Center and was based, in part, on the patients insurance status. 
49 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
  
TennesseeOIG entered a settlement agreement for $725,000 with Tristar Skyline Medical 
Center (Skyline), a 353-bed acute care hospital located in Nashville, Tennessee.  OIG 
identified 25 incidents in which Skyline violated EMTALA.  In each of these incidents, a 
patient presented to Skylines ED with an unstable psychiatric emergency medical 
condition.  In each incident, Skyline failed to provide, with the staff and facilities available at 
Skyline, further medical examination and treatment required to stabilize the patients 
emergency medical condition.  Rather than admitting the patient to Skylines inpatient 
psychiatric unit that had the capability and capacity to treat the patient, Skyline held the 
patient inappropriately in its ED for more than 24 hours before transferring the patient to 
Middle Tennessee Mental Health Institute, a State psychiatric hospital.  The decision to 
transfer the patient, and where to transfer the patient, was made by Skyline and the Tristar 
Behavioral Health Transfer Center and was based, in part, on the patients insurance status.  
Skyline asserts that its decision to transfer the patients was based on a recommendation 
from the State of Tennessees Mobile Crisis Services team. 
 
Self-Disclosure Programs  
Health care providers, suppliers, or other individuals or entities subject to CMPs can apply for 
acceptance into the Provider Self-Disclosure Protocol, a program created in 1998 for voluntary 
disclosure of self-discovered evidence of potential fraud.  The Self-Disclosure Protocol may give 
providers the opportunity to avoid costs or disruptions associated with Government-directed 
investigations and civil or administrative litigation.  
 
Application processes for two additional self-disclosure programs were recently added to the OIG 
website for HHS contractors and grantees.  The OIG contractor self-disclosure program provides 
contractors the opportunity to self-disclose when they have potentially violated the False Claims 
Act or other Federal criminal laws prohibiting fraud, conflict of interest, bribery, or gratuity.  This 
self-disclosure process is only available to those with a FAR-based contract with HHS.  The OIG 
Grant Self-Disclosure Program is available for application by HHS grantees or HHS grant 
subrecipients and provides the opportunity for voluntary disclosure to OIG of potential fraud.  OIG 
evaluates the reported results of each internal investigation under the provider self-disclosure 
protocol to determine the appropriate course of action.  The self-disclosure guidelines are available 
on the OIG website at https://oig.hhs.gov/compliance/self-disclosure-info/index.asp.  During this 
semiannual reporting period, provider self-disclosure cases resulted in more than $26.6 million in 
HHS receivables. 
 
The following case examples pertain to provider self-disclosure settlements:  
  
FloridaLee Memorial Health System dba Lee Health, and Cape Memorial Hospital, Inc. 
dba Cape Coral Hospital (collectively, Lee Health) entered a $12,721,885.58 settlement 
agreement with OIG.  In its submission to the OIG Self-Disclosure Protocol, Lee Health 
50 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
disclosed that during the period of January 1, 2011, through May 10, 2018, Lee Health 
submitted 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 (E.D.M, M.D., and G.A, M.D.) 
at Lee Healths facilities that did not meet Federal health care program coverage criteria.  
The specific procedures that were improperly billed by Lee Health 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. 
 
TexasAfter it self-disclosed conduct to OIG, Texas Centers for Infectious Disease 
Associates (TCIDA) entered a settlement agreement for $609,579.93.  The agreement 
resolves TCIDA's liability under the CMPL for its submission of claims to Medicare Part D for 
the entire vial of certain drugs to particular patients when in fact, the patients had been 
dispensed only part of the vial of the drug, and for overbilling Medicare Part D for 
dispensed doses.   
 
VermontAfter it self-disclosed conduct to OIG, Visiting Nurse Association and Hospice of 
Vermont and New Hampshire, Inc. (VNH), agreed to pay $2,389,706.26 for allegedly 
violating the CMPL.  OIG alleged that VNH submitted claims for home health services 
based on orders signed by a qualified clinician but not cosigned by a physician or allowed 
practitioner. 
 
IndianaAfter it self-disclosed conduct to OIG, Advanced OrthoPro Inc. (AOP) agreed to 
pay $7,191,730.77 for allegedly violating theCMPL.  OIG alleged that AOP submitted false 
claims for DME dispensed at AOP locations not enrolled as DME providers with CMS, where 
the claims were submitted under the enrollment number of an AOP location on North 
Illinois Street in Indianapolis, Indiana. 
 
Corporate Integrity Agreements  
Many health care providers elect to settle their cases before litigation.  As part of the settlements, 
providers often agree to enter into CIAs with OIG to avoid exclusions from Medicare, Medicaid, 
and other Federal health care programs.  Under a CIA, a provider commits to establishing a 
compliance program and taking other specified steps to ensure future compliance with Medicare 
and Medicaid rules.  The compliance programs are designed, in part, to prevent future fraud.  OIG 
monitors providers compliance with these agreements and may impose penalties on parties that 
fail to comply with the requirements of their CIAs. 
 
The following case example involves CIA enforcement: 
 
51 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
Puerto RicoOn December 8, OIG entered a $518,923 CMPL settlement with Walgreen Co.  
Walgreens is under a CIA with OIG that became effective on January 11, 2019.  On June 29, 
2021, Walgreens reported to OIG that it paid improper remuneration to induce referrals in 
violation of the anti-kickback statute and physician self-referral law.  Specifically, Walgreens 
paid remuneration in the form of discounts on retail product purchases at Walgreens 
locations in Puerto Rico to 1,719 health care professionals who wrote prescriptions for items 
filled at Walgreens locations in Puerto Rico that were paid for by a Federal health care 
program. 
 
Public Health and Human Service Agency 
Reports and Reviews  
Public Health Agency Reports and Reviews 
Office of the Secretary 
Two Critical HHS Systems Were Deployed Without Authorizations To Operate, November 2021 
  
Due to the current public health emergency and increased cyberactivity, we are posting only the 
title of our cybersecurity audits. 
 
Office of the Assistant Secretary for Preparedness and Response 
HHSs Suspension and Debarment Program Helped Safeguard Federal Funding, But Opportunities for 
Improvement Exist (OEI-04-19-00570), January 2022  
Most HHS suspension and debarment referrals received between FYs 2015 and 2019 resulted in 
actions to protect Federal funds, but opportunities to improve program timeliness, efficiency, and 
effectiveness exist.  (Suspensions are preliminary, immediate actions that exclude persons from 
receiving new funds.  Debarments are final determinations that exclude persons from receiving 
new funds for a specified time.)  Our findings and recommendations can help the Assistant 
Secretary for Financial Resources (ASFR) strengthen HHSs suspension and debarment program 
and better safeguard Federal funds.   
 
ASFR concurred with all four of our recommendations, which were for it to: (1) take steps to ensure 
that HHSs suspension and debarment program has more consistent senior leadership and 
sufficient staffing, (2) improve the case management and tracking of referrals, (3) develop and 
disseminate guidance regarding how to prepare and submit complete referrals, and (4) conduct 
outreach and provide additional training about the suspension and debarment program to HHS 
awarding agencies that make few or no referrals. 
52 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
 
Food and Drug Administration 
The Food and Drug Administration Needs To Improve Its Contract Closeout Processes To Identify 
Contracts Eligible for Closeout and Close Contracts Timely (A-03-20-03004), December 2021  
FDA did not always identify contracts eligible for closeout and did not always follow FAR 
requirements for closing contracts timely but otherwise generally closed contracts in accordance 
with the FAR, the HHS Acquisition Regulation, and other HHS acquisition policies and procedures.  
FDA did not always identify and close contracts timely because FDA utilized manual processes for 
some contract closeout review functions when an automated process may have been more 
efficient.  In addition, FDA personnel did not always communicate to each other information that 
would have helped identify contracts eligible for closeout, contracting officers and contracting 
officers representatives (CORs) were not required to notify contract closeout specialists that a 
contract was complete, and the CORs change requests were not always submitted before the 
CORs left their positions.  Finally, FDA contract closeout specialists did not have the ability to run 
ad hoc query reports from the Purchase Request Information System, the system that HHS uses to 
formulate, administer, and distribute contract documents.  
 
Because contracts were not always closed timely, FDA may not have identified unused funds that 
could be deobligated and released to another appropriate need.  Specifically, we found that two of 
the contracts that should have been closed had remaining funds of $88,152 that should have been 
deobligated and released to another appropriate need. 
 
FDA agreed with our recommendation that it deobligate $88,152 in contract funding and close the 
six contracts that remain open but eligible for closeout.  We also made several procedural 
recommendations for improving the contract closeout process.  
 
National Institutes of Health 
The National Institutes of Health Administered Superfund Appropriations During Fiscal Year 2020 in 
Accordance With Federal Requirements (A-04-21-04081), October 2021  
During FY 2020, NIH administered Superfund appropriations in accordance with applicable Federal 
requirements.  Specifically, NIH obligated and disbursed Superfund appropriations in accordance 
with Federal requirements and in similar proportions to prior years.  In addition, the Institutes 
monitoring of Superfund grants generally ensured that grantees met requirements for financial, 
performance, and audit reporting.  This report contains no recommendations. 
 
53 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
The National Institutes of Health Could Improve Its Post-Award Process for the Oversight and 
 
Monitoring of Grant Awards (A-03-20-03001), February 2022 
The National Cancer Institutes (NCIs) postaward process for providing oversight and monitoring of 
grants was generally effective in ensuring that grantees met the program objectives and that NCI 
was able to identify potential problems.  However, for 12 of the 20 grants in our sample that were 
closed in FY 2019, the grantee did not submit final reports within 120 days of the end of the period 
of performance as required.  
 
NIHs Division of Grants System Integration (DGSI/Closeout Center) provides outreach on NCIs 
behalf to grantees with respect to the due dates of the final reports within 10 days of the end of the 
period of performance but does not provide another reminder until after the final reports are late. 
This delays the closeout process.  A recipient may draw funds up to the date that its Final Federal 
Financial Report is due to NIH or up to 120 days past the period of performance end date.  
 
If grantees submit final reports late, it could indicate an issue with the grantees ability to comply 
with grant requirements, including accounting for grant funds and tracking the progress and 
outcomes of the grant.  
 
NIH agreed with our recommendation that NCI coordinate with NIHs DGSI/Closeout Center to 
update policies and procedures for monitoring grantees submission of closeout documents to 
include more periodic outreach to grantees before the final reports become delinquent. 
 
Human Services Agency Reports and Reviews 
Administration for Children and Families 
Characteristics of Separated Children in ORRs Care: June 27, 2018November 15, 2020 (OEI-BL-20-
00680), November 2021  
OIG found that 1,178 children were separated from a parent or legal guardian and referred to 
ORRs care between June 27, 2018 (the day after a Federal district court halted most family 
separations) and November 15, 2020 (the date of the most recent complete data available at the 
time of our review).  Separated children were 9 years old on average, with more than a quarter 
under 5 years old; in comparison, non-separated children were 15 years old on average.  Seventy 
percent of separated children referred to ORR had been separated by immigration officials 
because of a parents criminal history, the nature of which varied widely.  Separated children spent 
longer in ORRs care and were less likely than non-separated children to be released to a sponsor.  
Of the 1,178 separated children referred to ORR during the period we reviewed, ORR ultimately 
reunified 182 children (15 percent) with the parent from whom the child was separated.  This data 
brief contains no recommendations. 
 
54 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
Child Care Background Checks 
States that receive funding from the Child Care and Development Fund (CCDF) are required to 
conduct comprehensive criminal background checks on staff members and prospective staff 
members of child care providers every 5 years.  During this reporting period, OIG conducted two 
audits that were designed to assess whether the States monitoring process ensured provider 
compliance with requirements related to criminal background checks established under the Child 
Care and Development Block Grant Act.  Complete recommendations and providers responses can 
be found in the final reports, which are summarized below. 
 
The District of Columbias Monitoring Did Not Ensure Child Care Provider Compliance With Criminal 
Background Check Requirements at 7 of 30 Providers Reviewed (A-03-20-00252), November 2021  
The Districts monitoring process did not ensure provider compliance related to criminal 
background checks for 7 of the 30 child care providers (55 of the 541 individuals requiring 
background checks) we reviewed.  In response to our audit, the District took action and completed 
background checks for 52 of the 55 individuals.  The errors we found occurred because:  
(1) providers did not send the in-State child abuse and neglect (Child Protection Register) check 
results to the District, (2) District law did not allow Child Protection Register check results to be sent 
directly to the District unless the individual was found not to be suitable for employment, and  
(3) processing delays resulted in incomplete FBI fingerprint checks and inter-State checks.  To 
ensure the safety of children at these child care providers, the District needs to strengthen its 
process for conducting criminal background checks for all individuals who supervise or have 
routine unsupervised contact with children. 
 
Louisianas Monitoring Did Not Ensure Child Care Provider Compliance With Criminal Background 
Check Requirements at 8 of 30 Providers Reviewed (A-06-19-02001), December 2021  
Louisianas monitoring process did not ensure provider compliance with State requirements for 
criminal background checks at 8 of the 30 child care provider locations we reviewed.  We found 
that 15 of the 264 individuals requiring a background check did not have 1 or more of the required 
criminal background checks by the required deadlines.  
 
The providers did not initiate a timely background check request for these 15 individuals.  Because 
the State agency relies on child care providers to initiate the background check process, it was 
unaware that these individuals were lacking required background checks.  As a result, the safety 
and well-being of children were potentially at risk.  
 
55 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
Office of Refugee Resettlement Generally Ensured That Selected Care Provider Facilities for Its 
Unaccompanied Children Program Complied With Federal Emergency Preparedness Requirements 
(A-04-20-02025), February 2022  
The Office of Refugee Resettlement (ORR) ensured that the 10 selected facilities generally complied 
with Federal requirements in preparing for and responding to emergency events.  Each of the 10 
facilities complied with most Federal emergency preparedness requirements, such as having 
written safety plans that addressed evacuations during emergency events.  However, none of the 
selected facilities complied with the Federal requirement to maintain a complete list of emergency 
contacts to notify when a childs location changes due to an emergency evacuation.  Without a 
complete emergency contact list, and because ORRs monitoring did not identify this 
noncompliance with a Federal requirement, facilities were at risk of failing to fully protect childrens 
interests in the event of a future emergency.  
 
ACF neither agreed nor disagreed with our recommendation that ORR issue guidance to ORR 
facilities regarding the requirement to include all relevant ORR and Department of Homeland 
Security contacts in their emergency contact lists. 
 
Substance Abuse and Mental Health Services Administration 
SAMHSAs Oversight Generally Ensured That the Commission on Accreditation of Rehabilitation 
Facilities Verified That Opioid Treatment Programs Met Federal Opioid Treatment Standards (A-09-
20-01002), October 2021  
SAMHSAs oversight generally ensured that the Commission on Accreditation of Rehabilitation 
Facilities (CARF) verified that opioid treatment programs (OTPs) met Federal opioid treatment 
standards.  As part of its oversight activities, SAMHSA: (1) reviewed CARFs renewal application, 
which included CARFs policies and procedures and accreditation elements; (2) inspected a selected 
sample of OTPs that CARF accredited and surveyed; and (3) reviewed accreditation reports 
submitted by CARF.  In addition, SAMHSAs oversight ensured that CARFs survey teams met 
Federal requirements.  Specifically, SAMHSAs review of CARFs renewal application included a 
review of CARFs policies and procedures for: (1) hiring surveyors with required education and 
experience, (2) training provided to surveyors, (3) selecting surveyors for each survey, and (4) 
avoiding conflicts of interest. 
 
SAMHSA could improve its oversight to ensure that CARFs records contain sufficient detail to 
support each accreditation decision made by CARF.  SAMHSAs policies and procedures did not 
require verification that accreditation bodies (including CARFs) records contained sufficient detail 
supporting each accreditation decision.  Not reviewing an accreditation bodys records to 
determine whether they contain sufficient detail could make it difficult for SAMHSA to determine 
whether accreditation decisions are supported and to effectively evaluate the accreditation bodys 
performance. 
 
56 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
SAMHSA concurred with our recommendation that it update its policies and procedures to require 
verification that accreditation bodies maintain records that contain sufficient detail to support each 
accreditation decision. 
 
Texas Did Not Ensure Documentation Supported That Individuals Met Eligibility Requirements and 
That Its Annual Report Was Accurate Under Its Projects for Assistance in Transition From 
Homelessness Program (A-02-21-02001), February 2022 
Texas complied with Projects for Assistance in Transition From Homelessness (PATH) program 
requirements related to certain program costs and non-Federal contributions.  However, it did not 
always comply with PATH program requirements when determining consumers eligibility and 
reporting the number of consumers enrolled in its PATH program.  In addition, Texas overstated 
the number of consumers enrolled in its PATH program in its Annual PATH Reports.  
  
These deficiencies occurred because Texas lacked adequate oversight to ensure that PATH 
providers maintained sufficient documentation to support that consumers met eligibility 
requirements to enroll in the PATH program.  In addition, Texas did not ensure that PATH 
providers reported accurate enrollment data for the State agencys annual PATH reports to 
SAMHSA.  On the basis of our sample results, we estimated that 1,001 consumers (10 percent) 
enrolled in Texas PATH program were ineligible to enroll in the Texas PATH program.  
  
Texas did not indicate concurrence or nonconcurrence with our recommendations that it:  
(1) expand the scope of its site visits of PATH providers to include reviews of consumers case files 
maintained by PATH providers to strengthen its current risk assessment process and ensure that 
providers only enroll eligible individuals into the PATH program and (2) work with relevant parties 
to provide guidance and training to PATH providers to ensure that its Annual PATH Report 
accurately represents the number of consumers served by its PATH program. 
 
Legal and Investigative Activities Related to 
Public Health and Human Service Agencies 
Health Education Assistance Loan Program Exclusions 
OIG excludes from Federal health care programs individuals who have defaulted on Health Education 
Assistance Loan (HEAL) loans.  Under the HEAL program, which stopped making loans in 1998, HRSA 
guaranteed commercial loans to students seeking education in health-related fields.  The students can 
defer repayment of the loans until after they graduate and begin to earn income.  Although HHSs 
Program Support Center (PSC) takes steps to ensure repayment, some loan recipients do not resolve their 
debt.  After PSC has exhausted efforts to secure repayment of a debt, it declares an individual in default.  
57 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
The Social Security Act permits that thereafter, such individuals may not receive reimbursement under 
Medicare, Medicaid, and all other Federal health care programs for nonpayment of the loans. 
 
Currently, there is a moratorium on collection activities.  Accordingly, PSC is not referring any individuals in 
default at this time.  Therefore, OIG has no figures to report for this semiannual reporting period.  
 
Child Support Enforcement Activities 
OIG Investigations 
OIG investigates noncustodial parents who violate 18 U.S.C.  228 by failing to pay court-ordered 
child support.  OIG works with ACFs Office of Child Support Enforcement; DOJ; U.S. Attorneys 
Offices; the U.S. Marshals Service; and Federal, State, and local partners to address egregious child 
support enforcement cases with appropriate law enforcement and prosecutorial action.  During this 
semiannual reporting period, OIG investigations of child support enforcement cases nationwide 
resulted in 1 criminal action and court-ordered restitution and settlements of $79,079.   
 
The following case example involves child support enforcement:  
 
South DakotaOn December 3, 2021, Jacob A. Tate was sentenced to 5 years of probation, 
ordered to pay $78,979.14 in restitution to the South Dakota Department of Social Services, 
Office of Child Support Enforcement, and a special assessment to the Federal Crime Victims 
Fund in the amount of $100.  The conviction stemmed from Tates failure to pay child 
support from on or about October 1, 2012, through June 6, 2018.  Tate has five children 
who live in South Dakota.  Tate knew that a support order had been issued against him to 
pay child support, but he willfully did not make payments toward the child support.  
 
 
Engaging the Public in Capturing Deadbeat Parents 
Because of the success of OIGs Most Wanted Fugitives website, OIG launched its Most Wanted 
Deadbeat Parents website.  The site identifies parents who fail to pay court-ordered child support 
for their children and thereby put an unnecessary strain on the custodial parents and the children 
as well as on agencies that enforce these matters.  The site, which is updated frequently, includes 
information on OIGs role in pursuing parents who fail to pay court-ordered child support.  OIGs 
Most Wanted Deadbeat Parents website can be found at https://oig.hhs.gov/fraud/child-support-
enforcement/index.asp. 
 
 
58 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
Other HHS-Related Reviews and Investigative 
Activities 
General Departmental 
U.S. Department of Health and Human Services Met the Requirements of the Digital Accountability 
and Transparency Act of 2014, With Areas That Require Improvement (A-17-21-54000), October 2021  
Our performance audit determined that HHS implemented and used Governmentwide financial 
data standards and complied with the reporting requirements of the Digital Accountability and 
Transparency Act of 2014 (DATA Act) as stipulated by the Office of Management and Budget 
(OMB) and Treasury.  HHSs overall data quality earned a rating of Excellent based on the areas we 
tested, indicating that HHSs data were generally reliable.  Although HHS met the reporting 
requirements, our performance audit determined that:  
 
  Although progress was noted from the FY 2020 DATA Act audit and compensating controls 
were identified, we continue to recommend that management address certain control 
deficiencies identified within HHS information technology systems that house the source 
data utilized as part of the reporting of the DATA Act.  
 
  Ernst & Young identified the following: (1) 21 accuracy exceptions for data element 26, the 
period of performance start date; (2) 10 accuracy exceptions for data element 27, the 
period of performance end date; and (3) 5 accuracy exceptions for data element 28, the 
period of performance potential end date.  In the 36 period of performance exceptions, the 
information in Files D1/D2 did not agree with the supporting documentation provided. 
 
We recommend that HHS focus on refreshing the OpDivs understanding of Departmental 
guidance and identifying those areas for which OpDiv training would be developed to prevent and 
detect future accuracy issues related to the performance dates.  
 
The Office of Intergovernmental and External Affairs Needs To Improve Internal Controls Over Its 
Travel Card Program (A-03-19-00501), November 2021  
During our audit period, IEAs travel card program did not always comply with Federal 
requirements.  Specifically, 58 of the 114 travel transactions selected for review did not comply.  IEA 
also did not have signed HHS Traveler Agreements for 17 of the 40 employees who had travel card 
activity during FY 2018.  Of these 17 cardholders, 2 did not complete the required travel card 
training course.  
 
59 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
These deficiencies occurred because IEA had a high staff turnover rate and IEAs internal controls 
were not adequate to ensure that staff, approving officials, and travel card Program Coordinators 
understood and executed their responsibilities.  
 
For the FY 2017 transactions that we reviewed, IEA incurred $7,657 in invitational travel 
expenditures that may have constituted misuse.  (Invitational travel allows individuals not employed 
by the Federal Government or appointed as consultants or experts to confer on Government 
business.)  In addition, on the basis of our sample results, we estimate that in FY 2018, IEA and its 
employees may have incurred $50,046 in travel expenditures that constituted misuse or that were 
otherwise unallowable.  
 
We made several procedural recommendations, including that IEA develop and distribute to staff a 
quick reference document that includes key staff responsibilities and requirements to ensure that 
travel card transactions comply with the Federal Travel Regulation and the HHS Travel Policy 
Manual.  We also recommend that IEA establish an oversight program for travel transactions. The 
detailed recommendations are in the report.  IEA did not indicate concurrence or nonconcurrence 
with our recommendations. 
 
Financial Statement Audit of the Department of Health and Human Services for Fiscal Year 2021 
(A-17-21-00001), November 2021 
Based on its audit, Ernst & Young found that the FY 2021 HHS consolidated balance sheets and the 
related consolidated statements of net cost and changes in net position and combined statements 
of budgetary resources were presented fairly, in all material respects, in conformity with U.S. 
generally accepted accounting principles.  Ernst & Young was unable to obtain sufficient audit 
evidence for the amounts presented in the statements of social insurance as of January 1, 2021, 
2020, 2019, 2018, and 2017, and the related statements of changes in social insurance amounts for 
the periods ended January 1, 2021, and 2020.  As a result, Ernst & Young was not able to, and did 
not, express an opinion on the financial condition of the HHS social insurance program and related 
changes in the social insurance program for the specified periods.  
 
Ernst & Young also noted two matters involving internal controls with respect to financial 
reporting.  Under the standards established by the American Institute of Certified Public 
Accountants and Government Auditing Standards, issued by the Comptroller General of the United 
States, Ernst & Young did not identify any deficiencies in internal control that it considered a 
material weakness.  Ernst & Young noted improvements over internal controls but continued to 
identify two significant deficiencies related to HHSs Financial Information Systems and HHSs 
Financial Reporting Systems, Analyses, and Oversight.  Ernst & Young also reported that HHS did 
not comply with the Payment Integrity Information Act (P.L. No. 116-117), identified potential 
violations of the Anti-Deficiency Act (P.L. No. 101-508), and determined that HHS did not adjudicate 
Medicare appeals within the time frames requirements by the Social Security Act (P.L. No. 74-271). 
  
60 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
The Assistant Secretary for Administration Awarded and Managed Five Sole Source Contracts for 
COVID-19 Testing in Accordance With Federal and Contract Requirements (A-05-21-00014), January 
2022  
The Assistant Secretary for Administration (ASA) awarded and managed five sole source COVID-19 
testing contracts, totaling $1.8 billion, in accordance with Federal regulations and contract 
requirements. Specifically, ASA complied with sole source justification requirements when awarding 
the contracts and set reasonable payment rates for COVID-19 tests in accordance with Federal 
regulations.  ASA appropriately managed the contracts by establishing and maintaining ongoing 
communications with contractors, by verifying that laboratory result numbers matched the number 
of tests administered, and by reviewing invoices to ensure payment rates were in accordance with 
the contract terms and conditions.  This report contains no recommendations. 
 
Drug Control Attestation Reports 
 
Federal law and the ONDCP Circular National Drug Control Program Agency Compliance Reviews, 
dated September 9, 2021 (ONDCP Compliance Reviews Circular), require OIG to conduct reviews of 
OpDivs drug control activities.  During this reporting period, OIG conducted two such audits, 
which are summarized below.  
 
Independent Attestation Review: Centers for Medicare & Medicaid Services Fiscal Year 2021 Detailed 
Accounting Submission and Budget Formulation Compliance Report for National Drug Control 
Activities, and Accompanying Required Assertions (A-03-22-00351), January 2022  
This report provides the results of our review of the CMS Office of National Drug Control Policy 
(ONDCP) Detailed Accounting Report, which includes the table of Drug Control Obligations, 
related disclosures, and managements assertions for the fiscal year ended September 30, 2021.  
We also reviewed the Budget Formulation Compliance Report, which includes budget formulation 
information for the fiscal year ending September 30, 2023, and the Chief Financial Officers or 
accountable senior executives assertions relating to the budget formulation information.  
 
Based on our review, we are not aware of any other material modifications that should be made to 
CMSs Detailed Accounting Report for FY 2021 and CMSs Budget Formulation Compliance Report 
for FY 2023 for them to be in accordance with the ONDCP Compliance Reviews Circular. 
 
Independent Attestation Report: Food and Drug Administration Budget Formulation Compliance 
Report and Detailed Accounting Submission for Fiscal Year 2021 National Drug Control Activities, and 
Accompanying Required Assertions (A-03-22-00352), January 2022  
This report provides the results of our review of the FDA ONDCP Budget Formulation Compliance 
Report, which includes budget formulation information for the fiscal year ending September 30, 
2023, and the Chief Financial Officers or accountable senior executives assertions relating to the 
budget formulation information.   
61 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
 
We also received FDAs ONDCP Detailed Accounting Report and managements assertions for the 
fiscal year ended September 30, 2021.  FDA did not provide this report in sufficient time for OIG to 
review and authenticate the report.  Accordingly, we do not express a conclusion about the 
reliability of managements assertions.  
 
Based on our review, FDA did not conform in all material respects to the ONDCP Compliance 
Reviews Circular.  Specifically, FDA did not provide a timely ONDCP Detailed Accounting Report for 
the fiscal year ended September 30, 2021.  Except for this deficiency, we are not aware of any 
material modifications that FDA should make to be in accordance with the ONDCP Compliance 
Reviews Circular. 
 
Grants and Contracts 
HHS is the largest grant-making organization and one of the largest contracting agencies in the Federal 
Government.  In FY 2019, HHS awarded more than $531 billion in grants and more than $39 billion in 
contracts across all program areas.  OIGs direct annual discretionary appropriation funding is used to 
conduct program integrity and enforcement activities with regard to the more than 100 public health and 
human services programs carried out by more than 80,00 employees worldwide.  The size and scope of 
departmental awards make their operating effectiveness crucial to the success of programs designed to 
improve the health and well-being of the public. 
 
Grant Fraud Investigations 
The following case example relates to misuse of grant funds:  
  
WisconsinOn October 29, 2021, Fredericka DeCoteau was sentenced to 2 years in prison 
and Edith Schmuck was sentenced to 1 year and 1 day in prison for theft of Federal 
program funds.  DeCoteau and Schmuck were also ordered to jointly pay restitution of 
$777,283.  DeCoteau and Schmuck worked at Ain Dah Ing (ADI) which has operated as a 
nonprofit halfway house in Spooner, Wisconsin, since 1971.  DeCoteau worked as the 
Executive Director at ADI from 2002 to 2017.  Schmuck worked as the bookkeeper from 
1990 to 2017.  Both DeCoteau and Schmuck pleaded guilty to embezzling a total of 
$777,283 from ADI by paying themselves unauthorized bonuses via payroll checks that 
were signed using a rubber signature stamp of the ADI Treasurer.  The embezzlement 
lasted from 2007 to 2017.         
 
Recovery Act Retaliation Complaint Investigations  
The Recovery Act,  1553, prohibits non-Federal employers that have received Recovery Act 
funding from retaliating against employees who disclose evidence of mismanagement of Recovery 
Act funds or any violation of law related to Recovery Act funds.  OIGs are required to include in 
62 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
their Semiannual Report the retaliation complaint investigations that they decided not to conduct 
or continue during the reporting period.  During this semiannual reporting period, OIG did not 
close, decline, or give extensions on Recovery Act Retaliation Complaint investigations of 
whistleblower retaliation. 
 
Contract Audits 
Pursuant to the National Defense Authorization Act for FY 2008,  845, OIGs appointed under the 
Inspector General Act of 1978 are required to submit information on final completed contract audit 
reports issued during the period to the contracting activity as part of their semiannual report, 
pursuant to section 5 of the Inspector General Act.  This information must contain significant audit 
findings.  OIG issued no final reports meeting  845 criteria during this semiannual reporting 
period. 
 
OIG Reviews of Non-Federal Audits  
OIG reviews audits conducted by non-Federal auditors of entities receiving Federal awards.  During 
this semiannual reporting period, OIGs National External Audit Review Center reviewed 157 reports 
covering $579.1 billion in audited costs.  Federal dollars covered by these audits totaled 
$203.8 billion, of which about $90.3 billion were HHS funds. 
Uniform guidance at 2 CFR 200 Subpart F establishes audit requirements for State and local 
governments, colleges and universities, and nonprofit organizations receiving Federal 
awards.  Under the uniform guidance, covered entities must conduct annual organizationwide 
single audits of all Federal money they receive.  These audits are conducted by non-Federal 
auditors, such as public accounting firms and State auditors.  OIG reviews the quality of these 
audits and assesses the adequacy of the entities management of Federal funds. 
OIGs oversight of non-Federal audit activity informs Federal managers about the soundness of 
management of Federal programs and identifies any significant areas of internal control weakness, 
noncompliance, and questioned costs for resolution or followup.  We identify entities for high-risk 
monitoring, alert program officials to any trends that could indicate problems in HHS programs, 
and profile non-Federal audit findings of a particular program or activity over time to identify 
systemic problems.  We also provide training and technical assistance to grantees and members of 
the auditing profession.  OIG maintains a process to assess the quality of the non-Federal reports 
received and the audit work that supports the selected reports. 
OIGs reports on non-Federal audits reviewed during this reporting period are categorized in the 
following table. 
 
Non-Federal Audits, October 1, 2021, Through March 31, 2022 
 
63 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
Not requiring changes or having minor changes   117 
Requiring major changes  6 
Having significant technical inadequacies  34 
Total Number of Non-Federal Audits  157 
 
Other Reporting Requirements and Reviews  
Legislative and Regulatory Reviews  
Pursuant to the Inspector General Act,  4(a)(2), OIG is required to review existing and proposed 
legislation and regulations relating to HHSs programs and operations and make recommendations 
concerning their impact on economy and efficiency or the prevention and detection of fraud and 
abuse.  Most audits and other reviews that we conduct are designed to test compliance with 
and/or assess the administration and oversight of existing laws and regulations.  Our reports of 
such reviews describe findings, which include questioned costs, inefficiencies, vulnerabilities to 
fraud, inconsistencies, errors in application, or weaknesses in oversight or supporting systems.  Our 
corresponding recommendations tell HHS and its OpDivs or staff divisions (StaffDivs) what 
administrative, regulatory, or legislative actions we believe are needed to effectively respond to the 
findings.  Our regularly published core publications reflect the relationship between our work and 
laws and regulations. 
 
  This report, like our previous Semiannual Reports to Congress, describes findings and 
recommendations from recently completed reviews, many of which focus on existing laws and 
regulations.   
  Our Solutions To Reduce Fraud, Waste, and Abuse in HHS Programs: OIGs Top 
Recommendations describes priority findings and recommendations from past periods that 
remain to be implemented.   
  Our Work Plan provides citations to laws and regulations that are the subject of ongoing or 
future reviews. 
 
We also review proposed legislation and regulations related to HHS programs and operations.  In 
addition, we provide independent, objective technical assistance on a bipartisan, bicameral basis to 
congressional committees and members who request it. 
   
64 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
Appendix A: Questioned Costs and Funds To 
Be Put to Better Use 
The following tables summarize OIGs monetary recommendations and HHS responses to them.  This 
information is provided in accordance with the Inspector General Act,  5(a)(8) and (a)(9) (5 U.S.C. App.  
5(a)(8) and (a)(9)), and the Supplemental Appropriations and Rescissions Act of 1980.  
 
Audit Reports With Questioned Costs 
As defined by the Inspector General Act, the term questioned cost means a cost that is questioned by 
OIG because of: (1) an alleged violation of a provision of law, regulation, contract, grant, cooperative 
agreement, or other agreement or document governing the expenditure of funds; (2) a cost that is not 
supported by adequate documentation at the time of the audit; or (3) the expenditure of funds for the 
intended purpose is unnecessary or unreasonable.  Questioned costs that HHS program officials have, in a 
management decision, sustained or agreed, should not be charged to the Government are disallowed 
costs.  Superscripts indicate end notes that follow the tables below. 
 
Table 1: Audit Reports With Questioned Costs 
Number of  Dollar Value  Dollar Value 
Description  Reports  Questioned  Unsupported 
Section 1          
Reports for which no management decisions had been 
made by the beginning of the reporting period1  70  $2,578,509,000  $848,834,000 
Issued during the reporting period  15  $1,560,533,000  $1,060,659,000 
Total Section 1  85  $4,139,042,000   $1,909,493,000 
Section 2        
Reports for which management decisions were made 
during the reporting period2, 3        
Disallowed costs  37  *$1,136,191,000  $34,849,000 
Costs not disallowed  12  $1,320,759,000  $813,862,000 
Total Section 2  49  $2,456,950,000  $848,711,000 
* Audit receivables (expected recoveries)       
Section 3       
Reports for which no management decisions had been 
made by the end of the reporting period 
(Section 1 minus Section 2)  36  $1,682,092,000  $1,060,782,000 
Section 4       
Reports for which no management decisions were made   
within 6 months of issuance4  22  $519,290,000  $123,000 
65 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
 
Table 1 End Notes 
1 The opening balance was adjusted upward by $493.4 million because of a reevaluation of previously 
issued recommendations.  
2 Revisions to previously reported management decisions: 
  A-09-02-00054, Audit of State of California DSH Program for FY 1998.  CMS subsequent review of 
the State plan determined that disallowed cost should be reduced by $33,319,000. 
 
  A-05-09-00021, Review of Indiana's Reporting Fund Recoveries for Federal and State Programs on 
the CMS-64.  CMS subsequent review of supporting documentation determined that overpayments 
totaled $11,758,489, reducing disallowed cost by $27,100,000. 
 
  A-02-10-01042, New Jersey Claimed Excessive Medicaid Disproportionate Share Hospital Payments 
to Four Hospitals.  CMS subsequent review of the State plan determined that disallowed cost 
should be reduced by $22,005,000. 
 
  A-09-01-00098, Audit of Kern Medical Center Disproportionate Share Hospital Payments for FY 1998.  
CMSs subsequent review of State Plan language determined that disallowed cost should be 
reduced by $14,166,000. 
 
  Not detailed are reductions to previously disallowed management decisions totaling $14.2 million. 
3 Included are management decisions to disallow $41,000 in questioned costs that were identified by non-
Federal auditors in audits of State and local governments, colleges and universities, and nonprofit 
organizations receiving Federal awards conducted in accordance with OMB Circular A-133.  OIG is currently 
ensuring that work performed by these non-Federal auditors complies with Federal audit standards; 
accordingly, OIG tracks, resolves, and reports on recommendations in these audits. 
4 Because of administrative delays, some of which were beyond management control, resolution of the 
following 22 audits were not completed within 6 months of issuance of the reports; however, agency 
management has informed us that the agency is working to resolve the outstanding recommendations 
before the end of the next semiannual reporting period. 
 
Audits Not Completed Within 6 Months of Issuance 
Audit CIN  Audit Title 
A-07-16-01165  Medicare Advantage Compliance Audit of Diagnosis Codes That Humana, Inc. 
(Contract H1036), Submitted to CMS, APR 2021, $197,720,651 
A-02-14-02017  New York Misallocated Costs to Establishment Grants for a Health Insurance 
Marketplace, NOV 2016, $149,654,512 
A-01-14-02503  Maryland Misallocated Millions to Establishment Grants for a Health Insurance 
Marketplace, MAR 2015, $28,400,000 
66 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
A-04-14-07050  Kentucky Misallocated Millions to Establishment Grants for a Health Insurance 
Marketplace, FEB 2017, $25,530,429 
A-07-18-04111  Mississippi Needs To Improve Oversight of Its Child Care Payment Program, 
APR 2020, $22,284,900 
A-02-15-02008  New York Did Not Comply With Federal Grant Requirements for Allocating and 
Claiming Marketplace Contract Costs, DEC 2017, $20,415,344 
A-07-15-04226  Not All of Missouri's Child Care Subsidy Program Payments Complied With Federal 
and State Requirements, NOV 2017, $19,076,167 
A-02-18-01028  Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Blue Cross 
Blue Shield of Michigan (Contract H9572) Submitted to CMS, FEB 2021, $14,534,375 
A-06-17-07004  Southwest Key Programs Failed To Protect Federal Funds Intended for the Care and 
Placement of Unaccompanied Alien Children, SEP 2020, $13,130,848 
A-01-15-02500  Vermont Did Not Properly Allocate Millions to Establishment Grants for a Health 
Insurance Marketplace, SEP 2016, $11,243,006 
A-07-19-05117  Medicare Made Millions of Dollars in Overpayments for End-Stage Renal Disease 
Monthly Capitation Payments, MAY 2021, $3,963,618 
A-07-19-01187  Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Anthem 
Community Insurance Company, Inc. (Contract H3655) Submitted to CMS, 
MAY 2021, $3,468,954 
A-02-16-02013  The Children's Village Inc., an Administration for Children and Families Grantee, Did 
Not Always Comply With Applicable Federal and State Policies and Requirements, 
APR 2019, $2,623,785 
A-07-17-02808  The Colorado Health Insurance Marketplaces Financial Management System Did 
Not Always Comply With Federal Requirements, JUL 2018, $2,567,604 
A-07-11-06013  The University of Colorado Denver Did Not Always Claim Selected Costs Charged 
Directly to Department of Health and Human Services Awards in Accordance With 
Federal Regulations, JUN 2013, $1,419,524 
A-05-14-00045  The Minnesota Marketplace Misallocated Federal Funds and Claimed Unallowable 
Costs, NOV 2016, $1,279,677 
A-02-18-02011  Gateway Community Action Partnership Claimed Unallowable Costs, Did Not 
Comply With Federal Regulations on Construction and Major Renovations, and Did 
Not Accurately Account for Grant Funds, MAY 2021, $932,907 
A-09-14-01007  Nevada Misallocated Costs for Establishing a Health Insurance Marketplace to Its 
Establishment Grants, FEB 2016, $893,464 
A-03-19-00002  Audit of Medicare Part D Pharmacy Fees: Group Health Cooperative, Inc., JUL 2021, 
$122,583 
A-03-16-00250  Youth for TomorrowNew Life Center, Inc., an Administration for Children and 
Families Grantee, Did Not Comply With All Applicable Federal Policies and 
Requirements, SEP 2020, $16,851 
A-04-18-02010  Florida's Refugee Medical Assistance Payments Were Generally Allowable, 
JAN 2020, $8,772 
A-05-18-00015  The University of Minnesota Complied With Federal Requirements To Perform Risk 
Assessments and Monitor Subrecipients, NOV 2019, $1,924 
67 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
TOTAL CINS: 22 
TOTAL AMOUNT: $519,290,000 
 
 
Audit Reports With Funds Recommended To Be Put to Better Use 
The phrase recommendations that funds be put to better use means that funds could be used more 
efficiently if management took action to implement an OIG recommendation through reductions in 
outlays, de-obligation of funds, and/or avoidance of unnecessary expenditures.  Table 2 reports HHS 
program officials decisions to take action on these audit recommendations.   
 
Table 2: Audit Reports With Funds Put to Better Use 
Number of 
Description  Reports  Dollar Value 
 
Section 1   
Reports for which no management decisions had been made by the 
beginning of the reporting period  8  $16,271,900,000 
Reports issued during the reporting period  4  $1,157,914,000 
Total Section 1  12  $17,429,814,000 
Section 2     
Reports for which management decisions were made during the 
reporting period     
Value of recommendations agreed to by management     
Based on proposed management action  2  $162,095,000 
Based on proposed legislative action  0  $0 
Value of recommendations not agreed to by management  1  $20,351,000 
Total Section 2  3  $182,446,000 
Section 3     
Reports for which no management decisions had been made by the 
end of the reporting period1 (Sec. 1Sec. 2)  9  $17,247,368,000 
 
Table 2 End Notes 
1 Because of administrative delays, some of which were beyond management control, five of the nine audits open at 
end of the period were not resolved within 6 months of issuance of reports.  OIG is working with management to 
reach resolution on these recommendations before the end of the next semiannual reporting period. 
 
 
Audits Open at End of the Period 
Audit CIN  Audit Title 
68 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
A-05-12-00020  Medicare and Beneficiaries Could Save Billions If CMS Reduces Hospital Outpatient 
Department Payment Rates for Ambulatory Surgical Center-Approved Procedures 
to Ambulatory Surgical Center Payment Rates, APR 2014, $15,000,000,000 
A-03-17-00010  Hospitals Overbilled Medicare $1 Billion By Incorrectly Assigning Severe Malnutrition 
Diagnosis Codes To Inpatient Hospital Claims, JUL 2020, $1,024,623,449 
A-03-13-03002  HHS Did Not Identify and Report Antideficiency Act Violations, MAY 2017, 
$49,445,025 
A-07-17-01176  Incorrect Acute Stroke Diagnosis Codes Submitted by Traditional Medicare Providers 
Resulted in Millions of Dollars in Increased Payments to Medicare Advantage 
Organizations, SEP 2020, $14,417,533 
A-09-18-03030  Medicare Incorrectly Paid Providers for Emergency Ambulance Transports From 
Hospitals to Skilled Nursing Facilities, SEP 2019, $968,718 
TOTAL CINS: 5 
TOTAL AMOUNT: $16,089,455,000 
 
 
 
 
 
 
 
 
 
   
69 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
Appendix B: Peer Review Results 
The Inspector General Act of 1978, as amended, requires OIGs to report the results of peer reviews of their 
operations conducted by other OIGs, the date of the last peer review, outstanding recommendations from 
peer reviews, and peer reviews conducted by an OIG of other OIGs in the semiannual reporting period.  
Peer reviews are conducted by member organizations of the Council of the Inspectors General on Integrity 
and Efficiency (CIGIE).   
 
Office of Audit Services  
During this semiannual reporting period, no peer reviews involving OAS were completed.  Information 
concerning OASs peer review activity during prior reporting periods are listed below. 
 
 
OAS  Date  Reviewing Office  Office Reviewed 
 
September 2021  HHS-OIG, OAS  U.S. Department of the 
 
Treasury (Treasury) OIG 
The system of quality control for the audit organization of Treasury OIG in effect for the year 
ending March 31, 2021, has been suitably designed and complied with to provide Treasury OIG 
with reasonable assurance of performing and reporting in conformity with applicable professional 
standards in all material respects.  Federal audit organizations can receive a rating of Pass, Pass 
With Deficiencies, or Fail.  Treasury OIG received a peer review rating of Pass. 
 
OAS  Date  Reviewing Office  Office Reviewed 
March 2021  General Services  HHS-OIG, OAS 
Administration OIG 
The system of quality control for the audit organization of HHS-OIG in effect for the year ending 
September 30, 2020, has been suitably designed and complied with to provide HHS-OIG with 
reasonable assurance of performing and reporting in conformity with applicable professional 
standards in all material respects.  Federal audit organizations can receive a rating of Pass, Pass 
With Deficiencies, or Fail.  HHS-OIG received a peer review rating of Pass. 
 
Office of Investigations 
During this semiannual reporting period, no peer reviews involving OI were completed.  Listed below is 
information concerning OIs peer review activities during prior reporting periods. 
   
 
70 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
OI  Date  Reviewing Office  Office Reviewed 
  October 2018  SSA OIG  HHS-OIG, OI 
The system of internal safeguards and management procedures for the investigative function of 
HHS-OIG in effect for the year ending September 30, 2018, was in full compliance with the quality 
standards established by CIGIE and the Attorney Generals guidelines. 
 
OI  Date  Reviewing Office  Office Reviewed 
  August 2017  HHS-OIG, OI  U.S. Postal Service OIG 
The system of internal safeguards and management procedures for the investigative function of 
the U.S. Postal Service OIG in effect for the year ending September 30, 2015, was in full compliance 
with the quality standards established by CIGIE and the Attorney Generals guidelines.  
 
Office of Evaluation and Inspections 
During this semiannual reporting period, no peer reviews involving OEI were completed.  Information 
concerning OEIs peer review activity during a prior reporting period is also listed below. 
 
OEI  Date  Reviewing Office  Office Reviewed 
November 2020  Department of State,  HHS-OIG, OEI 
OIG 
A CIGIE external peer Review Team assessed the extent to which HHS-OIG, OEI met seven Quality 
Standards for Inspection and Evaluation (Blue Book) standards.  The seven covered standards are: 
Quality Control, Planning, Data Collections and Analysis, Evidence, Records Maintenance, 
Reporting, and Followup.  The assessment included a review of OEIs internal policies and 
procedures documented in the OEI procedures manual.  It also included a review of four reports 
issued between June 1, 2019, and June 1, 2020, to determine whether the reports compiled with the 
seven standards and internal policies and procedures.  The Review Team determined that OEIs 
policies and procedures generally met the seven standards.  The four reports reviewed generally 
met the standards and complied with OEIs internal policies and procedures.  
 
 
OEI  Date  Reviewing Office  Office Reviewed 
  June 2020  HHS-OIG, OEI  Department of Veterans Affairs 
  (VA) OIG 
The Veterans Affairs, Office of Inspector General, Office of Audits and Evaluations and Office of 
Healthcare Inspections (collectively VA-OIG) policies and procedures addressed the Quality 
Standards for Inspection and Evaluation of CIGIE.  The seven covered standards are: Quality 
Control, Planning, Data Collections and Analysis, Evidence, Records Maintenance, Reporting, and 
71 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
Followup.  In addition, each of the four reviewed VA-OIG reports complied with those standards 
and the VA-OIGs internal policies and procedures.  As a result of our findings, there are no 
recommendations associated with this external peer review.  The report also noted a VA-OIG 
beneficial practice of using specialized staff to conduct independent referencing reviews of its 
reports to achieve greater consistency in its quality assurance processes. 
 
 
OEI  Date  Reviewing Office  Office Reviewed 
September 2019  HHS-OIG, OEI  U.S. Department of Interior 
(DOI) OIG 
The DOI OIG Inspection and Evaluation components policies and procedures mostly met CIGIEs 
Blue Book standards.  We reviewed four reports: two fully met the applicable Blue Book standards 
and two did not.  DOI OIG concurred with recommendations related to Evidence, Planning, and 
Data Collection and Analysis but did not concur with recommendations related to Reporting. 
 
 
OEI  Date  Reviewing Office  Office Reviewed 
September 2018  HHS-OIG, OEI  U.S. Department of Defense 
(DoD) OIG 
The DoD OIG Inspection and Evaluation components policies and procedures generally met 
CIGIEs Blue Book standards.  In addition, the 10 reports reviewed generally met the applicable Blue 
Book standards.  Onsite visits for these reviews were conducted from October 2, 2017, through 
November 17, 2017. 
 
 
72 
 
 
  Department of Health and Human Services, Office of Inspector General 
Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
Appendix C: Summary of Sanction Authorities 
The Inspector General Act of 1978, as amended, specifies requirements for semiannual reports to be made 
to the HHS Secretary for transmittal to Congress.  A selection of other authorities appears below.  
 
Program Exclusions 
The Social Security Act,  1128 (42 U.S.C.  1320a-7), provides several grounds for excluding individuals and 
entities from participation in Medicare, Medicaid, and other Federal health care programs.  Exclusions are 
required (mandatory exclusion) for individuals and entities convicted of the following types of criminal 
offenses: (1) Medicare or Medicaid fraud; (2) patient abuse or neglect; (3) felonies for other health care 
fraud; and (4) felonies for illegal manufacture, distribution, prescription, or dispensing of controlled 
substances.   
 
OIG is authorized (permissive exclusion) to exclude individuals and entities on several other grounds, 
including misdemeanors for other health care fraud (other than Medicare or Medicaid); suspension or 
revocation of a license to provide health care for reasons bearing on professional competence, 
professional performance or financial integrity; provision of unnecessary or substandard services; 
submission of false or fraudulent claims to a Federal health care program; or engaging in unlawful kickback 
arrangements.  
 
The ACA added another basis for imposing a permissive exclusion, that is, knowingly making, or causing to 
be made, any false statements or omissions in any application, bid, or contract to participate as a provider 
in a Federal health care program, including managed care programs under Medicare and Medicaid, as well 
as Medicares prescription drug program.  
 
Providers subject to exclusion are granted due process rights.  These include a hearing before an 
administrative law judge and appeals to the HHS Departmental Appeals Board and Federal district and 
appellate courts regarding the basis for and the length of the exclusion.  
 
Civil Monetary Penalties Law 
The CMPL, found at Section 1128A of the Social Security Act (42 U.S.C.  1320a-7a), authorizes penalties, 
assessments, and exclusion from participation in Federal health care programs for engaging in certain 
activities.  For example, a person who submits, or causes to be submitted, to a Federal health care program 
a claim for items and services that the person knows, or should know, is false or fraudulent is subject to a 
penalty of up to $20,000 for each item or service falsely or fraudulently claimed, an assessment of up to 
three times the amount falsely or fraudulently claimed, and exclusion.  
 
For the purposes of the CMPL, should know is defined to mean that the person acted in reckless 
disregard or deliberate ignorance of the truth or falsity of the claim.  The law and its implementing 
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regulations also authorize actions for a variety of other violations, including submission of claims for items 
or services furnished by an excluded person; requests for payment in violation of an assignment 
agreement; and payment or receipt of remuneration in violation of the anti-kickback statute (42 U.S.C.  
1320a-7b(b)).   
 
The ACA added more grounds for imposing CMPs.  These include, among other types of conduct, 
knowingly making, or causing to be made, any false statements or omissions in any application, bid, or 
contract to participate as a provider in a Federal health care program (including Medicare and Medicaid 
managed care programs and Medicare Part D); the ACA authorizes a penalty of up to $100,000 for each 
false statement (42 U.S.C. 1320a-7a(9)).   
 
The 21st Century Cures Act (enacted on December 13, 2016) added more grounds for imposing CMPs, 
assessments, and exclusion from Federal health care programs for fraudulent conduct in an HHS grant, 
contract, or other agreement.  OIG may assess CMPs of up to $10,000 per claim and assessments of up 
to three times the amount claimed for knowingly presenting a false or fraudulent claim.  In addition, OIG 
may impose a penalty of up to $50,000 and assessments of up to three times the amount of funds at issue: 
(1) for each instance of knowingly making a false statement in a document required to be submitted to 
receive funds under an HHS contract, grant, or other agreement; (2) for knowingly making or using a false 
record or statement that is material to a false or fraudulent claim; and (3) for knowingly making or using a 
false record or statement material to an obligation to pay or transmit funds or property owed to HHS.  OIG 
may impose a penalty of up to $10,000 per day and assessments of up to three times the amount at issue 
for knowingly concealing, or knowingly and improperly avoiding or decreasing, an obligation owed to HHS 
with respect to an HHS grant, contract, or other agreement.  Finally, HHS-OIG may impose a penalty of up 
to $15,000 per day for failing to grant timely access to OIG upon reasonable request for audits or to carry 
out other statutory functions in matters involving an HHS grant, contract, or other agreement.   
 
Patient Dumping 
The Social Security Act, 1867 (42 U.S.C.  1395dd), provides that when an individual goes to the ER of a 
Medicare-participating hospital, the hospital must provide an appropriate medical screening examination 
to determine whether that individual has an emergency medical condition.  If an individual has such a 
condition, the hospital must provide either treatment to stabilize the condition or an appropriate transfer 
to another medical facility.  
 
If a transfer is ordered, the transferring hospital must provide stabilizing treatment to minimize the risks of 
transfer and must ensure that the receiving hospital agrees to the transfer and has available space and 
qualified personnel to treat the individual.  In addition, the transferring hospital must effect the transfer 
through qualified personnel and transportation equipment.  Further, a participating hospital with 
specialized capabilities or facilities may not refuse to accept an appropriate transfer of an individual who 
needs services if the hospital has the capacity to treat the individual.  
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OIG is authorized to collect CMPs of up to $53,484 against small hospitals (fewer than 100 beds) and up 
to $106,965 against larger hospitals (100 beds or more) for each instance in which the hospital negligently 
violated any of the section 1867 requirements.  In addition, OIG may collect a penalty of up to 
$106,965 from a responsible physician for each negligent violation of any of the section 1867 requirements 
and, in some circumstances, may exclude a responsible physician.   
 
Anti-Kickback Statute and Civil False Claims Act Enforcement Authorities 
The Anti-Kickback Statute 
The Federal anti-kickback statute authorizes penalties against anyone who knowingly and willfully 
solicits, receives, offers, or pays remuneration, in cash or in kind, to induce or in return for: (1) 
referring an individual to a person or an entity for the furnishing, or arranging for the furnishing, of 
any item or service payable under the Federal health care programs; or (2) purchasing, leasing, or 
ordering, or arranging for or recommending the purchasing, leasing, or ordering, of any good, 
facility, service, or item payable under the Federal health care programs (Social Security Act,  
1128B(b) (42 U.S.C.  1320a-7b(b)).  
 
Individuals and entities who engage in unlawful referral or kickback schemes may be subject to 
criminal penalties under the general criminal anti-kickback statute; a CMP under OIGs authority 
pursuant to the Social Security Act,  1127(a)(7) (42 U.S.C.  1320a-7a); and/or program exclusion 
under OIGs permissive exclusion authority under the Social Security Act,  1128(b)(7) (42 U.S.C.  
1320a-7(b)(7)).  
 
The False Claims Act 
Under the False Claims Act, as amended by the False Claims Amendments Act of 1986 (31 U.S.C.  
37293733), a person or an entity is liable for up to treble damages and a penalty between 
$11,181 and $22,363 for each false claim it knowingly submits, or causes to be submitted, to a 
Federal program.  Similarly, a person or an entity is liable under the False Claims Act if it knowingly 
makes or uses, or causes to be made or used, a false record or statement to have a false claim 
paid.  The False Claims Act defines knowing to include the traditional definition and also 
instances in which the person acted in deliberate ignorance or reckless disregard of the truth or 
falsity of the information.  Under the False Claims Act, no specific intent to defraud is required.  
Further, the False Claims Act contains a qui tam, or whistleblower, provision that allows a private 
individual to file a lawsuit on behalf of the United States and entitles that whistleblower to a 
percentage of any fraud recoveries.  The False Claims Act was amended again in 2009 in response 
to recent Federal court decisions that narrowed the laws applicability.  Among other things, these 
amendments clarify the reach of the False Claims Act to false claims submitted to contractors or 
grantees of the Federal Government.   
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Appendix D: Reporting Requirements in the 
Inspector General Act of 1978 
The reporting requirements of the Inspector General Act of 1978, as amended, are listed in the following 
table along with the location of the required information.  
 
Section  Requirement  Location 
Section 4 
(a)(2)  Review of legislation and regulations  Other HHS-Related 
Reviews and 
Investigations section   
Section 5 
(a)(1)  Significant problems, abuses, and deficiencies  Throughout this report 
(a)(2)  Recommendations with respect to significant problems,  Throughout this report 
abuses, and deficiencies 
(a)(3)  Prior significant recommendations on which corrective  Solutions To Reduce 
action has not been completed  Fraud, Waste, and Abuse 
in HHS Programs: Top 
Unimplemented 
Recommendations  
(a)(4)  Matters referred to prosecutive authorities  Legal and Investigative 
Activities Related to the 
Medicare and Medicaid 
Programs section 
(a)(5)  Summary of instances in which information requested by  None for this reporting 
OIG was refused  period 
(a)(6)  List of audit reports  Throughout this report  
(a)(7)  Summary of significant reports  Throughout this report 
(a)(8)  Statistical Table 1Reports With Questioned Costs  Appendix A 
(a)(9)  Statistical Table 2Funds Recommended To Be Put to  Appendix A 
Better Use 
(a)(10)  Summary of previous audit reports without management  Appendix A 
decisions, in which no establishment comment was returned 
within 60 days, and in which there are any outstanding 
unimplemented recommendations 
(a)(11)  Description and explanation of revised management  Appendix A 
decisions 
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Section  Requirement  Location 
(a)(12)  Management decisions with which the Inspector General  None for this reporting 
disagrees  period 
(a)(13)  Information required by the Federal Information Security  Other HHS-Related Reviews 
and Investigative Activities 
Management Act  
section 
 
(a)(14)-(16)  Results of peer reviews of HHS-OIG conducted by other  Appendix B 
OIGs or the date of the last peer review, outstanding 
recommendations from peer reviews, and peer reviews 
conducted by HHS-OIG of other OIGs 
(a)(17)  Investigative statistical tables  Appendix E 
(a)(18)  Metrics description for statistical tables  Appendix E 
(a)(19)  Investigations on senior Government employees  Appendix E  
(a)(20)  Description of whistleblower retaliation instances  Appendix E 
(a)(21)  Description of attempts to interfere with OIG independence  Appendix E 
(a)(22)  Description of closed and nondisclosed reports and  Appendix E 
investigations regarding senior Government employees 
 
Other Reporting Requirements 
Section  Requirement  Location 
845  Significant contract audits required to be reported pursuant  Other HHS-Related 
to the National Defense Authorization Act for FY 2008  Reviews and 
(P.L. No. 110-181),  845.  Investigations section 
   205  Pursuant to HIPAA (P.L. No. 104-191),  205, the Inspector  Appendix F  
General is required to solicit proposals annually via a Federal 
Register notice for developing new and modifying existing 
safe harbors to the anti-kickback statute of the Social 
Security Act,  1128(b) and for developing special fraud 
alerts.  The Inspector General is also required to report 
annually to Congress on the status of the proposals received 
related to new or modified safe harbors. 
1553  Pursuant to the American Recovery and Reinvestment Act of  Other HHS-Related 
2009, P.L. No. 111-5,  1553, OIG reports to Congress the  Reviews and 
retaliation complaint investigations it decided not to 
Investigations section 
conduct or continue during the period. 
 
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Appendix E: Reporting Requirements in the 
Inspector General Empowerment Act of 2016 
The Inspector General Empowerment Act of 2016 establishes new reporting requirements for the 
Semiannual Reports.  These requirements amend portions of  5 of the Inspector General Act.  The 
requirements are below in italics, followed by OIGs responses.  
Each Inspector General shall, not later than April 30 and October 31 of each year, prepare 
semiannual reports summarizing the activities of the Office during the immediately preceding 6 
month periods ending March 31 and September 30.  Such reports shall include, but need not be 
limited to- 
(10) A summary of audit, inspection, and evaluation reports issued before the commencement of the 
reporting period- 
(A) for which no management decision has been made by the end of the reporting period (including 
the date and title of each such report), an explanation of the reasons such management decision has 
not been made, and a statement concerning the desired timetable for achieving a management 
decision on each such report;  
 
For audit and evaluation reports issued from FY 2011 through FY 2021 OIG had a total of 87 reports 
with overdue final management decisions (FMD) as of the end of this reporting period.  The 
breakdown of those 87 reports by HHS OpDiv is as follows: 
 
OpDiv  Overdue FMDs 
ACF   22 
ASPR   1 
CDC  1 
CMS   39 
IHS   13 
NIH   4 
OASH   1 
OS   6 
 
OIG is unable to provide reasons and timetables for each of these overdue management decisions, 
because of the volume and that OIG did not historically track this information.  
 
(B) for which no establishment comment was returned within 60 days of providing the report to the 
establishment; and  
 
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For draft reports that include recommendations, OIG typically requests establishment comments 
within 30 days.  In some instances, OIG grants extensions when requested and appropriate.  When 
OIG does not receive establishment comments or a request for extension within the 30-day 
timeframe, OIG typically issues the report and notes the lack of establishment comments.   
 
For this semiannual reporting period, OIG had no reports for which no establishment comment 
was returned within 60 days of providing the report to the establishment. 
 
(C) for which there are any outstanding unimplemented recommendations, including the aggregate 
potential cost savings of those recommendations.  
 
OIG is actively tracking 1,219 unimplemented open recommendations made in reports issued since 
FY 2011.  Given the volume of recommendations OIG makes each year, the table below reflects 
summary data by FY: 
 
Number of Reports 
Number of 
FY (2011 with  Dollar Value of Aggregate 
Unimplemented 
2022)  Unimplemented  Potential Cost Savings 
Recommendations 
Recommendations 
2011  12  17  $408,135,515 
2012  19  22  $369,932,148 
2013  25  38  $234,261,321 
2014  22  40  $15,072,080,989 
2015  21  34  $301,645,457 
2016  18  36  $184,156,192 
2017  29  72  $1,089,280,765 
2018  41  121  $566,596,322 
2019  62  178  $731,236,787 
2020  82  278  $2,443,603,271 
2021  104  259  $920,907,432 
2022  39  124  $2,705,635,037 
474  1,219  $25,027,471,236 
Totals 
 
 
OIG annually produces a Solutions To Reduce Fraud, Waste, and Abuse in HHS Programs: OIGs Top 
Recommendations, which constitutes OIGs response to a specific requirement of the Inspector 
General Act, as amended ( 5(a)(3)).  It identifies significant recommendations with respect to 
problems, abuses, or deficiencies for which corrective actions have not been completed.  It also 
includes an appendix listing OIGs significant unimplemented recommendations, which represent 
opportunities to achieve expected impact through cost savings, improvements in program 
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effectiveness and efficiency, or increasing quality of care and safety of beneficiaries.  In OIGs view, 
these recommendations would most positively impact HHS programs in terms of cost savings 
and/or quality improvements and should therefore be prioritized for implementation.   
 
(17) Statistical tables showing- 
(A) the total number of investigative reports issued during the reporting period; 
(B) the total number of persons referred to the DOJ for criminal prosecution during the reporting 
period; 
(C) the total number of persons referred to State and local prosecuting authorities for criminal 
prosecution during the reporting period; and 
(D) the total number of indictments and criminal information during the reporting period that 
resulted from any prior referral to prosecuting authorities; 
 
Total number of investigative reports issued during the reporting period,  None 
including Management Implication Reports and Investigative Advisories 
Total number of persons referred3 to Federal prosecuting authorities for  1,214 
criminal prosecution during the reporting period4 
Total number of persons referred to State and local prosecuting authorities  127 
for criminal prosecutions during the reporting period  
Total number of Federal indictments and criminal information during the  323 
reporting period that resulted from any prior referral to prosecuting 
authorities 
Total number of State and local indictments and criminal information during  48 
the reporting period that resulted from any prior referral to prosecuting 
authorities 
 
 
(18) A description of the metrics used for developing the data for the statistical tables under 
paragraph (17);  
 
Regarding (17)(A), OIG considers Investigative Reports as Management Implication Reports and 
Investigative Advisories.  A Management Implication Report identifies systemic weaknesses or 
vulnerabilities within HHS programs, which are generally identified during the course of an OIG 
investigation and could lead to fraud, waste, or abuse.  It provides recommendations to correct or 
minimize the problem.  Corrective actions may require administrative, procedural, policy, 
regulatory, or legislative change.  When a Management Implication Report is issued to an HHS 
OpDiv or StaffDiv, it is generally signed by the Inspector General.  Investigative Advisories are 
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similar documents that bring renewed attention to an identified HHS issue and are generally signed 
by the Deputy Inspector General for Investigations.  
 
Regarding (17)(B) and (C), OIG defines this measure as the term presentations to both Federal and 
State/local prosecuting jurisdictions as the representation of the work we do.  For example, when 
OIG opens an investigation, it evaluates the complaint and decides whether to present the matter 
for prosecution.  Generally, if the case has prosecutorial merit, and is accepted for Federal 
prosecution, OIG works with DOJ as the primary investigative agency, as opposed to referring the 
matter to DOJ without further involvement on OIG's part.  OIG works with State and local 
prosecutorial authorities in addition to working with DOJ.  
 
Regarding (17)(D), the table above provides the number of indictments/criminal information during 
the semiannual reporting period, including sealed indictments/criminal information.  However, the 
information cannot be limited to only those that occurred as a result of a presentation in a previous 
period.  In certain situations, the presentation and charging dates are in the same reporting period.  
 
(19) A report on each investigation conducted by the Office involving a senior Government employee 
where allegations of misconduct were substantiated, including a detailed description of- 
(A) the facts and circumstances of the investigation; and 
(B) the status and disposition of the matter, including- 
(i) if the matter was referred to the Department of Justice, the date of the referral; and 
(ii) if the Department of Justice declined the referral, the date of the declination; 
 
To respond fully to this subparagraph, OIG would need to make a finding of misconduct.  
However, OIG does not make findings regarding its investigations relating to substantiated 
allegations of departmental employee misconduct.  Our reports relay the facts obtained during the 
investigations (e.g., parties involved, dates of events) related to any substantiated allegations.  At 
the conclusion of an OIG investigation related to substantiated allegations concerning possible 
employee misconduct, OIG provides a report to management in the employing agency.  The 
agency management makes determinations of employee misconduct.  The disposition of the 
matter and any resulting administrative actions are taken by the agency.   
 
However, we request from the agency a copy of an SF-50 documenting a personnel action, if one is 
taken.  To the extent that we have information regarding subsequent administrative action, OIG can 
provide that information.  However, because there are sometimes settlement agreements that may 
impact the final action, OIG may not have a complete record of the disposition of the investigation.  
Accordingly, such information might be more efficiently and effectively provided directly by the 
employing agency.   
 
For this section, OIG describes investigations during this reporting period, both criminal and 
administrative, involving senior Government employees for whom allegations of misconduct were 
substantiated.  The descriptions below include a level of detail appropriate for each investigation, 
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depending on whether the case details were available in public documents.  During this reporting 
period, OIG investigated 1 senior Government employee for misconduct. 
(20) A detailed description of any instance of whistleblower retaliation, including information about 
the official found to have engaged in retaliation and what, if any, consequences the establishment 
imposed to hold that official accountable; 
 
A For departmental agencies, OIG conducts investigations and gathers facts related to whistleblower 
complaints.  OIG makes a determination as to whether retaliatory action has been taken and 
includes these findings in its reports, along with recommendations as to what, if any, corrective 
action(s) should be taken.  Under this system, OIG submitted one report that included findings of 
retaliation to the HHS Office of the Secretary on February 2, 2022.  When determining the level of 
detail to provide for a description of any instance of whistleblower retaliation, OIG is always mindful 
of the risk that a detailed description of the allegation could inadvertently reveal the whistleblowers 
identity, thus having a chilling effect on future whistleblowers. 
  
The whistleblower in this matter was an employee of a university which receives funds from CDC 
through the U.S. Presidents Emergency Plan for AIDS Relief (PEPFAR).  The whistleblower made 
protected disclosures to the immediate supervisor and CDC staff, raising concerns of gross 
mismanagement of a PEPFAR grant and violations of Federal and local law.  The whistleblower also 
raised allegations that reprisal was suffered in the form of termination.  OIG found that it was more 
likely than not that the whistleblower was subjected to reprisal for whistle blowing activities in this 
matter for the following reasons.  
  
First, the whistleblower made multiple protected disclosures.  Second, management was aware of 
those communications (because many of the communications were sent to management).  Third, an 
unfavorable personnel action (termination) was taken against the whistleblower during the relevant 
time period.  Fourth, a causal connection existed between the protected disclosure and the 
unfavorable personnel action because the personnel action occurred weeks after the whistleblower 
made protected disclosures and the whistleblowers supervisor was unable to succinctly state why the 
whistleblower was terminated. 
  
The report issued to the Office of the Secretary on February 2, 2022, included the following 
recommendations for corrective action: (1) that whistleblower protection training be required for the 
grantee and its employees, as well as CDC employees who work in the PEPFAR program; and (2) that 
the whistleblower be made whole in the form of reinstatement to his role at the university and 
backpay since his termination.  In accordance with IG Act Section 5(a)(20)(B), OIG will revise this entry 
in a future report to incorporate any decisions imposed by HHS towards the subject grantee.   
. 
 
For departmental agencies, OIG conducts investigations and gathers facts related to whistleblower 
complaints.  OIG makes a determination as to whether retaliatory action has been taken and includes 
these findings in its reports, along with recommendations as to what, if any, corrective action(s) should be 
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taken.  Under this system, OIG submitted one report that included findings of retaliation to the HHS Office 
of the Secretary on February 2, 2022.  When determining the level of detail to provide for a description of 
any instance of whistleblower retaliation, OIG is always mindful of the risk that a detailed description of the 
allegation could inadvertently reveal the whistleblowers identity, thus having a chilling effect on future 
whistleblowers. 
  
The whistleblower in this matter was an employee of a university which receives funds from CDC through 
the U.S. Presidents Emergency Plan for AIDS Relief (PEPFAR).  The whistleblower made protected 
disclosures to the immediate supervisor and CDC staff, raising concerns of gross mismanagement of a 
PEPFAR grant and violations of Federal and local law.  The whistleblower also raised allegations that 
reprisal was suffered in the form of termination.  OIG found that it was more likely than not that the 
whistleblower was subjected to reprisal for whistle blowing activities in this matter for the following 
reasons.  
  
First, the whistleblower made multiple protected disclosures.  Second, management was aware of those 
communications (because many of the communications were sent to management).  Third, an unfavorable 
personnel action (termination) was taken against the whistleblower during the relevant time period.  
Fourth, a causal connection existed between the protected disclosure and the unfavorable personnel 
action because the personnel action occurred weeks after the whistleblower made protected disclosures 
and the whistleblowers supervisor was unable to succinctly state why the whistleblower was terminated. 
  
The report issued to the Office of the Secretary on February 2, 2022, included the following 
recommendations for corrective action: (1) that whistleblower protection training be required for the 
grantee and its employees, as well as CDC employees who work in the PEPFAR program; and (2) that the 
whistleblower be made whole in the form of reinstatement to his role at the university and backpay since 
his termination.  In accordance with IG Act Section 5(a)(20)(B), OIG will revise this entry in a future report to 
incorporate any decisions imposed by HHS toward the subject grantee. 
 
(21) A detailed description of any attempt by the establishment to interfere with the independence of 
the Office, including: 
(A) with budget constraints designed to limit the capabilities of the Office; and 
(B) incidents where the establishment has resisted or objected to oversight activities of the Office 
or restricted or significantly delayed access to information, including the justification of the 
establishment for such action; and 
 
Although there have been instances in which HHS agencies have questioned OIG oversight 
activities or have not provided all information in the precise content, format, and timeline as 
requested, OIG has not identified any instances in which HHS interfered with the independence of 
OIG during this reporting period.  OIG would immediately take appropriate action in accordance 
with the Inspector General Act if it were unable to resolve these issues within HHS.   
 
(22) Detailed descriptions of the particular circumstances of each: 
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(A) inspection, evaluation, and audit conducted by the Office that is closed and was not 
disclosed to the public; and 
 
The table below lists evaluation and audit reports for this semiannual reporting period that did not 
result in public reports.  However, in some circumstances, a public summary of these nonpublic 
reports was published.   
 
 
Nonpublic Reports by Category, October 1, 2021, Through March 31, 2022 
 
Number of 
Category/Description 
Reports 
IT security reviews (involve IT systems, e.g., penetration test audits)  2 
Other  0 
HHS technical assistance reports  0 
Finance-related attestation reviews  0 
Total  2 
 
(B) Investigation conducted by the Office involving a senior Government employee that is closed and 
was not disclosed to the public.  
 
In section 5(a)(19), we detail investigations of senior Government employees in which allegations 
were substantiated.  Those investigations are all closed and none have been disclosed to the 
public.  OIG interprets section 5(a)(22)(B) as requiring reporting on investigations with either 
substantiated or unsubstantiated allegations.  As such, we refer to our section 5(a)(19) response to 
address investigations of senior Government employees in which allegations were substantiated 
that were closed and not disclosed to the public.  Our section 5(a)(22)(B) response describes 
investigations during this reporting period, both criminal and administrative, involving a senior 
Government employee in which OIG did not substantiate allegations of misconduct.   
 
When determining the level of detail to provide for the investigations described above, OIG is 
mindful of the risk that a detailed description of the investigation could inadvertently reveal the 
subjects identity.  During this reporting period, OIG investigated five senior Government 
employees for misconduct, but OIG determined the allegations to be unsubstantiated.  
Descriptions of the investigations are below.  
 
 
 
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Description of  Status  Disposition  DOJ  DOJ  DOJ  DOJ 
Investigation  Referral  Referral  Declination  Declination 
Date  Date 
A senior  Closed  Insufficient  No  N/A  N/A  N/A 
Government  evidence 
employee was 
allegedly providing 
insider information 
to family and 
friends and 
receiving kickbacks 
from them. 
A senior  Closed  Insufficient  No   N/A  N/A  N/A 
Government  evidence 
employee who 
represented a 
company on behalf 
of an OpDiv was 
said to have a 
conflict of interest. 
Two senior  Closed  Unsubstantiated  No  N/A  N/A  N/A 
Government 
employees were 
accused of 
retaliation against 
an employee after 
the employee 
reported violations. 
A senior  Closed  Insufficient  No   N/A  N/A  N/A 
Government  evidence. 
employee was 
alleged to own 
multiple prohibited 
stocks in 
pharmaceutical 
companies, a 
violation of the U.S. 
Code. 
   
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Appendix F: Anti-Kickback StatuteSafe 
Harbors 
Pursuant to HIPAA,  205, the Inspector General is required to solicit proposals annually via a Federal 
Register notice for developing new and modifying existing safe harbors to the Federal anti-kickback 
statute, section 1128B(b) of the Social Security Act, and for developing special fraud alerts.  The Inspector 
General is also required to report annually to Congress on the status of the proposals received related to 
new or modified safe harbors.   
 
In crafting safe harbors for a criminal statute, it is incumbent upon OIG to engage in a complete and 
careful review of the range of factual circumstances that may fall within the proposed safe harbor subject 
area to uncover all potential opportunities for fraud and abuse by unscrupulous industry 
stakeholders.  Having done so, OIG must then determine, in consultation with DOJ, whether it can develop 
effective regulatory limitations and controlsnot only to foster beneficial or innocuous arrangements
but also to protect the Federal health care programs and their beneficiaries from abusive practices. 
 
Public proposals for new and modified safe harbors  
Annual Solicitation  
 
In December 2020, OIG published its annual solicitation in the Federal Register (Annual Solicitation).1  In 
response to the Annual Solicitation, OIG received the following proposals related to safe harbors:  
 
Proposal   OIG Response  
A new safe harbor to protect the use  In December 2020, as part of HHSs broader Regulatory Sprint 
of cash and cash-equivalent  to Coordinated Care initiative, OIG issued a final rule (the 
payments offered as part of  Regulatory Sprint Final Rule),2 creating a new safe harbor for 
contingency management in the  patient engagement tools and supports, which could protect 
treatment of substance use disorders.  certain in-kind incentives in connection with contingency 
management, if all safe harbor conditions were met.3  Due to 
heightened fraud and abuse concerns with respect to incentives 
in the form of cash or cash equivalents, we elected not to 
expand the safe harbor to include cash and cash-equivalent 
 
 
1 OIG, Solicitation of New Safe Harbors and Special Fraud Alerts, 85 Fed. Reg. 81,439 (Dec. 16, 2020), available at 
https://www.govinfo.gov/content/pkg/FR-2020-12-16/pdf/2020-26043.pdf.  
2 Medicare and State Health Care Programs: Fraud and Abuse; Revisions to Safe Harbors Under the Anti-Kickback Statute, and Civil 
Monetary Penalty Rules Regarding Beneficiary Inducements, 85 Fed. Reg. 77,684 (Dec. 2, 2020), available at 
https://www.govinfo.gov/content/pkg/FR-2020-12-02/pdf/2020-26072.pdf. 
3 42 CFR 1001.952(hh). 
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Proposal   OIG Response  
payments offered as part of contingency management 
interventions or other programs to motivate beneficial 
behavioral changes.  However, and as we explained in the 
Regulatory Sprint Final Rule, this does not mean that all such 
cash or cash-equivalent payments offered as part of a 
contingency management intervention are unlawful, but they 
would be subject to case-by-case analysis under the Federal 
anti-kickback statute and the civil monetary penalty provision 
prohibiting inducements to beneficiaries.   
 
For the same reason as set forth in the Regulatory Sprint Final 
Rule, we decline to adopt this suggestion.  We may consider this 
topic in future rulemaking or through other guidance.   
A new safe harbor for Indian Health  Although not specific to IHCPs, OIG believes existing 
Care Providers (IHCPs) similar to the  regulations, including new and modified safe harbors that were 
safe harbor for federally qualified  finalized in the Regulatory Sprint Final Rule, may offer sufficient 
health centers at 42 CFR  regulatory flexibility and can facilitate innovative value-based 
 1001.952(w).  and care coordination arrangements for American Indians and 
  Alaska Natives.  Accordingly, OIG is not adopting this 
suggestion.  We may consider this topic in future rulemaking. 
 
A new safe harbor or modifications  As explained in the Regulatory Sprint Final Rule, remuneration 
to existing value-based safe harbors  exchanged by pharmaceutical manufacturers and, in certain 
at 42 CFR  1001.952(ee), (ff), (gg),  circumstances, medical device manufacturers and DMEPOS 
and (hh) that would protect  entities, are not eligible for protection under the new value-
remuneration exchanged in value- based safe harbors due to (among other reasons) concerns that 
based arrangements involving  such entities could use the safe harbor to protect arrangements 
pharmaceutical manufacturers and, in  that are intended to market their products or inappropriately 
circumstances not limited to digital  tether clinicians to the use of a particular product.4  
health technology, device  Consequently, OIG declines to adopt this suggestion.     
manufacturers and durable medical 
equipment, prosthetics, orthotics, or 
supplies (DMEPOS) companies. 
 
New or modified safe harbors to  OIG is not adopting this suggestion.  We believe that existing 
protect remuneration furnished or  regulations, including new and modified safe harbors that were 
exchanged by health care suppliers,  finalized in the Regulatory Sprint Final Rule, offer sufficient 
providers, or manufacturers in  regulatory flexibility and protection for beneficiary incentives 
 
 
4 See, e.g., 85 Fed. Reg. at 77,709, 77,782. 
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Proposal   OIG Response  
support of medically underserved  and financial arrangements that may support the care needs of 
communities.  medically underserved communities.  We may consider this 
  topic in future rulemaking. 
 
One or more new safe harbors that  OIG has repeatedly expressed concerns regarding routine 
would protect patient cost-sharing  waivers of Medicare cost-sharing amounts that do not meet an 
waivers in the following  exception to the civil monetary penalty provision prohibiting 
circumstances: (i) clinical trials, (ii)  inducements to beneficiaries at section 1128A(i)(6)(A) of the 
care management, (iii) remote  Social Security Act.  Accordingly, we decline to adopt these 
physiological monitoring, and (iv) for  suggestions.   
the duration of the COVID-19 public   
health emergency.   With respect to the COVID-19 public health emergency, we 
highlight OIGs March 2020, Policy Statement,5 in which we 
notified providers that, subject to specified conditions, they will 
not be subject to administrative sanctions for reducing or 
waiving cost-sharing obligations that Federal health care 
program beneficiaries may owe for telehealth services furnished 
during the COVID-19 public health emergency.  
 
In addition, on May 5, 2021, OIG published an FAQ addressing 
ambulance providers or suppliers waiving or discounting 
beneficiary cost-sharing obligations resulting from ground 
ambulance services paid for by the Medicare program under a 
waiver established pursuant to section 1135(b)(9) of the Social 
Security Act.  There, we concluded that such cost-sharing 
waivers represent a sufficiently low risk of fraud and abuse if 
certain conditions are met. 
 
A new safe harbor that would protect  OIG is not adopting this suggestion.  These kinds of 
value-based contracting and  manufacturer arrangements raise unique program integrity 
outcomes-based contracting for the  issues that OIG continues to consider.  We may consider this 
purchase of pharmaceutical or  topic in future rulemaking.  
medical device items and related 
services.   
 
 
 
5 HHS-OIG, OIG Policy Statement Regarding Physicians and Other Practitioners That Reduce or Waive Amounts Owed by Federal 
Health Care Program Beneficiaries for Telehealth Services During the 2019 Novel Coronavirus (COVID-19) Outbreak (Mar. 17, 2020) 
available at https://oig.hhs.gov/fraud/docs/alertsandbulletins/2020/policy-telehealth-2020.pdf.  
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Semiannual Report to CongressOctober 1, 2021, Through March 31, 2022
 
 
Proposal   OIG Response  
Modification of the space rental safe  OIG is not adopting this suggestion.  With respect to payments 
harbor to remove the fair market  made by a lessee to a lessor for the use of premises, we believe 
value requirement.   that the fair market value requirement helps to ensure that such 
  lease payments are for legitimate purposes and are not a 
payment to induce referrals or otherwise reward Federal health 
care program business generated between the parties.   
 
Repeal or modification of the group  OIG is not adopting commenters suggestion to repeal or 
purchasing organization (GPO) safe  modify the GPO safe harbor, but we may consider this topic in 
harbor to facilitate greater public  future rulemaking.  OIG also highlights that there is a statutory 
transparency and address potential  exception addressing GPOs at section 1128B(b)(3)(C) of the 
conflict of interests between GPOs, its  Social Security Act. 
members, and contracting vendors.    
 
Repeal or modification of the  On March 22, 2021, OIG issued a notification of the court-
pharmacy benefit manager service  ordered delay of the effective date of this final rule.  That 
fees safe harbor and the point-of- notification stated that the effective date of the amendments to 
sale reductions in price for  42 C.F.R.  1001.952(h)(6) through (9), (cc), and (dd) is delayed 
prescription pharmaceutical products  until January 1, 2023.  The notification also stated that the 
safe harbor, as finalized in a 2020  effective date of the corrections published at 86 Fed. Reg. 7815 
rulemaking.6  (Feb. 2, 2021), is delayed from March 22, 2021, to January 1, 
  2023. See 86 Fed. Reg. 15,132 (Mar. 22, 2021). 
 
On November 15, 2021, Public Law 117-58 became law. Section 
90006 of Public Law 117-58 states that: 
 
Notwithstanding any other provision of law, the 
Secretary of Health and Human Services shall not, prior 
to January 1, 2026, implement, administer, or enforce the 
provisions of the final rule published by the Office of the 
Inspector General of the Department of Health and 
Human Services on November 30, 2020, and titled 
"Fraud and Abuse; Removal of Safe Harbor Protection 
for Rebates Involving Prescription Pharmaceuticals and 
Creation of New Safe Harbor Protection for Certain 
Point-of-Sale Reductions in Price on Prescription 
 
 
6 OIG, Fraud and Abuse; Removal of Safe Harbor Protection for Rebates Involving Prescription Pharmaceuticals and Creation of 
New Safe Harbor Protection for Certain Point-of-Sale Reductions in Price on Prescription Pharmaceuticals and Certain Pharmacy 
Benefit Manager Service Fees, 85 Fed. Reg. 76,666 (Nov. 30, 2020), available at https://www.govinfo.gov/content/pkg/FR-2020-11-
30/pdf/2020-25841.pdf. 
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Proposal   OIG Response  
Pharmaceuticals and Certain Pharmacy Benefit Manager 
Service Fees" (85 Fed. Reg. 76666). 
 
Consequently, there is a three-year moratorium on 
implementation of the amendments to 42 C.F.R.  1001.952(h)(5) 
and 42 C.F.R.  1001.952(h)(6) through (9), (cc), and (dd). 
 
 
 
 
 
 
 
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