Report Template Update:  04-03-08  
    
 Department of Health and Human Services
OFFICE OF 
   
INSPECTOR GENERAL 
 
 
 
 
 
 
 
CMS P
S  ROCESSING OF 
 
 
C R
OMPLAINTS  ECEIVED 
 
T   1-800-HHS-TIPS
HROUGH THE   
 
H  
  OTLINE
 
 
 
 
 
 
Daniel R. Levinson  
Inspector General 
 
March 2011 
OEI-07-09-00020  Report Template Update:  04-03-08 
  
   
 I N T R O D U C T I O N  
 EE XX EE CC UU TT II VV EE  S SU UM MM MA AR RY Y   
OBJECTIVE
 
To assess the Centers for Medicare & Medicaid Services (CMS) 
processing of complaints received through the 1-800-HHS-TIPS hotline. 
BACKGROUND 
Many Offices of Inspector General (OIG) operate hotlines to respond to 
citizen and employee allegations of fraud, waste, or abuse in Federal 
programs.  The Department of Health & Human Services (HHS) OIG 
maintains such a hotline (1-800-HHS-TIPS), for individuals to provide 
information that may assist in combating fraud, waste, or abuse in HHS 
programs (e.g., Medicare, Medicaid, child support enforcement, and 
Head Start).  Individuals may call the hotline or send their written 
concerns by email, postal mail, or fax. 
We obtained a copy of the hotline complaint data in CMSs information 
system as of March 2009.  We identified 1,427 complaints that OIG 
forwarded to CMS in the first 6 months of 2008.  From these, we 
selected a simple random sample of 120 complaints.  We telephoned 
staff at each contractor assigned to the sampled complaints to inquire 
about what initial research the contractor performed to validate each 
complaint; how and when the contractor contacted the complainant; and 
what outcomes (e.g., recouping an overpayment from the provider) 
resulted from the contractors actions on the complaint.  We also 
conducted structured telephone interviews with contractor staff, CMS 
central office staff, and CMS regional office staff about the complaint 
process.  Finally, to check the status of complaints 1 year after we 
initially received the hotline complaint data, in March 2010 we obtained 
a copy of the hotline complaint data in CMSs information system.  
FINDINGS 
At least 1 year after receiving complaints through the 
1-800-HHS-TIPS hotline, CMS had resolved the majority of them, 
but 12 percent remained unresolved.  CMS has no requirements 
regarding the length of time within which contractors should resolve 
complaints.  Our period of review allowed at least 1 year to elapse after 
CMS received the complaints from OIG.  As of March 2010, interviews 
with contractors and a review of data in CMSs information system 
confirmed that CMS resolved or closed administratively 88 percent of 
complaints received during the first 6 months of 2008.  (Complaints are 
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 EE XX EE CC UU TT II VV EE    SS UU MM MM AA RR YY   
closed administratively if they are below the dollar-amount threshold 
required for research or if the information in the complaint is 
insufficient to conduct further work.)  Overall, 32 percent of complaints 
were confirmed as services billed in error.  Eleven percent of complaints 
involved allegations of fraud.  Contractors closed 11 percent of 
complaints administratively.  For another 32 percent, contractors 
researched complaints and found no problems.  Two percent of 
complaints were referred to another agency.  CMS had not resolved 
12 percent of the complaints it received during our period of review. 
Long timeframes and inefficient processes delay starting work on 
complaints.  For 58 percent of complaints, contractors reported starting 
work within 30 days of CMSs receipt of the complaints from OIG, but 
for 29 percent of complaints, contractors took more than 4 months to 
start work.  Included in the latter group are complaints that contractors 
were unaware had been assigned to them (22 percent of all complaints).  
Only following our inquiry did the contractors begin work on these 
complaints.  CMS and contractor staff described processes that 
contribute to delays in transmitting complaints from the CMS central 
office to contractor staff.  Such delays add to the time that it takes to 
resolve complaints. 
Lack of guidance and an inadequate information system hinder 
complaint processing.  Some CMS and contractor staff reported the 
need for written guidance defining their roles and responsibilities for 
processing hotline complaints.  Although CMS provides some guidance 
to contractors, some CMS and contractor staff stated that guidance is 
lacking for processing complaints from receipt through resolution.  No 
written procedures for processing complaints exist at the level of the 
CMS central office; however, staff from two CMS regional offices 
reported developing standard operating procedures for handling 
complaints.  Most contractors have developed internal policies and 
procedures for handling complaints; however, some contractors desired 
guidance from CMS.  In addition, the status of complaints cannot be 
tracked in CMSs information system.   
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RECOMMENDATIONS 
The 1-800-HHS-TIPS hotline is widely publicized as an avenue that 
individuals can use to provide information that may assist in combating 
fraud, waste, or abuse in Federal health care programs.  While the extent 
of health care fraud is unknown, it is estimated to be in the billions of 
dollars each year.  HHS emphasizes that Medicare beneficiaries are the 
front line of defense in detecting Medicare fraud because they have 
firsthand knowledge of the health care services they have received.  
When researched and resolved, hotline complaints can lead to 
recovering overpayments and identifying fraud.  Therefore, it is 
important for CMS to have a clear and consistent approach to process 
hotline complaints.  
We recommend that CMS: 
Issue written guidance for processing hotline complaints.  CMS should 
issue guidance defining the roles and responsibilities of CMS and 
contractor staff and timeframes for assigning, researching, and resolving 
complaints.   
 
Upgrade its information system for processing hotline complaints.  CMS 
should ensure that its information system tracks user activity on each 
complaint and alerts CMS when a complaint has not been assigned to a 
contractor.  
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
In its written comments on the draft report, CMS concurred with our 
recommendations.  In response to our first recommendation, CMS 
stated that it will create written guidance that defines the specific roles 
and responsibilities for CMS and its contractor staff to achieve greater 
clarity in administration of its database (i.e., its information system).  
Where they are not already established, CMS will establish timeframes 
for assigning, researching, and resolving complaints.  CMS stated that 
it is revising its national contractor list to include contact names and 
contract numbers associated with the contractors.  In response to our 
second recommendation, CMS stated that it is upgrading and updating 
its database with the following features:  auditing mechanisms to track 
user activity, contractor assignments, and status of complaints; and the 
capacity to alert CMS when complaints have not been assigned.  CMS 
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 E X E C U T I V E   S U M M A R Y  
stated that it will work with OIG to establish an electronic method to 
deliver hardcopy evidence received from complainants concurrently with 
the electronic complaint.  
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 T A B L E   O F   C O N T E N T S  
EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i
 
 
I N T RO DUC T IO N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 
 
 
F I N D IN G S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 
At least 1 year after receiving complaints through the 
1-800-HHS-TIPS hotline, CMS had resolved the majority of  
them, but 12 percent remained unresolved . . . . . . . . . . . . . . . . . . . 7 
Long timeframes and inefficient processes delay starting work 
on complaints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 
Lack of guidance and an inadequate information system hinder 
complaint processing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 
 
 
R E C O MMEN D A T ION S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 
Agency Comments and Office of Inspector General Response . . . 16 
 
 
APPENDIXES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 
A:  Flowchart of Processing of Complaints Received Through 
the 1-800-HHS-TIPS Hotline and Referred 
to the Centers for Medicare & Medicaid Services . . . . . . . . . . 17 
  B:  Point Estimates and Confidence Intervals. . . . . . . . . . . . . . . . 18 
  C:  Agency Comments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 
 
A C K NO WL E D G M E N T S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21  Report Template Update:  04-03-08 
  
   
 
 I N T R O D U C T I O N  
OBJECTIVE 
To assess the Centers for Medicare & Medicaid Services (CMS) 
processing of complaints received through the 1-800-HHS-TIPS hotline. 
BACKGROUND 
Many Offices of Inspectors General (OIG) operate hotlines to respond to 
citizen and employee allegations of fraud, waste, or abuse in Federal 
programs.  The Department of Health & Human Services (HHS) OIG 
maintains such a hotline (1-800-HHS-TIPS), which individuals can use 
to provide information that may assist in combating fraud, waste, or 
abuse in HHS programs (e.g., Medicare, Medicaid, child support 
enforcement, and Head Start).  Individuals may call the hotline or send 
their written concerns by email, postal mail, or fax.     
The availability of the hotline is widely publicized on the Internet and 
in various publications, such as the CMS Medicare & You handbook 
distributed annually to Medicare beneficiaries.  These media strongly 
encourage individuals to report suspicious activity, emphasizing that 
they can help stop fraud in HHS programs.  The CMS Web site states 
that it is in the best interest of beneficiaries and of all citizens to report 
suspected fraud, as fraud increases health care costs.  In addition, HHS 
emphasizes that Medicare beneficiaries are the front line of defense in 
detecting Medicare fraud because they have firsthand knowledge of the 
health care services they have received.  Given the hotlines prominence, 
it is vital that information reported to the hotline be thoroughly 
reviewed and appropriately addressed in a timely fashion.   
Written Procedures and Guidance 
Three groups process hotline complaints related to CMS programs:  OIG 
hotline staff, CMS central and regional office staff, and contractor staff.  
OIG has developed two written guidance documents pertaining to the 
handling of hotline calls:  OIG Hotline Program Orientation and OIG 
Hotline Screening Protocols.  The CMS central office has not issued 
written procedures or guidance for processing hotline complaints.     
In the absence of written procedures or guidance from CMS, the 
information in this report regarding CMSs complaint processing is 
based primarily on information that OIG obtained through verbal 
contacts made during this evaluation.  For a flowchart of complaint 
processing as explained to and observed by OIG, see Appendix A. 
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 I N T R O D U C T I O N  
OIG Hotline Complaint Processing 
In 2008, the OIG hotline received approximately 124,000 telephone calls 
and 15,000 pieces of written correspondence.  However, most contacts to 
the hotline do not result in complaints logged into the OIG hotline 
database.  Using OIGs written procedures, customer service 
representatives (CSR) determine whether an issue rises to the level of a 
complaint and whether it falls within OIGs jurisdiction.  For issues that 
fall outside OIGs jurisdiction or that do not rise to the level of a 
complaint, CSRs provide individuals contacting the hotline with, 
whenever possible, another avenue to seek assistance, such as calling 
their State health and human services agencies or 1-800-MEDICARE.  
For example, if callers inquire about terminology on a Medicare 
Summary Notice (MSN), CSRs refer them to 1-800-MEDICARE.  If 
callers have complaints involving Medicaid eligibility, CSRs refer the 
callers to State Medicaid agencies.  In contrast, if a caller alleges that a 
Medicare beneficiary was billed for services not received, the CSR logs a 
complaint.  
When CSRs determine that a written or telephone contact rises to the 
level of a complaint, they enter informationincluding beneficiary 
contact information, provider contact information, and a summary of 
the complaintinto the OIG hotline database.  The database 
automatically assigns a number to identify the complaint.  When taking 
telephone complaints, CSRs do not conduct detailed inquiries with 
callers or call complainants back for followup.  CSRs also do not update 
complainants on the disposition of individual complaints. 
Forwarding complaints for resolution.  In 2008, hotline calls and 
correspondence resulted in approximately 6,200 complaints.  OIG 
hotline staff forward complaints to either an OIG field office or the 
appropriate HHS staff division or operating division (e.g., CMS) or other 
Federal agency for resolution.  OIG forwarded approximately 
2,400 complaints to field offices for followup, forwarded more than 
3,000 complaints to CMS, and distributed the balance of the complaints 
among other HHS operating divisions and other Federal agencies. 
An OIG analyst reviews the CSRs data entry for quality control and 
prints a cover sheet that includes the complaint number, beneficiary 
and provider contact information, and a summary of the complaint.  If 
any hardcopy documents (e.g., letters or MSNs) accompany the 
complaint, the analyst attaches them to the cover sheet.  OIG staff 
package the cover sheets and documents and mail them in batches to 
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CMS.  OIG also sends an electronic file containing complaint 
information to an information technology (IT) staff member at the CMS 
central office. 
CMS Complaint Processing 
Staff in CMSs central and regional offices, as well as staff at Medicare 
claims processing contractors (hereinafter referred to as claims 
processing contractors), process complaints referred to CMS by OIG.  
CMS staff and claims processing contractors use an information system 
(a Microsoft Access database) to assign, research, and resolve OIG-
referred complaints.  The database includes each complaints unique 
identifier, date of intake by OIG, date of entry into CMSs information 
system, date of the complaints assignment to a CMS regional office and 
to a claims processing contractor, closure date, and resolution code (if 
applicable).     
Assigning complaints.  An IT staff member at the CMS central office 
receives the electronic file from the OIG hotline and uploads it to the 
CMS information system.  Using the provider address information in 
the complaint, the information system electronically assigns the 
complaint to the appropriate CMS regional office.1 
When a batch of new complaints is pending in the database, an IT staff 
member concurrently sends an electronic notice to alert CMS regional 
office staff and claims processing contractors to assign complaints.  
After receiving the notice, claims processing contractors review the 
complaints.  Typically, a claims processing contractor assigns to itself 
any complaints involving claims that it originally paid,  a process known 
as self-assigning.  Any complaints not self-assigned in this manner are 
assigned electronically among the contractors by the CMS regional 
office staff.   
Staff in the CMS central office mail the hardcopy complaint packages to 
the appropriate regional offices.  Regional office staff then mail the 
packages to the appropriate claims processing contractors.     
Researching and resolving complaints.  Claims processing contractors 
conduct initial research on each complaint to determine such things as 
the amount paid for the claim and patterns of complaints related to an 
 
1 If the complaint is related to durable medical equipment (DME) or the provider address 
is not available, the complaint is assigned to the CMS regional office that corresponds 
geographically to the beneficiary address. 
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individual provider.  CMS requires claims processing contractors to 
research complaints for services with a claim paid amount of $100 or 
greater.  Complaints for services of less than $100 must be retained and 
tracked for 1 year.  If a claims processing contractor receives three 
complaints on the same provider within 1 year, the contractor is 
required to conduct an in-depth review of all related complaints.2     
CMS directs claims processing contractors to, within certain 
timeframes, (1) review complaint documentation and (2) determine 
whether fraud and/or abuse is suspected.3  If claims processing 
contractors suspect fraud and/or abuse, they must forward the 
complaint to the Program Safeguard Contractor or Zone Program 
Integrity Contractor (hereinafter referred to as program integrity 
contractors) within 45 business days of receipt of the complaint or 
within 30 business days of receiving medical records, whichever is 
later.4  
To resolve complaints, claims processing contractors use a variety of 
research techniques, such as calling the beneficiary or provider and 
reviewing the claims history.5  Although claims processing contractors 
may begin working on complaints as soon as they are electronically 
assigned, any hardcopy documents associated with a complaint may not 
be available for several weeks because of processing and mailing time.  
CMS does not specify a timeframe within which contractors must 
resolve complaints. 
Updating complaint status.  When a complaint is resolved, claims 
processing contractors or program integrity contractors update the 
status of the complaint to closed in the CMS database.  After this 
update, no further action is taken on a complaint.  Some claims 
processing and program integrity contractors notify the complainant of 
the resolution by letter; however, this is not a CMS requirement.  
Periodically, a CMS IT staff member provides OIG with an electronic 
file of the complaint information in CMSs information system.  An OIG 
 
2 CMS Program Integrity Manual, ch. 4,  6.2. 
3 CMS Program Integrity Manual, ch. 4,  6.2. 
4 A provider has 45 days to submit medical records to the contractor. 
5 We use the term resolve to indicate that Medicare contractors have completed the 
actions that they are able to take on complaints.  For some complaints, these actions may be 
limited, especially if the contractors are unable to contact complainants. 
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staff member uploads this information to the OIG hotline database, 
thereby updating the status of complaints in OIGs records.   
METHODOLOGY 
Scope 
This evaluation includes a sample of complaints received through 
1-800-HHS-TIPS during the first 6 months of 2008 that OIG referred to 
CMS.  This evaluation excludes complaints that OIG forwarded to its 
field offices, other HHS operating divisions, and other Federal agencies, 
as well as complaints that CMS received from sources other than 
1-800-HHS-TIPS.  We did not evaluate OIG hotline processes, including 
its intake process, nor did we evaluate the accuracy of the process of 
forwarding the complaints. 
Sample and Data Sources 
We obtained a copy of the complaint data in CMSs information system 
as of March 2009.  We identified 1,427 complaints that OIG forwarded 
to CMS from January 1 to June 30, 2008.  From these, we selected a 
simple random sample of 120 complaints.  One year later, in 
March 2010, we obtained a copy of CMSs information system to check 
the status of complaints at the completion of our data collection.  Our 
period of review allowed at least 1 year to elapse after CMS received the 
complaints. 
Data Collection 
Contractor staff.  We telephoned staff at each claims processing and 
program integrity contractor (hereinafter referred to as contractor) 
assigned to the sampled complaint(s) to inquire about the initial research 
that the contractor performed on the complaint.  We asked contractors 
how and when they contacted the complainant and what outcomes 
(e.g., recouping an overpayment from the provider) resulted from the 
contractors actions on complaints.  At the same time that we contacted 
contractors about sampled complaints, we conducted structured telephone 
interviews with them about the complaint process.  We asked about any 
challenges they had encountered, any circumstances that had impeded 
timely resolution of complaints, and any suggested solutions.  We 
interviewed staff from 24 contractors (14 claims processing contractors 
and 10 program integrity contractors).   
CMS central and regional office staff.  Upon completing our interviews with 
contractors, we conducted structured interviews with CMS central office 
staff and staff involved in complaint processing from each of the 10 CMS 
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regional offices.6  We asked CMS staff whether they had encountered any 
challenges when processing complaints, whether any processing changes 
were anticipated or underway, and how feasible the solutions that 
contractors suggested were. 
Analysis 
We analyzed contractors responses to determine the actions they 
reported taking to resolve the sampled complaints.  To ensure that our 
analysis included the most up-to-date information, we used the 
March 2010 version of CMSs information system to determine the 
reported status of sampled complaints.   
Using data from contractor interviews and data in CMSs information 
system, we projected the amount of time that elapsed between CMSs 
receipt of complaints and contractors receipt of complaints. 
Limitations 
Using data from CMSs information system, we contacted the contractor 
assigned to the sampled complaint.  In many instances, the contractor 
stated that the complaint had been transferred to another contractor, 
but the contractor to which it had been transferred reported that it had 
no record of the complaint.  For this reason, we could not determine 
which contractor researched and/or resolved 16 of the complaints 
(13 percent).  Therefore, the information about these 16 complaints is 
limited to data in CMSs information system.  We note that the 
timeframe of our fieldwork intersected with the transition from legacy 
claims processing contractors to Medicare Administrative Contractors 
(MAC), which may have made it more complex for OIG and CMS to 
determine which contractor was responsible for a complaint.7 
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation approved by the Council of the Inspectors 
General on Integrity and Efficiency. 
 
6 One CMS regional staff member has responsibility for complaint processing in two 
regions. 
7 Section 911 of the Medicare Prescription Drug, Improvement, and Modernization Act of 
2003 requires that CMS replace fiscal intermediary and carrier contracts (legacy claims 
processing contractors) with competitively procured contracts that conform to the Federal 
Acquisition Regulation.  P.L. 108-173  911, Social Security Act,  1874A, 42 U.S.C. 
1395kk-l.  CMS was given 6 years (between 2005 and 2011) to complete the transfer of 
claims processing activities to MACs.  
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 F I N D I N G S  
As of March 2010, interviews with 
At least 1 year after receiving complaints 
contractors and a review of data in 
through the 1-800-HHS-TIPS hotline, CMS had 
CMSs information system 
resolved the majority of them, but 12 percent 
confirmed that CMS had resolved 
 remained unresolved
or closed administratively 
88 percent of complaints.  However, CMS had not resolved 12 percent of 
complaints received during the first 6 months of 2008.8  CMS has no 
requirements regarding the length of time within which contractors 
should resolve complaints.  Our period of review allowed at least 1 year 
to elapse after CMS received the complaints. 
Of the 15 unresolved complaints, 6 were allegations of fraudulent 
Medicare billing, 6 were complaints of services not rendered, 2 were 
allegations of unlicensed providers, and 1 was a complaint regarding 
unsafe conditions at a clinic.  One complaint of services not rendered 
alleged that a hospice provider visited a beneficiarys home once, but the 
beneficiary decided not to sign up with their program.  The beneficiary 
received a MSN stating that Medicare paid the provider more than 
$10,000.   
CMS resolved 88 percent of complaints received during the first 6 months 
of 2008 
Overall, 32 percent of complaints were confirmed as services billed in 
error, such as rental charges that continued after the supplier picked up 
a hospital bed from the beneficiarys home.  Contractors collected 
$35,487.60 in overpayments based on these sampled complaints.  
Eleven percent of complaints involved allegations of fraud, such as 
medical studies and tests billed using stolen Medicare identification 
numbers.  Outcomes of these complaints included an arrest of a 
provider, termination of a provider from Medicare, seizure of a 
providers bank account, and a large monetary settlement with a 
provider.  Contractors closed 11 percent of complaints administratively 
(i.e., the complaint was below the $100 threshold, or the information in 
the complaint was not sufficient to conduct further work).  For another 
32 percent, contractors researched complaints and found no problems.  
Two percent of complaints were referred to another agency.  Table 1 
describes the resolutions of sampled complaints as reported by 
contractors. 
 
8 Appendix B presents the point estimates and confidence intervals for all statistics. 
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 F I N D I N G S  
Table 1:  Resolutions of Complaints as Reported by Contractors 
Number of 
Description of Resolution  Sampled  Percentage of  
Complaints  Complaints 
(n=120) 
Allegations researched; no problems found  38  31.7% 
Service(s) billed in error  38  31.7% 
Allegations involved fraud  13  10.8% 
 
Allegations involved services with claim paid amounts of 
less than $100; complaints closed and retained for  7  5.8% 
provider tracking 
 
Information in allegations insufficient; complaints closed 
6  5.0% 
with no action 
Complaints referred to another agency  3  2.5% 
Subtotal, resolved complaints  105  87.5% 
Unresolved  15  12.5% 
   Total  120  100.0% 
Source:  OIG analysis of contractor interviews and March 2010 version of CMSs information system, 2010. 
 
Complaint research and resolution.  Contractors used a variety of 
methods to research and resolve complaints.  For the sampled 
complaints, this included reviewing medical records or other 
documentation requested from the provider, reviewing data in the 
contractors internal systems, and interviewing complainants or 
providers by telephone.   
Some complainants submitted hardcopy documents (e.g., MSNs, 
photographs, letters) in support of their allegations.  Staff from 17 of the 
24 contractors reported problems with receiving such documents.  
Contractors reported seeing notes in the database saying that 
complainants had submitted hardcopy documents but not receiving the 
documents for 30 to 90 days after complaint assignment, if at all.  Not 
receiving the documents can impede resolution of a complaint or cause 
the contractor to request the same documents from the complainant.  
Staff from 2 of the 24 contractors stated that they received hardcopy 
documents after a complaint had been closed and that they had to 
reopen the complaint to evaluate whether the documents changed the 
resolution.  In addition to contractors, staff from all 10 CMS regional 
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 F I N D I N G S  
offices reported challenges with handling hardcopy documents, 
including not receiving them in a timely manner and the potential for 
them to be lost. 
Complainant contact.  Contractors contacted complainants by telephone 
or postal mail for 45 complaints.9  The reasons for contacting 
complainants included acknowledging that a complaint was received 
(9 complaints), interviewing complainants to gain information 
(14 complaints), and notifying complainants of resolution 
(26 complaints). 
Not all contractors notify complainants of the outcomes, and CMS does 
not require them to do so.  For a complaint that results in the 
contractors adjustment of the provider claim payment (e.g., a complaint 
resolved as service(s) billed in error), the beneficiary receives a revised 
MSN indicating the amount of the adjustment.  Some contractors 
consider the revised MSN as a notice to the beneficiary (who may or 
may not be the complainant) of the complaints resolution.  In addition, 
upon receiving a revised MSN, some beneficiaries place another call to 
the hotline because they misinterpret the information on the revised 
MSN as meaning that the provider received an additional payment for 
services.  
 
For a complaint to be resolved, it 
Long timeframes and inefficient processes 
must be assigned to and 
delay starting work on complaints 
acknowledged by the contractor 
that paid the claim for the service 
in question.  Inefficient processes contribute to the delay in assigning 
complaints to contractors, thereby adding to the time it takes to resolve 
complaints. 
For 58 percent of complaints, contractors reported starting work within 
30 days of CMSs receipt of the complaints from OIG, but for 29 percent of 
complaints, contractors took more than 4 months to start work 
The number of days between the date that a complaint was uploaded to 
CMSs information system and the date that the contractor reported 
starting work on it ranged from 0 (i.e., uploaded and work started on 
the same day) to 660 days, with an average of 163 days.  On average, 
 
9 Contractors contacted some complainants for more than one reason. 
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 F I N D I N G S  
more than 5 months elapsed between CMSs receiving complaints from 
OIG and contractors starting work on them. 
Table 2 provides an overview of the time it took for contractors to start 
work on complaints after they were uploaded to CMSs information 
system.  Contractors took more than 120 days to start work on 
29.1 percent of complaints.  The bulk of the complaints in this 
category22 percent of all complaintsare those that contractors were 
unaware had been assigned to them.  Only following our inquiry did the 
contractors start work on these complaints.  During our interview with 
one contractor, OIG staff assisted the contractor staff in identifying 
complaints assigned to them by walking them through certain fields in 
the database.  The contractor had been looking only for complaints 
listed under one region, but the contractor was in fact assigned to 
complaints from multiple regions.   
Table 2:  Timeframes for Contractors To Start Work on Complaints 
Number of 
Timeframes for Contractors To Start Work on  Sampled  Percentage of  
Complaints After Upload to CMS Information 
Complaints  Complaints 
System 
(n=117) 
Same day30 days  68  58.1% 
31120 days  15  12.8% 
Greater than 120 days  34  29.1% 
Source:  OIG analysis of contractor interviews and March 2010 version of CMSs information system, 2010. 
 
CMSs processes for transmitting complaints to contractors are ad hoc and 
inefficient 
The processing, distribution, and assignment of complaints described by 
CMS and contractors contribute to delays in transmitting complaints 
from the CMS central office to contractors.  Such delays add to the time 
it takes to resolve complaints. 
  Batch processingComplaints are not immediately available to 
contractors when OIG sends the complaints to CMS.  An IT staff 
member at the CMS central office must first upload the batch of 
complaints to CMSs information system; this may add days or 
weeks to the date that the complaints are available to contractors to 
research and resolve. 
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 F I N D I N G S  
  Incomplete distribution listAfter uploading the complaints, an IT 
staff member sends electronic notices to the CMS regional office 
staff and to the MACs for which the IT staff member has email 
addresses.  However, a CMS IT staff member stated that CMSs 
electronic distribution list for sending notice of new complaints does 
not contain all contractors.  Staff from only 5 of 14 claims processing 
contractors reported that they receive electronic notices of pending 
complaints.  Staff from the remaining nine contractors reported that 
they check the information system daily or weekly to determine 
whether new complaints have been assigned to them. 
  Inconsistent timing of complaint assignmentStaff from the 
10 CMS regional offices electronically assign any remaining 
complaints that contractors did not self-assign.  Staff from two CMS 
regional offices said that the timing of their assignment of 
complaints is determined by their workload.  Staff at a third 
regional office said that they assign complaints within 10 days of the 
electronic notice.  Staff from four CMS regional offices indicated that 
they are unsure how long they should wait (to give contractors a 
chance to self-assign complaints) between receiving the electronic 
notice of new complaints and assigning unassigned complaints.   
 
Long timeframes and inefficient 
Lack of guidance and an inadequate information 
processes contribute to delays in 
system hinder complaint processing 
contractors starting work on 
complaints, whereas a lack of 
guidance and an inadequate information system hinder complaint 
processing.  Some CMS and contractor staff reported the need for 
written guidance defining their roles and responsibilities for processing 
hotline complaints.  Although CMS provides some guidance to 
contractors, some CMS and contractor staff stated that guidance is 
lacking for processing complaints from receipt through resolution.  In 
addition, the status of complaints cannot be tracked in CMSs 
information system.  Because there is little written guidance to inform 
CMS and contractor staff on their roles and responsibilities for 
processing complaints and an inadequate information system, CMS and 
contractor staff use inconsistent processes to handle complaints.  
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F FF  III NNN DDD III NNN GGG SSS    
 
CMS and contractor staff lack written guidance defining staff roles and 
responsibilities for processing complaints 
CMS staff.  Staff from 8 of 10 CMS regional offices reported that they 
have not received written guidance defining their responsibilities with 
respect to hotline complaints.  These staff told us they believed that 
written guidance would improve their work and would ensure consistent 
processes across regions.  Staff from one regional office remarked, Its 
hard to determine exactly what were supposed to do.  Its not all cut 
and dried.  Staff from the other two CMS regional offices told us that 
the guidance they were following had been developed by their regional 
offices as a standard operating procedure; it was not established or 
disseminated by the CMS central office.   
Staff from only three CMS regional offices reported receiving training in 
handling complaints.  These individuals reported that the training was 
conducted by their predecessors or other regional staff.  Absent written 
guidance and training, many regional staff reported relying on their 
colleagues in other regions for direction and advice.  As staff from one 
regional office stated, a typical interaction with a colleague in another 
region might be to discuss how a particular complaint should be 
handled, since the procedures to resolve [complaints] are not set in 
stone. 
Regional staff mentioned specific content areas that should be covered 
in the written guidance, such as how to determine to which line of 
business (e.g., Medicare Parts A, B, C, or D, or Medicaid) a complaint 
refers and how to transfer complaints to other contractors when they 
are misassigned or require handling by a program integrity contractor.  
Although staff from all 10 CMS regional offices reported having a 
contact list for contractors, they reported that these lists were 
self-developed and not national in scope.  Without written guidance, it is 
difficult for CMS regional staff to assign complaints to the correct 
contractor.   
Contractor staff.  Nearly all contractors identified the Program Integrity 
Manual and their internally developed policies and procedures as 
sources of written guidance.  However, one-third of contractors reported 
that further guidance on contractor responsibilities could improve their 
operations.  For example, staff from one contractor stated, We are 
unsure about all of our responsibilities.  We would like to know what 
CMS explicitly expects us to do.  Staff from another contractor 
remarked, [We would like] procedures on how CMS would like to see 
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complaints handled, to ensure we are in compliance with what CMS 
wants.  Staff from two CMS regional offices echoed the need for clearer 
guidance to contractors. 
Challenges with CMSs information system hinder complaint processing 
Staff from each of the 10 CMS regional offices and staff from 15 of the 
24 contractors responded that they have encountered challenges 
working with CMSs information system.  Those most frequently 
mentioned were the inability to track the status of the complaint and 
the inability to determine which contractor is assigned to the complaint, 
as a complaint can be transferred from one contractor to another.  This 
affects the ability of CMS and contractor staff to determine what work 
has been done on the complaint and the status of any transfers of the 
complaint to another contractor.  As staff from one contractor 
summarized, We need to be able to know which complaints are actually 
assigned to us and what the status is of each complaint.  Also, when a 
complaint involves more than one provider type (e.g., a physician and a 
DME provider), the information system is unable to indicate that more 
than one contractor is assigned.   
We encountered similar challenges when attempting to identify which 
contractors had been assigned to the sampled complaints.  When we 
selected the sample of complaints for review in April 2009, CMSs 
information system identified no contractor for 24 percent of the sample.  
We used other information in the system to attempt to identify the 
assigned contractor, but for 13 percent of the sampled complaints we 
were unable to do so. 
Contractors reported that they do not use the information system to 
track activities on complaints during their review of allegations; rather, 
they use their internal databases for this purpose.  Staff from six 
contractors reported that the CMS information system has inadequate 
fields to store information. 
Staff from four regional CMS offices reported maintaining a record of 
hotline complaints (e.g., an Excel spreadsheet) separate from CMSs 
information system.  These staff reported using such a record for a 
variety of purposes, such as tracking hotline complaint numbers, dates 
of contractor assignment, and dates that hardcopy documentation 
arrives in the regional office and is sent to the contractor.  Staff from 
one CMS regional office stated that the information system needs to be 
changed so that for each complaint, it would track which contractor took  
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 F I N D I N G S  
action, when the action occurred, and why the action was taken, so that 
staff will not have to maintain separate records for these purposes.
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 R E C O M M E N D A T I O N S  
 
CMS widely publicizes the 1-800-HHS-TIPS hotline as an avenue that 
individuals may use to provide information that may assist in 
combating fraud, waste, or abuse in Federal health care programs.  
Health care fraud is estimated to be in the billions of dollars each year.  
HHS emphasizes that Medicare beneficiaries are the front line of 
defense in detecting Medicare fraud because they have firsthand 
knowledge of the health care services they have received.     
At least 1 year after receiving complaints through the 1-800-HHS-TIPS 
hotline, CMS had resolved the majority of them, but 12 percent 
remained unresolved.  Long timeframes and inefficient processes delay 
starting work on complaints.  Additionally, lack of guidance and an 
inadequate information system hinder complaint processing. 
When researched and resolved, hotline complaints can lead to 
recovering overpayments and identifying fraud.  Therefore, it is 
important for CMS to have a clear and consistent approach in place to 
process hotline complaints.  
To address these findings, we recommend that CMS: 
Issue written guidance for processing hotline complaints 
CMS should issue guidance defining the roles and responsibilities of 
CMS and contractor staff and timeframes for assigning, researching, 
and resolving complaints.  If applicable, CMS may need to amend 
appropriate contracts to reflect any new contractor requirements, 
responsibilities, and/or timeframes.  As part of the guidance, CMS 
should create and maintain a national contact list of contractors, 
including staff names, contact information, and contract numbers 
associated with each contractor.  Such a list would assist CMS and 
contractor staff in accurately assigning and transferring complaints to 
contractors. 
Upgrade its information system for processing hotline complaints 
CMS should ensure that its information system tracks user activity on 
each complaint and that the system can handle complaints that have 
multiple provider types and contractors.  It should alert CMS when 
complaints have not been assigned.  CMS should establish an electronic 
method to deliver hardcopy documents submitted by complainants so 
they are received at the same time as the complaints.   
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R E C O M M E N D A T I O N SS   
 
AAGGEENNCCYY  CCOOMMMMEENNTTSS  AANNDD  OOFFFFIICCEE  OOFF  IINNSSPPEECCTTOORR  GGEENNEERRAALL  
RESPONSE 
In its written comments on the draft report, CMS concurred with our 
recommendations.  In response to our first recommendation, CMS 
stated that it will create written guidance that defines the specific roles 
and responsibilities for CMS and its contractor staff to achieve greater 
clarity in administration of its database (i.e., its information system).  
Where they are not already established, CMS will establish timeframes 
for assigning, researching, and resolving complaints.  CMS stated that 
it is revising its national contractor list to include contact names and 
contract numbers associated with the contractors.  As appropriate, CMS 
will amend contracts to reflect any new contractor requirements, 
responsibilities, or timeframes.  In response to our second 
recommendation, CMS stated that it is upgrading and updating the 
database with the following features:  auditing mechanisms to track 
user activity, contractor assignments, and status of complaints; the 
ability to handle complaints that have multiple provider types and 
contractors; and the capacity to alert CMS when complaints have not 
been assigned.  CMS stated that it will work with OIG to establish an 
electronic method to deliver hardcopy evidence received from 
complainants along with the electronic complaint.  We did not make any 
changes to the report based on CMSs comments.  The full text of CMSs 
comments on the draft report can be found in Appendix C.
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 A P P E N D I X   ~   A  
Flowchart of Processing of Complaints Received Through the 
1-800-HHS-TIPS Hotline and Referred to the Centers for 
Medicare & Medicaid Services*  
Complainant calls or writes to thehotline;OIG
determines whether the issue rises to the level of a
complaint; if it does, information is entered intoOIG
hotline database;OIG analyst reviews database
information and generates a cover sheet for each
complaint
Concurrently, OIG mails toCMS central office the
complaint cover sheet andhardcopy documentation
packages and sends an electronic file of complaint
information toCMS IT staff
Electronic
Hardcopy CMS central office IT staff upload file toCMS
database, and complaints are electronically
CMS central office staff sort documents assigned toCMS regional offices; regional office
and mail to regional office staff** staff and contractors are electronically notified of
new complaints
Regional office staff sort documents and Contractor staff self-assign complaints in their
mail to appropriate contractor and assign jurisdiction; regional office staff assign remaining
remaining complaints to contractors** complaints
Contractor staff research and resolve
complaints; notify complainants of
resolution; update status of the
complaints in theCMS database
 
*CMS. 
**Sorting and mailing often occur after electronic notice. 
 
 
Source:  Office of Inspector General (OIG) interviews, 2009.
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 A P P E N D I X   ~   B  
Table B-1:  Point Estimates and Confidence Intervals 
Sample  Point  95-Percent 
Statistic 
Size  Estimate  Confidence Interval 
Percentage of complaints not resolved by the Centers for Medicare 
120  12.5%  7.8%19.5% 
& Medicaid Services (CMS) 
Percentage of complaints resolved by CMS  120  87.5%  80.5%92.2% 
Percentage of complaints with allegations researched and no problems 
120  31.7%  24.2%40.2% 
found 
Percentage of complaints confirmed as services billed in error  120  31.7%  24.2%40.2% 
Percentage of complaints confirmed as illegal activity  120  10.8%  6.5%17.5% 
Percentage of complaints with allegations involving services with claim 
paid amounts of less than $100; complaints closed and retained for  120  5.8%  2.9%11.5% 
provider tracking 
Percentage of complaints with insufficient allegation information; 
120  5.0%  2.3%10.5% 
complaints closed with no action 
Percentage of complaints referred to another agency  120  2.5%  0.8%7.2% 
Average number of days between the date that complaints were 
uploaded to CMSs information system and the date that contractors  117  163.2 days  121.2 days205.3 days 
reported starting work on them 
Percentage of complaints that contractors were unaware had been 
120  21.7%  15.4%29.7% 
assigned to them 
Percentage of complaints on which contractors started work the same 
117  58.1%  49.3%66.5% 
day to 30 days after CMS uploaded them to its information system 
Percentage of complaints on which contractors started work between 
31 days and 120 days after CMS uploaded them to its information  117  12.8%  8.0%19.9% 
system 
Percentage of complaints on which contractors started work more than 
117  29.1%  21.8%37.6% 
120 days after CMS uploaded them to its information system 
Source:  Office of Inspector General (OIG) analysis of simple random sample of 120 complaints forwarded from OIG to CMS, 2010. 
 
 
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AGENCY COMMENTS 
DEPARTMENT OF HEALTH & HUMAN SERVICES  Centers tor Medicare & Medicaid Services 
Administrator 
Washington. DC 20201 
JAN 1 9 2011 
DATE: 
TO:  Daniel R. Levinson 
Inspector General 
FROM.:  Donald M. Berwick, M.D. 
Administrator 
SUBJECT: 	 Office ofInspector General (OIG) Draft Report: "eMS' Processing of 
Complaints Received Through the I-SOO-HHS-TIPS Hotline" (OEl-07-09-00020) 
The Centers for Medicare & Medicaid Services (eMS) appreciates the opportunity to review and 
comment on the Office of Inspector General (orG) draft report entitled "eMS' Processing of 
Complaints Received through the I-SOO-HRS-TIPS Hotline." The purpose of this report was to 
evaluate complaints received through the 1-800-HHS-TIPS Hotline, which individuals may llse 
to provide infonnation that may assist in combating fraud, waste, and abuse in the Department of 
Health and Human Services programs (Le., Medicare, Medicaid, Head Start and child support 
enforcement). 
The eMS takes complaints received from the 1-800-HHS-TJPS Hotline and from other sources 
seriously. These complaints play an important role in helping eMS and OIG in reducing and 
fighting fraud, waste, and abuse in the Medicare Program. Some complaints lead to new 
investigations and/or are incorporated into existing investigations. These complaints are also 
used to support revocation. deactivation, and/or suspension actions taken against providers and 
suppliers. 
The report accurately reflects the current process by which eMS and its contractors handle these 
referrals and in identifying the areas where improvement is needed.  CMS has already begun 
working to update, standardize, and improve the current internal handling and oversight 
monitoring procedures to address a number ofthe concerns expressed in the report.  Additional 
system changes are in development that will allow more effective screening, tracking of user 
activity, contractor assignments, and complaint status.  We are working with OIG on many of 
these changes. 
We appreciate the orG's efforts in working with eMS to assist in the complaints process.  Our 
response to each orthe 010 recommendations follows. 
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 A P P E N D I X   ~   C  
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 A C K N O W L E D G M E N T S  
 
This report was prepared under the direction of Brian T. Pattison, 
Regional Inspector General for Evaluation and Inspections in the 
Kansas City regional office, and Deborah K. Walden, Deputy Regional 
Inspector General.   
Tricia Fields served as the team leader for this study.  Other principal 
Office of Evaluation and Inspections staff from the Kansas City regional 
office who contributed to the report include LCDR Mike Garner and 
Dennis Tharp; central office staff who contributed include Robert 
Gibbons, Scott Manley, Megan Ruhnke, and Arianne Spaccarelli.  
 
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Office of Inspector General 
http://oig.hhs.gov 
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 
amended, is to protect the integrity of the Department of Health and Human Services 
(HHS) programs, as well as the health and welfare of beneficiaries served by those 
programs.  This statutory mission is carried out through a nationwide network of audits, 
investigations, and inspections conducted by the following operating components: 
Office of Audit Services 
The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting 
audits with its own audit resources or by overseeing audit work done by others.  Audits 
examine the performance of HHS programs and/or its grantees and contractors in carrying 
out their respective responsibilities and are intended to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and 
mismanagement and promote economy and efficiency throughout HHS. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud, waste, or abuse and promoting 
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations 
of fraud and misconduct related to HHS programs, operations, and beneficiaries.  With 
investigators working in all 50 States and the District of Columbia, OI utilizes its resources 
by actively coordinating with the Department of Justice and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to criminal 
convictions, administrative sanctions, and/or civil monetary penalties. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to 
OIG, rendering advice and opinions on HHS programs and operations and providing all 
legal support for OIGs internal operations.  OCIG represents OIG in all civil and 
administrative fraud and abuse cases involving HHS programs, including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program guidance, publishes fraud alerts, and provides other 
guidance to the health care industry concerning the anti-kickback statute and other OIG 
enforcement authorities.