Department of Health and Human Services 

OFFICE OF

INSPECTOR GENERAL

 

Daniel R. Levinson 

Inspector General 

August 2011 

OEI-05-09-00560 

 

MIAMI INDEPENDENT 

DIAGNOSTIC TESTING 

FACILITIES’ COMPLIANCE WITH 

MEDICARE STANDARDS 
OEI - 0 5 - 0 9 - 00560 MIAMI I NDEPENDENT D IAGNOSTIC T ESTING FACILITIES ’ C OMPLIANCE W ITH MEDICARE S TANDARDS i 

OBJECTIVES

1. To determine whether Independent Diagnostic Testing Facilities 

(IDTF) in the Miami area complied with selected Medicare 

standards requiring IDTFs to be at the locations on file with the 

Centers for Medicare & Medicaid Services (CMS) and to be open 

during business hours.

2. To describe CMS actions against IDTFs that did not comply with 

these standards. 

BACKGROUND

IDTFs, a type of Medicare provider, offer diagnostic services and are 

independent of a physician’s office or hospital. Medicare allowed almost 

$1 billion for IDTF claims for 2.4 million beneficiaries in 2010. Of this, 

$23.4 million was for claims by IDTFs in the Miami area.

IDTF services have historically been vulnerable to abuse. In site visits 

in 1997, the Office of Inspector General (OIG) found that 20 percent of 

IDTFs were not at the locations on file with CMS. A 2001 OIG review of 

IDTF claims projected $71.5 million in improper Medicare payments. 

To comply with Medicare standards, IDTFs must maintain a physical 

facility at the location on file with CMS and be open during business 

hours. IDTFs that do not comply with Medicare standards are subject 

to a variety of administrative actions, including revocation of their 

billing privileges.

To determine whether IDTFs in the Miami area were at the locations on 

file with CMS and were open during business hours, we conducted 

unannounced site visits to all IDTFs with fixed practice locations. We 

also determined the amount that Medicare allowed for noncompliant 

IDTFs and reviewed documentation about CMS actions against 

noncompliant IDTFs. 

FINDINGS

Twenty-seven of the ninety-two Miami-area IDTFs failed to comply 

with selected Medicare standards. Twenty-three IDTFs were not at 

the locations on file with CMS. Four IDTFs were not open during 

business hours. Of the 27 noncompliant IDTFs, 14 submitted claims 

representing services performed on the same dates that site reviewers 

visited their locations. 

 EXECUTIVE SUMMARY
OEI - 0 5 - 0 9 - 00560 MIAMI I NDEPENDENT D IAGNOSTIC T ESTING FACILITIES ’ C OMPLIANCE W ITH MEDICARE S TANDARDS ii

EXECUTIVE SUMMARY

CMS took action against most of the noncompliant IDTFs as a result 

of a special enrollment project and routine oversight. CMS took 

action against 23 of the 27 noncompliant IDTFs in the months after we 

completed our site visits. A special enrollment project resulted in 

13 actions against noncompliant IDTFs, and routine oversight resulted 

in 10 actions against noncompliant IDTFs. 

Three IDTFs against which CMS took action received Medicare 

payments while CMS was revoking their billing privileges. Medicare 

continued to pay 3 of the 12 noncompliant IDTFs while the revocations 

of their billing privileges were being finalized. CMS took an average of 

17 weeks to remove these three IDTFs from Medicare. Between the 

time when CMS determined that they were noncompliant and the time 

when the revocations were finalized, Medicare allowed $146,000 for 

claims submitted by these IDTFs.

RECOMMENDATIONS

Periodically conduct unannounced site visits to IDTFs. Periodically 

conducting nationwide unannounced site visits to IDTFs may enable

CMS to identify and remove nonoperational IDTFs from the program 

and potentially reduce erroneous Medicare payments. CMS could focus 

unannounced site visits on high-risk areas or base them on fraud-risk 

assessments. 

Immediately stop payments to noncompliant IDTFs whose billing 

privileges are being revoked. CMS should immediately stop payments 

to noncompliant IDTFs as soon as there is enough evidence to begin the 

revocation process. Currently, CMS may continue to pay providers 

between the time when they are determined to be noncompliant and the 

time when their revocations are finalized. These payments should be 

retroactively recouped; however, previous OIG work demonstrates that 

many Medicare overpayments are not recovered. If CMS immediately 

stops payments while concurrently pursuing appropriate action against 

noncompliant IDTFs, it will help avoid loss of Medicare funds. 
OEI - 0 5 - 0 9 - 00560 MIAMI I NDEPENDENT D IAGNOSTIC T ESTING FACILITIES ’ C OMPLIANCE W ITH MEDICARE S TANDARDS iii

EXECUTIVE SUMMARY

AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL

RESPONSE 

CMS concurred with our recommendations. CMS stated that it 

anticipates increasing the frequency of unannounced site visits to 

IDTFs. CMS also stated that it is exploring options to use payment 

suspensions in conjunction with revocation actions for providers and 

suppliers that are found to be nonoperational. We did not make any 

changes to the report based on CMS’s comments. 
 

 

 TABLE OF CONTENTS

EXECUTIVE SUMMARY ................................ ..... i

INTRODUCTION ............................................ 1 

FINDINGS .................................................. 9 

Twenty-seven of the ninety-two Miami-area IDTFs failed to

comply with selected Medicare standards .................... 9 

CMS took action against most of the noncompliant IDTFs 

as a result of a special enrollment project and routine oversight . 11

Three IDTFs against which CMS took action received Medicare 

payments while CMS was revoking their billing privileges ..... 13

 

RECOMMENDATIONS ..................................... 14

Agency Comments and Office of Inspector General Response ... 15

APPENDIXES ............................................. 16

A: Independent Diagnostic Testing Facility Standards ........ 16

B: Detailed Methodology................................ . 20

C: Agency Comments ................................... 23

ACKNOWLEDGMENTS ..................................... 26
OEI - 0 5 - 0 9 - 00560 MIAMI I NDEPENDENT D IAGNOSTIC T ESTING FACILITIES ’ C OMPLIANCE W ITH MEDICARE S TANDARDS 1 

OBJECTIVES 

1. To determine whether Independent Diagnostic Testing Facilities 

(IDTF) in the Miami area complied with selected Medicare 

standards requiring IDTFs to be at the locations on file with the 

Centers for Medicare & Medicaid Services (CMS) and to be open 

during business hours.

2. To describe CMS actions against IDTFs that did not comply with 

these standards. 

BACKGROUND

Medicare covers inpatient and outpatient clinical and diagnostic 

services. These services can be provided in a number of settings, 

including physicians’ offices, hospitals, and IDTFs. IDTFs, a type of 

Medicare provider, offer diagnostic services and are independent of a 

physician’s office or hospital.1 Medicare allowed almost $1 billion for 

IDTF claims for 2.4 million beneficiaries in 2010. Medicare allowed 

$23.4 million for claims by Miami-area IDTFs in 2010. 

Services that may be provided by an IDTF include, but are not limited 

to, magnetic resonance imaging, ultrasound, x-rays, and sleep studies. 

Although some IDTF services can be performed remotely, such as 

pacemaker monitoring, most IDTF services require a patient to be 

present at a facility. 

Historical Vulnerabilities

IDTF services have historically been vulnerable to fraud, waste, and 

abuse. IDTFs were originally known as Independent Physiological 

Laboratories (IPL). In 1997, after becoming concerned that IPL services 

were vulnerable to abuse—in particular, citing a lack of certification 

requirements and confusion about the type of services that IPLs should 

provide—CMS issued new standards to address these vulnerabilities.2, 3 

The new standards modified staffing, certification, and documentation 

requirements for IPLs. IPLs were also renamed IDTFs to help clarify 

their function.4

1 42 CFR § 410.33(a)(1).

2 62 Fed. Reg. 59048, 59071–72 (Oct. 31, 1997).

3 62 Fed. Reg. 59048, 59100–01 (Oct. 31, 1997) (adding 42 CFR § 410.33).

4 62 Fed. Reg. 59048, 59071–72 (Oct. 31, 1997).

 INTRODUCTION
OEI - 0 5 - 0 9 - 00560 MIAMI I NDEPENDENT D IAGNOSTIC T ESTING FACILITIES ’ C OMPLIANCE W ITH MEDICARE S TANDARDS 2 

INTRODUCTION

Also in 1997, the Office of Inspector General (OIG) conducted site visits 

to IPLs. In an August 1998 report based on these visits, OIG reported 

that 20 percent of IPLs were not at the locations on file with CMS.5 In 

the report, OIG also projected $11.6 million in improper payments for 

IPL services and expressed concerns that the new standards that CMS 

had issued would not be sufficient to reduce the vulnerabilities that OIG 

had identified.6

Despite the new standards, problems with IDTF services persisted. In a 

2001 review of IDTF services, OIG identified claims that were not 

reasonable, necessary, ordered by a physician, or sufficiently 

documented and projected $71.5 million in improper payments.7 In 

2007, CMS reported that it had denied $163 million in IDTF charges 

and terminated Medicare billing privileges for 83 IDTFs in 

Los Angeles.8

In May 2009, the Health Care Fraud Prevention and Enforcement 

Action Team (HEAT) initiative was launched to increase efforts to 

reduce Medicare fraud. A collaboration between officials from the 

Department of Health and Human Services and the Department of 

Justice, the HEAT initiative builds upon existing programs that combat 

fraud and identifies new methods to prevent fraud.

 

Medicare Standards 

CMS designed the IDTF standards—most recently updated in 2008—to 

ensure that IDTFs and their staffs operate in accordance with 

appropriate business practices. Among other things, these standards 

require IDTFs to:

● maintain a physical facility, 

● be accessible during regular business hours, and 

5 OIG, Independent Physiological Laboratories: Vulnerabilities Confronting Medicare, 

OEI-05-97-00240, August 1998. 6 Ibid.

7 OIG, Review of Claims Billed by Independent Diagnostic Testing Facilities for Services 

Provided to Medicare Beneficiaries During Calendar Year 2001, A-03-03-00002, June 2006.

8 CMS testimony before the House Budget Committee, July 17, 2007. Accessed at 

http://www.cms.hhs.gov on Oct. 5, 2009. 
OEI - 0 5 - 0 9 - 00560 MIAMI I NDEPENDENT D IAGNOSTIC T ESTING FACILITIES ’ C OMPLIANCE W ITH MEDICARE S TANDARDS 3 

INTRODUCTION

● report any change in location to CMS within 30 days of the 

change.9 

See Appendix A for the 17 Medicare standards for IDTFs.

IDTF Enrollments

An IDTF that wishes to enroll in Medicare must submit an application. 

The application collects various types of information, including the 

address at which the IDTF will provide services and the services that it

will provide. 10 

An applicant must indicate whether it will provide services at a fixed 

location or whether it will be mobile or portable. A mobile or portable 

IDTF does not provide services at one fixed location. An applicant must 

submit a separate application for each IDTF practice location and for 

each mobile or portable unit.11 

Before approving an IDTF’s enrollment, CMS reviews the application 

and conducts an initial site visit. These processes may help to ensure 

that information on the application is correct and that the applicant 

complies with all 17 Medicare standards. 

Postenrollment Site Visits

According to the Medicare Program Integrity Manual, if an existing 

IDTF requests an expansion of services and if the new services are 

sufficiently different from those already provided, CMS must conduct a 

postenrollment site visit.12 For example, if an IDTF that provides sleep 

studies submits a request to start providing ultrasound tests, CMS is 

required to conduct a postenrollment site visit. 

In addition, CMS may conduct postenrollment site visits at its 

discretion.13 CMS cites unannounced postenrollment site visits as a 

successful way to determine whether IDTFs are operational and are at 

the locations on file with CMS.14 According to the Medicare Program 

9 42 CFR §§ 410.33(g)(2), (g)(3), and (g)(14)(i).

10 Form CMS-855B. Accessed at http://www.cms.hhs.gov on October 13, 2009.

11 CMS, Medicare Program Integrity Manual, Pub. No. 100-08, ch. 10, § 4.19.1(C). 

Accessed at http://www.cms.hhs.gov on February 3, 2011.

12 CMS, Medicare Program Integrity Manual, Pub. No. 100-08, ch. 10, § 4.19.6(C). 

Accessed at http://www.cms.hhs.gov on February 3, 2011.

13 42 CFR § 410.33(g)(14).

14 Preamble to final rule implementing sections of the Patient Protection and Affordable 

Care Act of 2010. 76 Fed. Reg. 5862, 5869 (Feb. 2, 2011). 
OEI - 0 5 - 0 9 - 00560 MIAMI I NDEPENDENT D IAGNOSTIC T ESTING FACILITIES ’ C OMPLIANCE W ITH MEDICARE S TANDARDS 4 

INTRODUCTION

Integrity Manual, when CMS conducts a site visit to verify the 

operational status of an IDTF, CMS should attempt to make its 

determination using only an external review of the IDTF. CMS requires 

that reviewers document their visits using written observations of the 

facilities and photographs as appropriate.15 

CMS Administrative Actions

CMS may take the following administrative actions against 

noncompliant or inactive providers, including IDTFs: 

● Investigation. CMS investigations may include site visits and 

interviews with IDTF staff and Medicare beneficiaries, as well 

as analysis of claims data. 

● Prepayment review. CMS reviews documentation from 

providers before deciding whether to pay claims.

● Payment suspensions. CMS may immediately suspend some or 

all payments to an IDTF if there is a credible allegation of fraud 

against that IDTF.16 

● Revocation. CMS may revoke Medicare billing privileges for an 

IDTF that does not comply with Medicare standards.17 

Medicare should not pay for services provided after the date of a 

provider’s revocation. If CMS determines that a provider is no 

longer operational, the date of revocation is the date of this 

determination.18 

● Deactivation. CMS may deactivate a provider’s billing 

privileges when an IDTF has not submitted claims for 

12 consecutive months.19 This reduces the risk that the billing 

privileges associated with that provider’s identification number 

will be used for fraudulent purposes. 

15 CMS, Medicare Program Integrity Manual, Pub. No. 100-08, ch. 15, § 20.1. Accessed 

at http://www.cms.hhs.gov on February 22, 2011.

16 CMS, Medicare Program Integrity Manual, Pub. No. 100-08, ch. 8, § 8.3.1.1. Accessed 

at http://www.cms.hhs.gov on August 16, 2011.

17 CMS, Medicare Program Integrity Manual, Pub. No. 100-08, ch. 15, § 15.27.2(A). 

Accessed at http://www.cms.hhs.gov on January 31, 2011. See also 42 CFR § 424.535(a)(1).

18 CMS, Medicare Program Integrity Manual, Pub. No. 100-08, ch. 15, § 15.27.2(B). 

Accessed at http://www.cms.hhs.gov on January 31, 2011. See also 42 CFR § 424.535(g).

19 CMS, Medicare Program Integrity Manual, Pub. No. 100-08, ch. 15, § 15.27.1. 

Accessed at http://www.cms.hhs.gov on January 31, 2011. See also 42 CFR § 424.540(a).
OEI - 0 5 - 0 9 - 00560 MIAMI I NDEPENDENT D IAGNOSTIC T ESTING FACILITIES ’ C OMPLIANCE W ITH MEDICARE S TANDARDS 5 

INTRODUCTION

South Florida High Risk Enrollment Project

Concurrently with our review, CMS conducted a special project—the 

South Florida High Risk Enrollment Project—that targeted fraud 

among specific provider types that are vulnerable to abuse. As part of 

the project, CMS conducted site visits to all IDTFs in South Florida to

verify their existence. 

CMS used the results of these site visits, along with other information, 

to create a fraud-risk score for each IDTF. IDTFs with high fraud-risk 

scores could be subject to a variety of administrative actions. In some 

cases, CMS used evidence from the site visits to take action against 

noncompliant IDTFs. 

Related Work

OIG is conducting a concurrent analysis of national IDTF claims data. 

This analysis identifies areas with high utilization of services provided 

by IDTFs, compares the patterns of IDTFs in these areas with the 

patterns of IDTFs nationally, and identifies IDTF claims with unusual 

characteristics.

OIG also completed a companion report assessing IDTFs in the 

Los Angeles area, Los Angeles Independent Diagnostic Testing 

Facilities’ Compliance With Medicare Standards (OEI-05-09-00561).

METHODOLOGY

We performed unannounced site visits in May 2010 to all IDTFs with

fixed practice locations in the Miami–Miami Beach–Kendall, FL Core 

Based Statistical Area (Miami area). We determined whether these 

IDTFs complied with selected Medicare standards requiring IDTFs to 

be at the locations on file with CMS and to be open during business 

hours. We also reviewed documentation about CMS actions against

noncompliant IDTFs. See Appendix B for a detailed description of our 

methodology.

Scope

We focused our review on IDTFs with fixed practice locations because it 

was not feasible to locate mobile or portable IDTFs for unannounced site 

visits. Mobile or portable IDTFs do not provide services at one fixed 

location.

We focused on IDTFs in the Miami area because this area was 

highlighted by concurrent OIG work as having—in comparison to other 
OEI - 0 5 - 0 9 - 00560 MIAMI I NDEPENDENT D IAGNOSTIC T ESTING FACILITIES ’ C OMPLIANCE W ITH MEDICARE S TANDARDS 6 

INTRODUCTION

areas in the country—both a high concentration of IDTFs and a high 

proportion of IDTFs with unusual billing patterns. 

We focused on IDTF standards 3 and 14, which require an IDTF to 

maintain a physical facility and to be accessible during regular posted 

business hours to CMS and beneficiaries.20 We focused on these 

standards to limit our interaction with IDTF staff and reduce the risk of 

alerting staff at potentially fraudulent IDTFs to our presence. 

Data Sources and Data Collection

Identifying IDTF locations. To identify IDTF locations for our Miami-area 

site visits, we first used the 2009 Part B National Claims History (NCH) 

file to identify IDTFs that submitted claims in 2009 for practice 

locations in the Miami area. We then located addresses for all 

107 IDTFs with fixed practice locations through the Provider 

Enrollment, Chain, and Ownership System and a data request to CMS. 

Site visits to IDTFs. We conducted unannounced site visits in 

May 2010 to determine whether these IDTFs maintained a physical 

facility at the location on file with CMS and were open during business 

hours. We recorded all observations using a standard form. 

Updates after site visits. To account for any changes in our information 

between the time when we identified our study population and the dates 

of our site visits, we requested address updates and changes in 

enrollment status from CMS for all IDTFs that we found to be 

noncompliant. 

CMS actions against noncompliant IDTFs. To describe CMS actions 

against noncompliant IDTFs following our site visits, we requested the 

results of the special enrollment project through December 2010. Along 

with these results, we received data about routine actions taken by 

CMS through December 2010 for these noncompliant IDTFs. 

Payments to noncompliant IDTFs. We used the 2010 Part B NCH file to 

determine how much Medicare allowed for services reportedly provided 

by noncompliant IDTFs. 

Analysis

Before analyzing our site visit results, we removed 15 IDTFs from our 

analysis. Eleven of these were no longer enrolled in Medicare at the 

20 42 CFR §§ 410.33(g)(3) and (g)(14).
OEI - 0 5 - 0 9 - 00560 MIAMI I NDEPENDENT D IAGNOSTIC T ESTING FACILITIES ’ C OMPLIANCE W ITH MEDICARE S TANDARDS 7 

INTRODUCTION

time of our site visits. We categorized four IDTFs as “unable to 

determine.” Our analysis was performed on the remaining 92 IDTFs.

Determining compliance. We determined compliance with IDTF 

standards 3 and 14 in the following manner:

● We determined that an IDTF was at the location on file with 

CMS if it maintained a physical facility with its name clearly 

marked somewhere other than a building directory (e.g., a sign 

on or near the primary entrance to the IDTF). 

● We determined that an IDTF was open if it was accessible to 

CMS and beneficiaries during regular business hours (i.e., the 

door was unlocked) during either of two visits on separate days.

IDTFs that did not meet at least one standard were considered 

noncompliant for the purposes of this report.

We aggregated the results of the site visits to determine the numbers of 

IDTFs that (1) maintained physical facilities at the locations on file with 

CMS and (2) were open during business hours. We also categorized site 

reviewers’ observations about what was found (e.g., a sign with a 

different business name) at the locations on file with CMS. 

Payments to noncompliant IDTFs. We calculated the total amount that 

Medicare allowed in 2010 for IDTFs that were not at the locations on 

file with CMS and for IDTFs that were not open. For each IDTF, we 

also calculated the amount Medicare allowed in 2010 following our site 

visit (i.e., from the date of our last site visit through December 2010). 

In addition, we determined the number of noncompliant IDTFs that 

submitted claims representing services provided on the same dates that 

site reviewers visited their locations and the amount that Medicare 

allowed for such services.

Review of CMS actions against noncompliant IDTFs. We reviewed CMS 

actions against the noncompliant IDTFs identified by our site visits. 

We determined for how many IDTFs CMS took each type of action 

(e.g., prepayment review) and whether the actions resulted from the 

special enrollment project or from routine oversight. We aggregated 

these results to determine the number of noncompliant IDTFs that CMS 

took action against after our site visits, as well as the number of 

noncompliant IDTFs that had been subject to each type of action. 

Further, we calculated the amount of time that CMS took to implement 

each revocation and determined whether the IDTF continued to receive 
OEI - 0 5 - 0 9 - 00560 MIAMI I NDEPENDENT D IAGNOSTIC T ESTING FACILITIES ’ C OMPLIANCE W ITH MEDICARE S TANDARDS 8 

INTRODUCTION

Medicare payments during the process. Revocation was the only CMS 

action for which we completed this analysis because it is the only one for 

which we had relevant data. To calculate how long CMS took to 

implement the revocation, we compared the date that CMS determined 

the IDTF was not compliant and the date that CMS finalized the 

revocation. We then calculated the amount that Medicare allowed for 

claims representing services provided by the IDTFs between these 

dates. 

Limitations

Because we reviewed compliance with only 2 of the 17 Medicare IDTF 

standards, we may be understating the number of noncompliant IDTFs 

in the Miami area. IDTFs must meet all 17 standards to be eligible to 

bill Medicare for services. 

Standards

This study was conducted in accordance with the Quality Standards for 

Inspection and Evaluation issued by the Council of the Inspectors 

General on Integrity and Efficiency.
OEI - 0 5 - 0 9 - 00560 MIAMI I NDEPENDENT D IAGNOSTIC T ESTING FACILITIES ’ C OMPLIANCE W ITH MEDICARE S TANDARDS 9 

 FINDINGS

Twenty-seven of the ninety-two Miami-area IDTFs Twenty-seven of the IDTFs in the 

failed to comply with selected Medicare Miami area were not at the 

locations on file with CMS or were standards

not open during business hours. 

Medicare allowed $2.6 million for services provided by these IDTFs in 

2010, $1.5 million of which was allowed after our site visits. An 

additional two IDTFs were open only during the second visits made to 

their locations. We considered these IDTFs open for the purposes of this 

review. 

Twenty-three IDTFs were not at the locations on file with CMS 

After taking into account the IDTFs that submitted address updates to 

CMS, we found that 23 of the IDTFs that we visited did not maintain a 

facility at the location on file with CMS. CMS requires all IDTFs to 

“[m]aintain a physical facility.”21 Medicare allowed $2 million for these 

23 IDTFs in 2010. 

As Table 1 shows, when site reviewers visited the locations on file with 

CMS, they found different businesses, unmarked office suites, and 

private residences with no indication that IDTFs were located there. In 

four cases, the street addresses on file with CMS did not exist or the 

suite numbers on file with CMS did not exist at the given street 

addresses. See Photo 1 for an example of an empty store front that site 

reviewers found at the location CMS had on file for one IDTF. 

Table 1

Description of 

the locations on 

file with CMS for 

23 noncompliant 

IDTFs

What OIG Found at Location on File

Description Number

Sign with a different business name 9

No sign indicating a business name 6

Nonexistent address/suite 4

Private residence with no sign indicating an IDTF 4

Total 23

Source: OIG unannounced site visits to IDTFs, May 2010.

21 42 CFR § 410.33(g)(3). 
OEI - 0 5 - 0 9 - 00560 MIAMI I NDEPENDENT D IAGNOSTIC T ESTING FACILITIES ’ C OMPLIANCE W ITH MEDICARE S TANDARDS 10

Photo 1

No name was 

posted to indicate 

that an IDTF was 

operational at this 

location.

 Source: OIG unannounced site visits to IDTFs, May 2010.

FINDINGS

Four IDTFs were not open during business hours

Four IDTFs maintained a visible sign at the location on file with CMS 

but were locked during business hours on 2 separate days. CMS 

requires that each IDTF “[b]e accessible during regular business hours 

to CMS and beneficiaries” and “[m]aintain a visible sign posting its 

normal business hours.”22

Two additional IDTFs were locked during business hours on the first 

day we visited and open on the second day. These IDTFs were 

considered open for the purposes of this report because they were open 

on the second visits. However, these IDTFs may have been open on our 

second visits because they had become aware of our review. 

 Site reviewers visited three of the four IDTFs 

during their posted business hours. The remaining IDTF did not have 

posted business hours and was visited during reasonable business hours 

(9 a.m. to 5 p.m.). Medicare allowed almost $600,000 for these four 

IDTFs in 2010. 

22 42 CFR § 410.33(g)(14).
OEI - 0 5 - 0 9 - 00560 MIAMI I NDEPENDENT D IAGNOSTIC T ESTING FACILITIES ’ C OMPLIANCE W ITH MEDICARE S TANDARDS 11

FINDINGS

Fourteen noncompliant IDTFs submitted claims representing services 

provided on the dates of their site visits

Fourteen of the noncompliant IDTFs submitted claims representing 

138 services performed on the same dates that site reviewers visited 

their locations. Medicare allowed $16,000 for 102 of these services. 

Eleven of the fourteen IDTFs that submitted claims were not at the 

locations on file with CMS, and three were not open during business 

hours. 

The services reportedly performed on the same dates as OIG’s site visits 

generally would have required a beneficiary to be physically present. 

The most common services billed on the dates of OIG’s site visit were 

x-ray services and lung and vascular studies. 

Submitting claims representing services provided at a noncompliant 

location raises suspicion that these services may not have been 

legitimate. These IDTFs may have changed locations without notifying 

CMS. However, IDTFs that change locations without notifying CMS 

within 30 days are no longer compliant with all Medicare standards. 

CMS took action against 23 of the CMS took action against most of the 27 noncompliant IDTFs in the 

noncompliant IDTFs as a result of a special months after we completed our 

enrollment project and routine oversight site visits. These actions included 

investigation, prepayment review, 

revocation of billing privileges, and deactivation of billing privileges. 

More than half of these actions were because of the special enrollment 

project. The rest were because of routine oversight that applies to all 

Medicare providers. See Chart 1 for the actions CMS took against 

noncompliant IDTFs identified by this report. 

The special enrollment project resulted in actions against 13 noncompliant 

IDTFs

As a result of the special enrollment project, CMS revoked the billing 

privileges of 10 noncompliant IDTFs and monitored 3 others with 

prepayment review. During the project, CMS conducted site visits to 

Medicare providers in South Florida, including IDTFs. As a result of 

this project, CMS took action against 13 noncompliant IDTFs that may 

not have been identified through routine oversight. 
OEI - 0 5 - 0 9 - 00560 MIAMI I NDEPENDENT D IAGNOSTIC T ESTING FACILITIES ’ C OMPLIANCE W ITH MEDICARE S TANDARDS 12

FINDINGS

0

2

4

6

8

10

12

14

Prepayment 

review

Revocation Deactivation Investigation

Number of CMS Actions

Special Enrollment Project

Routine Oversight

Chart 1

CMS actions 

against 

noncompliant 

IDTFs

Source: CMS actions against IDTFs, May 2010.

Routine CMS oversight resulted in 10 actions against noncompliant IDTFs

CMS revoked the billing privileges of two IDTFs, deactivated the billing 

privileges of six IDTFs, and investigated two others as a result of 

routine oversight. CMS revoked the billing privileges of two providers 

that submitted updated applications, but did not pass the application 

review. CMS deactivated the billing privileges of six IDTFs that had 

not submitted claims in the previous 12 months. In addition, CMS 

investigated two IDTFs.

CMS took no actions against four noncompliant IDTFs 

CMS determined that no action was needed for the remaining 

four noncompliant IDTFs. After the OIG site visits, CMS visited these 

four IDTFs as part of the special enrollment project and found them to 

be operational. 
OEI - 0 5 - 0 9 - 00560 MIAMI I NDEPENDENT D IAGNOSTIC T ESTING FACILITIES ’ C OMPLIANCE W ITH MEDICARE S TANDARDS 13

FINDINGS

Three IDTFs against which CMS took action Medicare continued to pay 3 of the 

12 IDTFs while the revocations of received Medicare payments while CMS was 

their billing privileges were being revoking their billing privileges finalized.23 CMS took an average 

of 17 weeks to finalize these three 

revocations. 

 Between the time when CMS determined that these three IDTFs were 

noncompliant and the time when the revocations were finalized, 

Medicare allowed $146,000 for claims representing services provided by 

these IDTFs. Most of this amount was for a single IDTF whose billing 

privileges were revoked 6 months after CMS determined that the IDTF 

was noncompliant. Medicare allowed $145,000 for 883 services for this 

IDTF in that time period.

The remaining two IDTFs were allowed just over $1,000 for claims 

submitted while the revocations were being finalized. One of these 

IDTFs received frequent payments for low-cost services. This IDTF was 

paid for 199 services over 14 weeks while the revocation was processed. 

The other IDTF was paid for two services over 12 weeks while the 

revocation was processed.

23 CMS revoked the billing privileges of 12 IDTFs. Ten revocations were based on special 

enrollment project site visits and two were based on routine oversight. 
OEI - 0 5 - 0 9 - 00560 MIAMI I NDEPENDENT D IAGNOSTIC T ESTING FACILITIES ’ C OMPLIANCE W ITH MEDICARE S TANDARDS 14

 RECOMMENDATIONS

Twenty-seven of the ninety-two IDTFs in the Miami area did not comply 

with selected Medicare standards. Twenty-three of these noncompliant 

IDTFs were not found at the locations on file with CMS and four were 

not open during business hours. Fourteen of these noncompliant IDTFs 

submitted claims representing services provided on the same dates that 

OIG site reviewers visited their locations. 

CMS also identified noncompliant IDTFs in the Miami area and was 

able to remove or monitor many of them. CMS actions included 

revocation of billing privileges, deactivation of billing privileges, 

prepayment review, and investigation. Three of the IDTFs continued to 

receive payments while their billing privileges were being revoked. 

These findings indicate that further actions are needed to protect the 

integrity of the Medicare program and protect beneficiaries from 

potentially fraudulent IDTFs. Therefore, we recommend that CMS:

Periodically conduct unannounced site visits to IDTFs 

CMS advocates the use of unannounced postenrollment site visits to 

determine whether providers are operational. Periodically conducting 

nationwide unannounced site visits to IDTFs may enable CMS to 

identify and remove nonoperational IDTFs from the program and 

potentially reduce erroneous Medicare payments. CMS could focus 

unannounced site visits on high-risk areas or base them on fraud-risk 

assessments. 

Immediately stop payments to noncompliant IDTFs whose billing privileges 

are being revoked

CMS should stop payments for any services delivered on or after the 

dates that CMS identified the IDTFs as noncompliant. Currently, CMS 

may continue to pay providers between the time when they are 

determined to be noncompliant and the time when the revocations of 

their billing privileges are finalized. These payments should be 

retroactively recouped; however, previous OIG work demonstrates that 

many Medicare overpayments are not recovered.24 If CMS immediately 

stops payments while concurrently pursuing appropriate actions against 

noncompliant IDTFs, it will help avoid loss of Medicare funds. 

24 OIG, Collection Status of Medicare Overpayments Identified by Program Safeguard 

Contractors, OEI-03-08-00030, May 2010. 
OEI - 0 5 - 0 9 - 00560 MIAMI I NDEPENDENT D IAGNOSTIC T ESTING FACILITIES ’ C OMPLIANCE W ITH MEDICARE S TANDARDS 15

RECOMMENDATIONS

AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 

RESPONSE 

CMS concurred with our recommendations. In response to our first 

recommendation, CMS stated that it anticipates increasing the 

frequency of unannounced site visits to IDTFs. CMS plans to compare 

IDTF enrollment information with public records to identify potential 

changes to enrollment information that would warrant further 

investigation. In response to our second recommendation, CMS stated 

that it is exploring options to use payment suspensions in conjunction 

with revocation actions for providers and suppliers that are found to be 

nonoperational. We did not make any changes to the report based on 

CMS’s comments. For the full text of CMS’s comments, see Appendix C.
OEI - 0 5 - 0 9 - 00560 MIAMI I NDEPENDENT D IAGNOSTIC T ESTING FACILITIES ’ C OMPLIANCE W ITH MEDICARE S TANDARDS 16

 APPENDIX~A

Independent Diagnostic Testing Facility Standards25

The [independent diagnostic testing facility (IDTF)] must certify in its 

enrollment [application] that it meets the following standards and 

related requirements:

(1) Operates its business in compliance with all applicable Federal and 

State licensure and regulatory requirements for the health and safety of 

patients.

(2) Provides complete and accurate information on its enrollment 

application. Changes in ownership, changes of location, changes in 

general supervision, and adverse legal actions must be reported to the 

Medicare fee-for-service contractor on the Medicare enrollment 

application within 30 calendar days of the change. All other changes to 

the enrollment application must be reported within 90 days.

(3) Maintain a physical facility on an appropriate site. For the purposes 

of this standard, a post office box, commercial mailbox, hotel, or motel is 

not considered an appropriate site.

(i) The physical facility, including mobile units, must contain space 

for equipment appropriate to the services designated on the 

enrollment application, facilities for hand washing, adequate 

patient privacy accommodations, and the storage of both business 

records and current medical records within the office setting of the 

IDTF, or IDTF home office, not within the actual mobile unit.

(ii) IDTF suppliers that provide services remotely and do not see 

beneficiaries at their practice location are exempt from providing 

hand washing and adequate patient privacy accommodations.

(4) Has all applicable diagnostic testing equipment available at the 

physical site excluding portable diagnostic testing equipment. The 

IDTF must— 

(i) Maintain a catalog of portable diagnostic equipment, including 

diagnostic testing equipment serial numbers at the physical site;

(ii) Make portable diagnostic testing equipment available for 

inspection within 2 business days of a [Centers for Medicare & 

Medicaid Services (CMS)] inspection request.

25 These standards are taken verbatim from 42 CFR § 410.33(g).
OEI - 0 5 - 0 9 - 00560 MIAMI I NDEPENDENT D IAGNOSTIC T ESTING FACILITIES ’ C OMPLIANCE W ITH MEDICARE S TANDARDS 17

APPENDIX~A

(iii) Maintain a current inventory of the diagnostic testing 

equipment, including serial and registration numbers and provide 

this information to the designated fee-for-service contractor upon 

request, and notify the contractor of any changes in equipment 

within 90 days.

(5) Maintain a primary business phone under the name of the 

designated business. The IDTF must have its— 

(i) Primary business phone located at the designated site of the 

business or within the home office of the mobile IDTF units.

(ii) Telephone or toll free telephone numbers available in a local 

directory and through directory assistance.

(6) Have a comprehensive liability insurance policy of at least $300,000 

per location that covers both the place of business and all customers and 

employees of the IDTF. The policy must be carried by a 

nonrelative-owned company. Failure to maintain required insurance at 

all times will result in revocation of the IDTF’s billing privileges 

retroactive to the date the insurance lapsed. IDTF suppliers are 

responsible for providing the contact information for the issuing 

insurance agent and the underwriter. In addition, the IDTF must— 

(i) Ensure that the insurance policy [...] remain in force at all 

times and provide coverage of at least $300,000 per incident; and

(ii) Notify the CMS designated contractor in writing of any policy 

changes or cancellations.

(7) Agree not to directly solicit patients, which include[s], but is not 

limited to, a prohibition on telephone, computer, or in-person contacts. 

The IDTF must accept only those patients referred for diagnostic testing 

by an attending physician, who is furnishing a consultation or treating a 

beneficiary for a specific medical problem and who uses the results in 

the management of the beneficiary’s specific medical problem. 

Nonphysician practitioners may order tests as set forth in [42 CFR] 

§ 410.32(a)(3).

(8) Answer, document, and maintain documentation of a beneficiary’s 

written clinical complaint at the physical site of the IDTF[.] (For mobile 

IDTFs, this documentation would be stored at their home office.) This 

includes, but is not limited to, the following:

(i) The name, address, telephone number, and health insurance 

claim number of the beneficiary.
OEI - 0 5 - 0 9 - 00560 MIAMI I NDEPENDENT D IAGNOSTIC T ESTING FACILITIES ’ C OMPLIANCE W ITH MEDICARE S TANDARDS 18

APPENDIX~A

(ii) The date the complaint was received; the name of the person 

receiving the complaint; and a summary of actions taken to resolve 

the complaint.

(iii) If an investigation was not conducted, the name of the person 

making the decision and the reason for the decision.

(9) Openly post these standards for review by patients and the public.

(10) Disclose to the government any person having ownership, financial, 

or control interest or any other legal interest in the supplier at the time 

of enrollment or within 30 days of a change.

(11) Have its testing equipment calibrated and maintained per 

equipment instructions and in compliance with applicable 

manufacturers[’] suggested maintenance and calibration standards.

(12) Have technical staff on duty with the appropriate credentials to 

perform tests. The IDTF must be able to produce the applicable Federal 

or State licenses or certifications of the individuals performing these 

services.

(13) Have proper medical record storage and be able to retrieve medical 

records upon request from CMS or its fee-for-service contractor within 

2 business days.

(14) Permit CMS, including its agents, or its designated fee-for-service 

contractors, to conduct unannounced, on-site inspections to confirm the 

IDTF’s compliance with these standards. The IDTF must— 

(i) Be accessible during regular business hours to CMS and 

beneficiaries; and

(ii) Maintain a visible sign posting its normal business hours.

(15) With the exception of hospital-based and mobile IDTFs, a 

fixed-base IDTF is prohibited from the following:

(i) Sharing a practice location with another Medicare-enrolled 

individual or organization;

(ii) Leasing or subleasing its operations or its practice location to 

another Medicare-enrolled individual or organization; or

(iii) Sharing diagnostic testing equipment used in the initial 

diagnostic test with another Medicare-enrolled individual or 

organization.
OEI - 0 5 - 0 9 - 00560 MIAMI I NDEPENDENT D IAGNOSTIC T ESTING FACILITIES ’ C OMPLIANCE W ITH MEDICARE S TANDARDS 19

APPENDIX~A

(16) Enrolls for any diagnostic testing services that it furnishes to a 

Medicare beneficiary, regardless of whether the service is furnished in a 

mobile or fixed base location.

(17) Bills for all mobile diagnostic services that are furnished to a 

Medicare beneficiary, unless the mobile diagnostic service is part of a 

service provided under arrangement as described in section 1861(w)(1) 

of the [Social Security] Act.
OEI - 0 5 - 0 9 - 00560 MIAMI I NDEPENDENT D IAGNOSTIC T ESTING FACILITIES ’ C OMPLIANCE W ITH MEDICARE S TANDARDS 20

APPENDIX~B APPENDIX~B

Detailed Methodology

We conducted unannounced site visits to all Independent Diagnostic 

Testing Facilities (IDTF) with fixed practice locations in the 

Miami–Miami Beach–Kendall, FL Core Based Statistical Area (Miami 

CBSA) to determine whether they complied with selected Medicare 

standards. Specifically, we determined whether each IDTF was at the 

location on file with the Centers for Medicare & Medicaid Services 

(CMS) and was open during business hours. We then reviewed 

documentation about CMS actions against the noncompliant IDTFs and 

determined how much money Medicare allowed for services reportedly 

provided by these IDTFs in 2010.

Scope

We focused our review on IDTFs that submitted claims for Medicare 

payment in 2009 to concentrate our visits on IDTFs with recent activity 

in the Medicare program. At the time we developed our study 

population, data on claims from 2009 were the most recent available.

Data Sources and Data Collection

Identifying IDTF locations. We identified IDTFs that submitted claims in 

2009 using the specialty code and provider identification numbers 

(provider ID) fields in the 2009 Part B National Claims History (NCH) 

file. We counted each provider ID that had only claims with the 

specialty code 47 as an IDTF. We determined the CBSA to which each 

IDTF belonged by matching the ZIP Code field from the NCH with the 

ZIP Codes corresponding to each CBSA. We then selected the IDTFs in 

the Miami CBSA.

We located an address for each IDTF in the Miami CBSA with a fixed 

practice location using a combination of two sources. Our primary 

source was the practice location field from the Provider Enrollment, 

Chain, and Ownership System (PECOS).26 Most, but not all, IDTFs 

have enrollment information, such as their practice locations, stored in 

PECOS.27 When an IDTF did not have an address in PECOS, we 

26 PECOS is the system of record for Medicare provider enrollment information. PECOS 

is populated based on the initial provider enrollment application and updated any time a 

provider submits an updated application to CMS. 

27 An IDTF that enrolled before 2004 and has not submitted an updated application may 

not have an enrollment record in PECOS.
OEI - 0 5 - 0 9 - 00560 MIAMI I NDEPENDENT D IAGNOSTIC T ESTING FACILITIES ’ C OMPLIANCE W ITH MEDICARE S TANDARDS 21

APPENDIX~B

requested this information from CMS. This process resulted in 

addresses for 107 IDTFs in the Miami CBSA.28

Site visits to IDTFs. We conducted unannounced site visits to these 

107 IDTFs to determine whether they were at the locations on file with 

CMS and were open during business hours. We recorded all 

observations using a standard form. We conducted all site visits from 

May 17 through May 28, 2010. 

We designed our site visit protocol to ensure that we gave providers the 

benefit of the doubt when determining whether they complied with 

Medicare standards. For example:

● All visits to IDTFs were made during posted business hours if 

hours were posted or during reasonable business hours (9 a.m. 

to 5 p.m.) if none were posted.

● If an IDTF was locked, we made a second visit to that location 

on a different day. We considered IDTFs to be open if they were 

open on either the first visit or (if applicable) the second visit.

● When the building at an IDTF’s location on file with CMS was a 

multisuite office building, site reviewers searched for the IDTF 

by name as well as by suite number. We considered the IDTF to 

be at the location on file with CMS if site reviewers could find it 

in any suite or office space in the building.

● If an IDTF had a sign posted indicating that visitors should ring 

a buzzer or doorbell to enter the facility, site reviewers did so. If 

the door was opened (e.g., someone came to the door or the lock 

was released), we considered the IDTF to be open.

● If an IDTF had a sign posted indicating that services were

available by appointment only, a site reviewer attempted to 

make an appointment for services with that IDTF (e.g., called 

the phone number listed on the sign). If the site reviewer was 

able to make an appointment, we considered the IDTF to be 

open.

● If we found a different business name at the IDTF location on 

file with CMS, we attempted to determine whether the IDTF we 

were looking for was operating under the name we found. First, 

28 One IDTF with claims in 2009 was not identified either by PECOS supplier type or by 

CMS as being an IDTF. We removed this IDTF from our analysis.
OEI - 0 5 - 0 9 - 00560 MIAMI I NDEPENDENT D IAGNOSTIC T ESTING FACILITIES ’ C OMPLIANCE W ITH MEDICARE S TANDARDS 22

APPENDIX~B

we requested from CMS all names for IDTFs that we did not 

find and reviewed this information to ensure that we captured 

all possible aliases. Second, as a final check, we reviewed public 

Web sites, including the National Provider Identifier registry, to 

determine whether the IDTF we were looking for could be 

operating under the name we found. If we were able to connect 

the two names, we categorized the IDTF as being at the location 

on file with CMS. 

CMS actions against noncompliant IDTFs. Data received from the South 

Florida High Risk Enrollment Project (special enrollment project) 

through December 2010 included:

● administrative actions taken against noncompliant IDTFs, the 

source of these actions (i.e., special enrollment project activity 

or routine oversight), the effective dates of these actions, and 

the dates these actions were finalized by CMS; and

● dates and results of all special enrollment project site 

verification visits and in-depth investigations.

Analysis

Updates after site visits. CMS indicated that nine IDTFs had their 

billing privileges deactivated and two IDTFs had their billing privileges 

revoked before the dates of our site visits. We removed these 11 IDTFs 

from our analysis. 

IDTFs categorized as “unable to determine.” We removed four IDTFs 

from our analysis because we were unable to complete the full site visit 

protocol or were unable to access the door of the reported practice 

location. 
A P PEN D x c 


Agency Comments 

/,.....VIC~_~ . 

( DEPARTMENT OF HEALTH & HUMAN SERVICES Centers lor Medicare & Medicaid SOIVIc&s ,,5'r Admiflist1'ator 

Washington, DC 20201 

JUL 2 6 2011 DATE: 

TO: 	 Daniel R. Levinson 


Inspector General 


FROM: 	 Donald M. Berwick, M.D. 


Administrator 


SUBJECT: 	 Office ofInspector General (OIG) Draft Report: "Miami Independent Diagnostic 

Testing Facilities' Compliance with Medicare Standards" (OEI.05-09-00560) 

The Centers for Medicare & Medicaid Services (CMS) appreciates the opportunity to review and 

comment on the Office of Inspector General (OIG) draft report entitled, "Miami Independent 

Diagnostic Testing Facilities' Compliance with Medicare Standards." The purpose of this report 

is two-fold. First, it seeks to determine whether Independent Diagnostic Testing Facilities 

(IDTFs) in the Miami area complied with selected Medicare standards requiring IDTFs to be at 

the location on file with CMS and open during business hours. Secondly, it describes CMS 

actions against IDTFs that did not comply with these selected Medicare standards. 

IDTFs offer diagnostic services and are independent ofa physician'S office or hospital. 

According to OlG's report, Medicare paid almost $1 billion for IDTF claims for 2.4 million 

beneficiaries in 2010, Qfthis, $23.4 million was for claims by IDTFs in the Miami area. 

Medicare standards indicate that IDTFs must maintain a physical facility at the location on file 

with CMS and be open during business hours. IDTFs that do not comply with Medicare 

standards are subject to a variety ofadministrative actions, inclUding revocation of their billing 

privileges. 

The Affordable Care Act strengthens the focus on the integrity of the Medicare, Medicaid, and 

Children's Health Insurance Program (CHIP) programs and provides important new tools to 

combat fraud and abuse, including enhanced provider and supplier screening requirements; 

authority to suspend payments pending investigations of credible allegations of fraud; and, when 

necessary, authority to impose moratoria on new providers and suppliers. 

IDTF services have historically been vulnerable to abuse. As such, CMS is taking additional 

steps to address potential vulnerabilities in the enrollment and claims payment process for this 

supplier group using the authorities granted under the Affordable Care Act. Under the new 

oE1·0 5-09-00 560 MIAMI INDEPENDENT DIAGNOSTIC TESTING FACILITIES' COMPLIANCE WITH MEDICARE STANDARDS 23 
OE I - 0 5 - 0 9 - 00560 MIAMI I NDEPENDENT D IAGNOSTIC T ESTING FACILITIES ’ C OMPLIANCE W ITH MEDICARE S TANDARDS 24

APPENDIX ~ C
OEI - 0 5 - 0 9 - 00560 MIAMI I NDEPENDENT D IAGNOSTIC T ESTING FACILITIES ’ C OMPLIANCE W ITH MEDICARE S TANDARDS 25

APPENDIX ~ C
OEI - 0 5 - 0 9 - 00560 MIAMI I NDEPENDENT D IAGNOSTIC T ESTING FACILITIES ’ C OMPLIANCE W ITH MEDICARE S TANDARDS 26

 ACKNOWLEDGMENTS

This report was prepared under the direction of Ann Maxwell, Regional 

Inspector General for Evaluation and Inspections in the Chicago 

regional office, and Thomas Komaniecki, Deputy Regional Inspector 

General. 

Laura Kordish served as the team leader for this study, and Lisa Minich 

and Mara Werner served as lead analysts. 

We would also like to acknowledge the contributions of Office of 

Evaluation and Inspections central and regional offices. Contributing 

staff from these offices include Melissa Baker, Tim Chettiath, 

Ben Dieterich, Kevin Farber, Robert Gibbons, Jennifer Gist, 

Rose Goldberg, Melissa Hafner, Scott Horning, Maria Maddaloni, 

Dan Mallinson, Kevin Manley, Conswelia McCourt, Beth McDowell, 

Jeremy Moore, Christine Moundas, Brian Pattison, Margo Rodriguez, 

Megan Ruhnke, Rachel Siman, Arianne Spaccarelli, Mark Stiglitz, 

Holly Williams, and Chetra Yean.
 

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 OIG’s 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.