On June 1, 2015, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) released its “Semiannual Report to Congress October 1, 2014-March 31, 2015.” The OIG is mandated to provide a semiannual report to Congress that summarizes their activities from the past fiscal year. Included in this report was a section on the OIG Hotline (1-800-HHS-TIPS), available to 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).
Many in the healthcare sector are unfamiliar with how this process operates but it is worth taking the time to understand. The OIG Hotline is set up so that individuals may call or send their written concerns by email, postal mail or fax to the OIG. All complaints submitted to the OIG Hotline are treated confidentially and are shared only within HHS for the purpose of evaluating your complaint. Furthermore, individuals can report complaints anonymously and are protected by the Whistleblower Protection Act of 1989.
The OIG Hotline is considered a significant avenue of intelligence for the OIG. Complaints are received within the Office of Investigations (OI) where it is processed and analyzed. The OI also receives complaints from various other channels of communication, including the OIG’s Fraud, Waste and Abuse Hotline, OIG’s Fugitive Hotline and the Center for Disease Control’s Select Agent and Import Permit Hotlines. The OIG accepts tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement in HHS programs.
During the first 6 months of FY 2015, the OIG Hotline had 74,018 contacts. A contact is the total number of instances when an individual contacted the OIG Hotline, regardless of the nature of the contact, and receives service through automated or manual means. Of that number there were 67,014 calls, of which 12,339 were operator assisted. Most contacts logged into the OIG Hotline database resulted in an investigation.
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Follow-Up On Complaints
The OIG makes a determination whether an issue rises to the level of a complaint and whether it falls within the OIG’s jurisdiction. For issues that fall outside the OIG’s jurisdiction or that do not rise to the level of a complaint, the OIG provide individuals contacting the OIG 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, they will be referred to call 1-800-MEDICARE. If callers have complaints involving Medicaid eligibility, the caller is referred to call their State Medicaid agencies. In contrast, if a caller alleges that a Medicare beneficiary was billed for services not received, it is logged as a complaint.
About five percent of hotline calls and correspondence resulted in complaint referral 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 one third of the complaints to their field offices for follow-up, slightly less than half to CMS, with the balance referred to other HHS operating divisions and other Federal agencies.
Staff in CMS’s central and regional offices, as well as staff at Medicare claims processing contractors, process complaints referred to CMS by OIG. They use an information system to assign, research, and resolve OIG- referred complaints. The database includes each complaint’s unique identifier, date of intake by OIG, date of entry into CMS’s information system, date of the complaint’s assignment to a CMS regional office and to a claims processing contractor, closure date, and resolution code (if applicable).
For those matters referred to CMS, they are forwarded to direct claims processing contractors to: (1) review complaint documentation and (2) determine whether fraud and/or abuse are suspected. If fraud and/or abuse are suspected, the matter is turned over to the Program Safeguard Contractor or Zone Program Integrity Contractor. In complaint resolution, claims processing contractors use a variety of research techniques, such as calling the beneficiary or provider and reviewing the claims’ history. A review of the CMS processing of complaints by the OIG found that in nearly 90% of the cases CMS resolved or administratively closed the matters within six months of receipt. The results related to CMS’ actions on allegations are that most of the complaints are related to error or it was found absence of a problem. Only about 11 percent involved fraud.