Kusserow on Compliance: OIG Hotline Complaints

Richard P. Kusserow | June 2016

By Richard Kusserow, former HHS Inspector General and CEO of Compliance Resource Center.  Reprinted from Wolters Kluwer‘s Kusserow on Compliance Blog

The Office of Inspector General (OIG) is required to provide a semi-annual report to Congress to summarize its activities (see Semiannual Report to Congress). 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 health care sector are unfamiliar with how this process operates. The Hotline is considered a significant avenue of intelligence for the OIG and is worth taking the time to understand.

The Hotline is set up so that individuals may call or send their written concerns by email, postal mail, or fax to the OIG. It is received within the Office of Investigations (OI), and serves as the “public face” of the OIG through analysis and processing of complaints and information received. This includes various other channels of communication, including, the OIG’s Fraud, Waste and Abuse Hotline; OIG’s Fugitive Hotline; and the CDC’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.

All complaints submitted to the Hotline are treated confidentially and are shared only within HHS for the purpose of evaluating the complaint. Complaints may be reported anonymously and the OIG promises whistleblower protection for anyone who files reports in this way. During the first six months of fiscal year (FY) 2015, the OIG Hotline had 74,018 contacts. A contact is the total number of instances when an individual contacted the OIG Hotline Operations, regardless of the nature of the contact, and whether the complaint 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 result 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 OIG’s jurisdiction. For issues that fall outside OIG’s jurisdiction or that do not rise to the level of a complaint, the OIG 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), customer service representatives (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.

About 5 percent of Hotline calls and correspondence result in complaint referral to an OIG field office, the appropriate HHS staff division or operating division (e.g., CMS), or another 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. This staff uses 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).

Matters referred to CMS 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 (ZPIC). 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 percent of the cases, CMS resolved or administratively closed the matters within six months of receipt. The results of the CMS actions on allegations are that most of the complaints related to error or there was an absence of a problem. Only about 11 percent involved fraud.

About the Author

Richard P. Kusserow established Strategic Management Services, LLC, after retiring from being the DHHS Inspector General, and has assisted over 2,000 health care organizations and entities in developing, implementing and assessing compliance programs.