Kusserow on Compliance: OIG Hotline complaints

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.

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.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2015 Strategic Management Services, LLC. Published with permission.

Fake hospice nurse with stolen identity treated 243 patients

A district judge sentenced a Dallas woman to 48 months in prison and ordered her to pay $233,000.00 in restitution following her guilty plea to one count of fraud in connection with means of identification. According to a Federal Bureau of Investigation (FBI) press release, the woman treated 243 hospice patients while posing as nurse with a stolen driver’s license, social security number, and other identification.


Jada Necole Antoine, who was not licensed as a physician, registered nurse, or other health care provider, stole a registered nurse’s driver’s license and social security card and then used those and other means of identification to obtain employment at eight different hospice companies. According to a report from the Dallas Morning News, Antoine was not even a high school graduate.

During her fraudulent employment, Antoine worked as a registered nurse and had direct responsibility for patient care and treated 243 patients. She treated a wide variety of patients, including those who were mentally ill, comatose, asleep, and otherwise unresponsive to sound and touch. She was involved in admitting patients into hospice care. Antoine violated patient privacy because patients routinely revealed parts of their bodies to her for examination that they would not have otherwise revealed, had they known about the truth of her qualifications. She also violated patient privacy by gaining access to patient charts and by speaking with staff and family members.


During the course of the fraud, Antoine received approximately $107,000 in compensation from the hospice agencies where she was fraudulently employed. Antoine’s fraud caused the hospice companies to submit claims to Medicare and Medicaid for the hospice services performed by her. According to the FBI, from approximately January 2009 through April 20, 2012, about $800,000 in hospice claims were submitted to Medicare for services purportedly performed by Antoine while she was impersonating the nurse whose identification she stole. She pleaded guilty on December 9, 2014.

Colorado won’t back down, challenges $12M disallowance in federal court

After the Departmental Appeals Board (DAB) recently found that CMS properly disallowed $12 million in federal financial participation (FFP) in Medicaid expenditures claimed by the Colorado Department of Health Care Policy and Financing (HCPF), the department filed suit against the federal government challenging that decision. The complaint alleges that HHS wrongly denied the $12 million in payments based on FFP services between 2000 and 2006.

DAB Decision

Previously, the DAB found that the HCPF’s claims over the FFP service payments were time barred. Specifically, the DAB found that section 1132 of the Social Security Act provided that claims for expenditures be filed within two years after the end of the quarter in question and the HCPF’s claims that the delay in filing was due to the time it took to ensure the submissions were accurate were irrelevant (see Colorado loses $12 million in federal funds for twiddling their thumbs, Health Law Daily, August 10, 2015).


The FFP services in question are related to the requirement that state Medicaid plans include outstationing services for low-income individuals to more easily access the Medicaid application process. These services are to be outstationed to alternative locations such as disproportionate share hospitals (DSHs) and federally qualified health centers (FQHCs). In the Colorado matter, Denver Health, an integrated health care network, received repayment for outstationing services but later CMS notified HCPF that it was disallowing $12,064,042 in FFP for those outstationing services provided by Denver Health.


The complaint before the district court for the District of Colorado asks the court to set aside the DAB’s decision and to allow Colorado to avoid repayment of the $12 million in FFP funds to the federal government. Specifically, the HCPF states that the DAB decision was arbitrary and capricious, and that the disallowance constitutes a violation of the Medicaid Act. In response to finding that the claims were time barred, the HCPF argues in its complaint that the two-year time period for claiming did not begin to run until the state made the payments to Denver Health or until Denver Health calculated the costs associated with outstationing and certified that those costs were eligible for Medicaid reimbursement.

CMS extends temporary moratoriums for some HHAs and ambulance suppliers

CMS has released a notice that its temporary moratorium on the enrollment of ambulance suppliers and home health agencies (HHAs) in designated geographic locations is being extended to combat fraud, waste, and abuse. CMS made the announcement in an advance release that covers metropolitan areas in Florida, Illinois, Michigan, Texas, Pennsylvania, and New Jersey.


Section 6401(a) of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) provided the HHS Secretary with the authority to impose a temporary moratorium on providers and suppliers in Medicare, Medicaid, or CHIP if it is determined that a moratorium is necessary to “prevent or combat fraud, waste, or abuse” in the programs.


In 2013, CMS imposed moratoriums on the enrollment of new HHAs in Miami-Dade County, Florida and in Cook County, Illinois and their surrounding counties. It also imposed moratoria on Part B ambulance suppliers in Harris County, Texas and its surrounding counties. The moratoriums were extended for another six months in 2014 and expanded to include HHAs located in Broward County, Florida; Dallas County, Texas; Harris County, Texas; and Wayne County, Michigan and their surrounding counties. The ambulance supplier moratoriums were also expanded to include Philadelphia, Pennsylvania and its surrounding counties.


CMS consulted with the HHS Office of Inspector General (OIG) and the Department of Justice (DOJ) in identifying two types of providers and suppliers in nine geographic areas that warranted temporary moratoriums. CMS also consulted with appropriate state Medicaid agencies and state departments of emergency medical services and determined that the moratoriums would not create access care issues for Medicaid or CHIP beneficiaries.


Under 42 C.F.R. Sec. 424.570(b), temporary moratoriums will remain in effect for six months, and may be extended in six-month increments. CMS consulted with HHS OIG and determined that there remains a significant potential for fraud, waste, and abuse in the identified geographic areas and the circumstances that warranted the moratoriums have not abated. Additionally, CMS has determined that the moratoriums are needed to allow it to continue to monitor and proceed with administrative actions against providers and suppliers. As a result, CMS is extending the temporary moratoriums for the enrollment of HHAs and ground ambulance suppliers in Medicare, Medicaid, and CHIP.