Over the past few months, a number of my articles have covered a combination of social injustices and oddities from federal agencies. In this article, I am going to refocus on a central source of information for many Monitor Monday listeners and RACmonitor readers: that is, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG).
Members of the HHS OIG wake up every day with the hope of helping the American people combat fraud, waste, and abuse. Preventing “fraud” ensures integrity in our public programs; reducing “waste” right-sizes the resources required; stymying “abuse” safeguards benefit recipients.
As I reported in my May 12 Monitor Monday segment1, and reiterated in a June 11 RACmonitor article2, the OIG has clearly, professionally delineated its method of public engagement from the ideologically driven online solicitations posted by HHS3 and thinly veiled threats from the Centers for Medicare & Medicaid Services (CMS4).
In the OIG’s own words, “tips pertaining specifically to waste, fraud, and abuse in Medicare, Medicaid, and/or HHS programs should be submitted to HHS-OIG via the agency’s hotline5”.
Since 1978, per 5 U.S.C. Chapter 4, the Inspector General reports its findings semiannually to the head of HHS and Congress, with the most recent report – covering October 2024 through March 2025 – made public on June 2 of this year6. Acting HHS Inspector General (IG) Juliet Hodgkins posted a 3:44 overview7 of the OIG’s oversight activity identifying fraud, waste, and abuse during that interval, as well as the enforcement actions taken.
Like any high-level summary, plenty of eye-popping numbers demonstrate the impact of the OIG’s work, but there is also detailed substance within the full document6, complete with links to the individual reports.
Despite the frequently flaunted phrase of “fraud, waste, and abuse” being fundamentally nebulous, the OIG is quite focused on what it defined in 2024 as the “top management and performance challenges facing HHS.” These include Public Health, Financial Integrity, Medicare & Medicaid, Beneficiary Safety, and Data & Technology Security6. Although the 30-page, reader-friendly semi-annual spring report contains numerous granular assessments, enforcements, and recommendations, here are five insights for readers to consider:
1) It’s a prolific body of work. In total, there were 946 Investigations completed and 78 reports issued. That is an average of one report produced every 2.3 days, including weekends and holidays. Now, even though many of the reports contain data analyses during prior periods of time, this is still an impressive volume of content that is being assembled and made public.
2) In public health, the opioid epidemic was front and center. McKinsey & Company agreed to pay $650 million to resolve allegations of wrongdoing in their consulting for Purdue Pharma. As the OIG noted, “the resolution marks the first time a management consulting firm has been held criminally responsible for advice resulting in the commission of a crime by a client.” Additionally, the OIG examined potential patient limitations in accessing care for substance use disorder through established, federally funded pathways. The FindTreatment.gov clearinghouse was reviewed for accuracy in contact and services information, and the OIG found inaccuracies appearing in approximately two-thirds of the listings on the website.
3) Opportunities exist for financial integrity. CMS’s payment methodology is vulnerable to overpayment errors, totaling approximately $1.1 billion in the programs audited. These range from accidental Part D drug payments when skilled nursing facilities (SNFs) were already receiving a Part A benefit payment to outpatient hospice service payments for hospitalized hospice patients already being paid on a per diem basis. While these improper payments were made to hardworking provider organizations, these mistakes skew resource allocation projections and cost taxpayers dearly.
4) Balancing rising CMS costs with potential savings. The OIG estimates that $7.7 billion over a six-year period could be “saved” by CMS if critical access hospitals (CAHs) adopted a reimbursement methodology akin to SNFs for swing-bed services. However, this would require a legislative change to the existing reimbursement model, and any reduction in payments to CAHs could result in closure of critically needed facilities. Additionally, any potential savings in this arena pale in comparison to the OIG’s anticipated $86 billion increase in Medicaid and Part D spending on weight-loss drugs between 2023 and 2026.
5) Abuses continue in some Medicare Advantage (MA) plans. An OIG audit found that some Medicare Advantage Organizations (MAOs) are still gaming the Health Risk Assessments (HRAs), to the tune of at least $4 billion annually. The OIG continues to investigate plans that improperly report health variables to inflate their risk-adjusted payments. Insert the estimates released by MedPAC earlier this year8, and that number could be 10 or 20 times higher. A Special Fraud Alert was also directed at marketing arrangements with brokers and agents who mislead or steer beneficiaries6. Coupling these audits and penalties with the articulated focus outlined by CMS in its May 21 Press Release9, one would predict there will be a concerted effort to curtail taxpayers’ annual largesse towards MAOs.
These are only five thematic takeaways. The full report provides granular details on particular providers and payors that were investigated and convicted of civil and/or criminal actions. The results are real: during this six-month window, there were 1,507 referrals to or indictments by federal, state, or local prosecutorial jurisdictions. And there were 744 civil or criminal actions, resulting in jail time, fines/penalties, and an additional 1,503 exclusions of individuals/providers from federally funded programs.
So, what will the OIG be up to during the next six months?
It will keep doing the people’s work – “same as it ever was”10.
References
1. Updike J. “Field Report”. Monitor Mondays. MedLearn Publishing, 635(14); May 12 2025. https://podcasts.apple.com/us/podcast/speak-no-evil-asking-docs-to-weigh-in-became-a-%24202/id1346217226?i=1000708154721.
2. Updike J. “HHS Review of Youth Gender Health Appears to Reach Foregone Conclusion”. RACmonitor. MedLearn Media, June 11 2025. https://racmonitor.medlearn.com/hhs-review-of-youth-gender-health-appears-to-reach-foregone-conclusion/.
3. Dept of Health & Human Services. “Whistleblower Tips and Complaints Regarding the Chemical and Surgical Mutilation of Children”. Apr 14 2025. https://www.hhs.gov/protect-kids/index.html.
4. Oz M. “Urgent Review of Quality Standards and Gender Transition Procedures”. CMS Newsroom. May 28 2025. https://www.cms.gov/newsroom/press-releases/cms-launches-oversight-initiative-hospitals-performing-experimental-sex-trait-modification.
5. Dept of Health & Human Services. “HHS OIG Hotline”. Office of the Inspector General. https://tips.oig.hhs.gov/.
6. Dept of Health & Human Service. “Spring 2025 Semiannual Report to Congress”. Office of Inspector General; OIG-SAR-SPRING-2025. June 2 2025. https://oig.hhs.gov/reports/all/2025/spring-2025-semiannual-report-to-congress/.
7. Hodgkins J. “Spring 2025 Semiannual Report to Congress”. Office of Inspector General; Newsroom(Videos). June 17 2025. https://oig.hhs.gov/newsroom/videos/hhs-oigs-spring-2025-semiannual-report-to-congress/.
8. The Medicare Payment Advisory Commission. “March 2025 Report to the Congress: Medicare Payment Policy”. MedPAC; Our Work. Mar 13 2025. https://www.medpac.gov/document/march-2025-report-to-the-congress-medicare-payment-policy/.
9. Centers for Medicare & Medicaid Services. “CMS Rolls Out Aggressive Strategy to Enhance and Accelerate Medicare Advantage Audits”. CMS Newsroom. May 21 2025. https://www.cms.gov/newsroom/press-releases/cms-rolls-out-aggressive-strategy-enhance-and-accelerate-medicare-advantage-audits 10. Talking Heads, Eno B. “Once in a Lifetime”. Remain in Light. Sire Records, Jan 1981.
EDITOR’S NOTE: The author of this article used AI-assisted tools in its composition, but all content, analysis, and conclusions were based on the author’s professional
The Centers for Medicare & Medicaid Services (CMS) operates a surveillance platform called the Fraud Prevention System (FPS) that analyzes Medicare claims across the full
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