Department of Health and Human Services: Office of Inspector General’s use of agreements to protect the integrity of federal health care programs : report to Congressional requesters
- Collection:
- Health Policy and Services Research
- Contributor(s):
- United States. Government Accountability Office, issuing body. United States. Congress, issuing body.
- Publication:
- Washington, DC : United States Government Accountability Office, April 2018
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Delivery of Health Care Fraud -- prevention & control Government Programs Insurance Claim Review United States United States. Department of Health and Human Services. Office of Inspector General.
- Genre(s):
- Technical Report
- Abstract:
- Why GAO did this study. HHS-OIG has the authority to exclude providers and other entities that have committed certain acts, such as submitting false or fraudulent claims, from participation in federal health care programs. However, HHS-OIG can enter into agreements--CIAs and IAs--with providers and other entities as an alternative to exclusion. HHS-OIG is responsible for negotiating such agreements--which it typically does at the same time the Department of Justice (DOJ) is negotiating a legal settlement to resolve related allegations--and then monitoring the entities' compliance with them. GAO was asked to review HHS-OIG's use of these agreements. This report describes (1) the number of agreements and their general characteristics; (2) the circumstances that may lead to an agreement and the standard provisions of agreements; and (3) monitoring efforts and actions taken, if any, in response to noncompliance with the agreements. GAO examined agreements entered into from July 2005 (when HHS-OIG created its database) through July 2017 (most current at the time of GAO's analyses) and used HHS-OIG data to describe agreements' characteristics and actions to address noncompliance. GAO reviewed HHS-OIG documentation, including agreement templates and a selection of agreements to identify standard provisions. GAO also interviewed HHS-OIG and DOJ officials. GAO provided a draft of this report to HHS and DOJ. The agencies provided technical comments, which were incorporated as appropriate. What GAO Found. To help improve adherence to federal health care program requirements by entities that have allegedly engaged in certain acts, such as submitting false or fraudulent claims, the Department of Health and Human Services' Office of Inspector General (HHS-OIG) entered into 652 agreements with those entities from July 2005 to July 2017. Since 2010, two types of agreements have been used: Corporate Integrity Agreements (CIA) and Integrity Agreements (IA). The more commonly used CIAs apply to larger entities, compared to IAs, which apply to individual practitioners or small businesses. From July 2005 through July 2017, about half of all agreements were with 3 types of entities--individual or small group practices, hospitals, and skilled nursing facilities. For new agreements since July 2005, the most common initial allegations that led to an entity entering into an agreement included billing for services not provided and providing medically unnecessary services. When negotiating agreements, HHS-OIG uses one of six templates that address the different types of entities or conduct involved. Across agreements the provisions are generally similar--for example, requirements to provide training on specified topics or to hire a compliance officer. HHS-OIG uses multiple strategies to oversee agreements, such as requiring periodic reports from the entities that demonstrate compliance and assigning a monitor to review these reports and conduct site visits. HHS-OIG can also take certain actions to address noncompliance. For example, for new agreements from July 2005 through July 2017, HHS-OIG imposed monetary penalties 41 times, ranging from $1,000 to more than $3 million (median of $18,000), and excluded 4 entities from participation in federal health care programs.
- Copyright:
- The National Library of Medicine believes this item to be in the public domain. (More information)
- Extent:
- 1 online resource (1 PDF file (ii, 27 pages))
- Illustrations:
- Illustrations
- NLM Unique ID:
- 101765942 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/101765942