HHS OIG Reports & Publications

Louisiana Healthcare Connections Prior Authorization Audit Findings

HHS OIG completed an audit of Louisiana Healthcare Connections (LHCC), a Louisiana Medicaid managed care organization, examining 76 sampled behavioral health service denials requiring prior authorization. LHCC complied with Federal and State requirements for 64 of 76 sampled denials (84%), but 12 denials failed to meet administrative or procedural requirements, primarily missing written notices of adverse determination. OIG estimates 3,209 prior authorization denials (15.8%) during the audit period did not comply with requirements.

Michigan Medicaid: Diabetes/Weight Loss Drugs Dispensed Per Requirements

The HHS Office of Inspector General (OIG) reported that selected diabetes and weight loss drugs dispensed to Michigan Medicaid managed care enrollees were in accordance with federal and state requirements. The audit found that Michigan ensured managed care organizations followed all applicable coverage and utilization requirements, including prior authorizations and quantity limits.

OIG Report: Part B Drug Payments Included Noncovered Self-Administered Versions, Increasing Costs

An HHS OIG report found that Medicare Part B payment amounts for the drug Omvoh included noncovered self-administered versions in 2024, increasing costs. Excluding these versions would have saved Part B and its enrollees an estimated $1,742 per vial in the fourth quarter of 2024. The report also noted that CMS's prior removal of noncovered self-administered versions for five other drugs saved $1.3 billion from 2023 through 2024.

HHS FISMA Compliance Report: Not Effective, 10 Recommendations Made

The HHS Office of Inspector General (OIG) has released a report rating HHS's compliance with the Federal Information Security Modernization Act (FISMA) for Fiscal Year 2025 as 'Not Effective' for the sixth consecutive year. The report details ten recommendations to improve HHS's information security program.

Medicaid Fraud Control Units Annual Report: FY 2025

The HHS OIG has released its annual report for Medicaid Fraud Control Units (MFCUs) for Fiscal Year 2025. The report details nearly $2 billion in combined criminal and civil recoveries, 1,185 convictions, and 900 exclusions from federal health care programs. It highlights trends in fraud and patient abuse investigations and prosecutions.

HHS OIG: Nursing Homes Misdiagnosed Residents to Mask Antipsychotic Drug Misuse

The HHS Office of Inspector General (OIG) issued a report finding that nursing homes inappropriately diagnosed residents with schizophrenia to mask the misuse of antipsychotic drugs and artificially inflate their star ratings. The OIG recommends that CMS expand its use of data to monitor these diagnoses and increase efforts to inform residents and families about antipsychotic drug use.

HHS OIG: Nursing Homes Misuse Antipsychotics on Dementia Residents

The HHS Office of Inspector General (OIG) issued a report finding that nursing homes inappropriately administer antipsychotic drugs to residents with dementia, often to manage behavior for staff benefit, despite FDA warnings of increased mortality risk. The report recommends CMS develop resources and increase transparency to reduce misuse and improve dementia care.

HHS OIG: Indiana Nursing Homes Generally Complied with Federal Background Check Requirements

The HHS Office of Inspector General (OIG) reported that Indiana nursing homes generally complied with federal requirements for employee background checks. Out of 825 employees reviewed, only 13 lacked completed background checks, and none had disqualifying offenses.

HHS OIG Audit of Gateway Health Plan Medicare Advantage Compliance

The HHS Office of Inspector General (OIG) audited Gateway Health Plan, Inc.'s submission of diagnosis codes to CMS for Medicare Advantage risk adjustment. The audit found that most sampled diagnosis codes were not supported by medical records, leading to an estimated $4.3 million in net overpayments for 2018 and 2019.

HHS OIG: Over $15 Million in Improper Medicare Payments for Non-Emergency Services

The HHS Office of Inspector General (OIG) reported that Medicare improperly paid physicians $922,524 and potentially $14.2 million to hospitals for services billed with emergency department procedure codes but rendered at non-emergency sites. The OIG recommends recovery of improper payments and improved claims processing controls.