OIG publishes semiannual report to Congress
The Office of Inspector General (OIG) released the latest edition of its semiannual report to Congress, which details the agency’s oversight activities and enforcement actions between October 1, 2024, and March 31, 2025.
Overall, the OIG’s total monetary impact during this reporting period was $16.61 billion. The agency issued a total of 165 actionable recommendations across 78 reports over the six-month period, which could lead to nearly $13 billion in savings if implemented.
The report includes information that HHS can use to address its current top management and performance challenges, which were previously identified by the OIG in a 2024 report. For example, the OIG highlighted its recent audit work to help CMS prevent, reduce, and recover improper payments. The agency determined that Part D paid approximately $465.1 million for drugs for which payment was available under the Part A skilled nursing facility (SNF) benefit between 2018 and 2020. The OIG also found that Medicare may have improperly paid up to $454 million for claims that were not in accordance with the quantity limitation in the Over-the-Counter COVID-19 Test Demonstration, which ran from April 2022 to May 2023.
The report also highlights the OIG’s recent work to identify cost-saving opportunities. Notably, the agency discovered that Medicare could have saved roughly $7.7 billion with comparable access for enrollees between 2015 and 2020 if swing bed services at critical access hospitals were reimbursed using skilled nursing facility prospective payment system rates.
The OIG also detailed its findings from several audits of high-risk diagnosis codes that show CMS’ risk adjustment program overpaid approximately $13.6 million to three Medicare Advantage Organizations (UCare Minnesota, Blue Care Network of Michigan, and Triple-S Advantage, Inc.) from 2016 to 2019. In a separate audit, the OIG determined that diagnoses reported only on health risk assessments (HRA) and HRA-linked chart reviews generated $7.5 billion in Medicare Advantage risk-adjusted payments for 2023, and $4.2 billion of these payments came from in-home HRAs.
Other topics in the report include payments for opioid use disorder treatment, hospital price transparency compliance, cybersecurity, and more. Revenue integrity professionals should review the audits highlighted in the report to get up to speed on the OIG’s current oversight and enforcement priorities.
Editor’s note: Find more NAHRI coverage of OIG audits and reports here.