The Honorable Christi A. Grimm, who served as the sixth inspector general of the U.S. Department of Health and Human Services (HHS) until January, reflected on her tenure, the historic work of the Office of Inspector General (OIG), and vulnerabilities in managed care during a fireside chat at RISE West 2025.
Grimm, who began her career in 1999 as an evaluator in OIG’s Office of Evaluation and Inspections, rose through the ranks to become the sixth inspector general for HHS in 2022, following her nomination by the president and confirmation by the Senate. She managed a team of more than 1,500 doctors, investigators, evaluators, attorneys, and data and technology specialists who oversee approximately $2 trillion in HHS spending.
Her tenure with the federal government ended in January following President Donald Trump’s decision to terminate several inspectors general who oversaw cabinet-level agencies.
She discussed her work with Ari Yampolsky, founding partner of Whistleblower Partners, during a much-anticipated fireside chat this week at RISE West. Her comments were personal and don’t represent HHS-OIG.
Thoughts on the historic role of inspectors general
The role of the OIG and all inspectors general in government is to work for taxpayers. “We are your eyes and ears,” Grimm said.
She explained that inspectors general got their start following Watergate. Congress wanted better visibility, insights, and checks on what was happening within the executive branch and established tools to fight fraud-based corruption. The modern version of the HHS-OIG inspector general began in 1976 in what was then known as the Health Education Welfare, now the Department of Health and Human Services. Two years later, Congress passed, and President Jimmy Carter signed into law, the Inspector General Act of 1978.
Today there are more than 70 inspectors general for departments across government. Approximately 30 of those inspectors general are presidentially appointed and then Senate confirmed. The Senate confirmation process is critically important, she said, because it is meant to review their qualifications with the key one being that they are non-partisan. Their mission is to promote economy and efficiency in government programs. However, the HHS-OIG is unique in the scope and magnitude of what it does. It touches the lives of all Americans through its public health programs, wellness programs, insurance, and the role it plays in childhood development.
“And so, if HHS touches the lives of all Americans, so too does the inspector general in the Office of Inspector General,” Grimm said, noting that when she left the office, the resources within the department included 1,500 staff, a robust data unit, and a comprehensive toolkit. The office generates prevention guidance, fraud alerts, data briefs, and tools the industry can use to police itself.
“The impacts that OIG has are also very vast and return roughly $12 for every $1 taxpayers invest in it,” she said, noting that its work helps to protect the integrity of scientific medical research and patients in nursing homes and hospitals. Grimm encouraged attendees to think of the work of the OIG as prevention, detection, and enforcement. “They detect problems, cure problems, and prevent them from recurring.”
Thoughts on emerging risks and vulnerabilities in managed care
Managed care, she said, sits at the heart of how health care is delivered.
When Medicare + Choice (now known as Medicare Advantage) was first established, lawmakers believed there was a low risk within the program for health care fraud. At the time, she said, they didn’t envision that incentives within the program might drive patients to appear sicker and then not necessarily deliver on those services.
Grimm said she thinks about risk in three buckets: money, care delivery, and technology.
In the money bucket, she looks at the fact that the industry medical loss ratio is “shooting through the roof,” and there is increased utilization in hospice, preventive services, and mental health needs. In addition to the need for mental health services, there is also a shortage of providers in that space.
On top of those issues, Grimm said there are the pressures of expensive new drugs, gene therapies, and provider rates. That places a lot of pressure on plans financially, so she predicts government oversight will look at what this means for patient care.
“Are services being delivered? Are they stinted in critical areas? What do these factors look like when they play out with network adequacy? So, it raises a lot of questions when you are looking at what's happening financially and what incentives that creates. HHS OIG is always going to be looking at incentives for the way the program operates and where there might be achievements for abuse next in care delivery,” she said.
Although risk adjustment continues to be a concern, Grimm said that CMS is now investing a lot of resources in RADV audits, which she notes is something HHS-OIG has long recommended. “It really does take that amount of time for a program to pay attention and to implement the recommendations that OIG puts out. And that's an important thing to know about any inspector's general office. They can pinpoint problems, and they can recommend collection of overpayments, program improvements, and authoritative oversight, but they can’t be seen to administer the program; they have to be independent from that.”
Because there are people who work at CMS who previously worked for OIG and have a history of running program integrity, Grimm expects OIG will not want to duplicate resources and instead of focusing on risk adjustment, may pivot to patient experience, such as are patients getting access to post-acute care, are dual eligibles getting the services they need, and are patients being steered into plans where it’s expected they will pay more out-of-pocket costs.
As for technology, she said it brings enormous potential to optimize processes and flag problems earlier to potentially improve outcomes, but there are also risks. She expects that the government may want to look at clinical decision supports used, biases within algorithms, or whether populations are disproportionately disadvantaged by those algorithms. “I do think that if not now, it will be on the government's radar, as will accountability and transparency. If a decision is being made by an algorithm, plans are absolutely going to need to explain how it was made,” she said.
Medicare Advantage plans, she said, can get clues into what OIG will be focused on based on its work plan. She advised attendees to look at the recommendations the watchdog makes to CMS and states and take advantage of the tools it provides in its toolkit.