In its semiannual report to Congress, the Department of Health and Human Services (HHS) Office of Inspector General (OIG), the leading agency focused on combating health care fraud, said that its work led to billions in savings from October 1, 2024, to March 31, 2025.
Indeed, OIG’s total monetary impact during the six-month reporting period was $16.61 billion, including $3.51 billion in investigative receivables, $451 million in audit receivables, and $12.65 billion in potential cost savings, according to Juliet T. Hodgkins, acting inspector general.
“OIG consistently delivers a strong return on investment (ROI) through its oversight and enforcement,” Hodgkins said in the opening message of the report. The ROI, she said, is $11 in expected recoveries for every $1 invested.
The watchdog’s enforcement and oversight not only protects taxpayer dollars but also improves the quality and efficiency of HHS programs, she said.
By the numbers
During the six-month period, OIG:
- Published 78 reports, including audit reports, evaluations, and findings in response to Office of Special Counsel whistleblower disclosures
- Made 165 actionable recommendations to HHS
- Closed 946 criminal, civil, and administrative investigations of fraud and abuse related to HHS programs
- Implemented 290 recommendations made to HHS
- Excluded 1,503 untrustworthy individuals and entities from federally funded health care programs for several reasons, including conviction for Medicare or Medicaid fraud
- Made 298 criminal informations and indictments, formal accusations of a crime against an individual or entity by a grand jury or prosecuting attorney
- Crafted 1,209 referrals to federal, state, or local jurisdictions to consider for prosecution
- Involved in 349 criminal actions, such as convictions, that occurred upon determination of an individual or entity’s guilt or sentencing
- Participated in 395 civil actions, including settlements and judgments
Hodgkins said fraudsters have grown more sophisticated, but OIG’s law enforcement agents use cutting-edge data and investigative techniques to pursue and stop them.
“The magnitude of harm identified by OIG is consequential,” she wrote, noting that one investigation led to a 12-year prison sentence for a home health agency operator, who was also ordered to pay more than $99 million in restitution for her part in a fraud scheme involving billing for services never provided and kickbacks.
Potential Medicare Advantage fraud and abuse
One particular focus area for the OIG is fraud, waste, and abuse in the Medicare Advantage risk adjustment program, which provides higher payments to Medicare Advantage plans that cover sicker members, Hodgkins said. During the six-month reporting period, OIG issued three audits that found $13.6 million in net overpayments to three Medicare Advantage plans due to incorrect diagnosis coding used to calculate risk adjustment payments.
Furthermore, an OIG evaluation found that diagnoses reported only on health risk assessments (HRAs) 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. Inaccurate diagnoses from these in-home HRAs and associated chart reviews may have resulted in improper payments.
Hodgkins also pointed out that a Medicare Advantage plan that OIG investigated will pay up to $98 million to resolve alleged violations of the False Claims Act from submitting or causing the submission of invalid diagnosis codes to Medicare to increase the risk-adjusted payments it received. She said OIG will continue to monitor the Medicare Advantage plan as part of a corporate integrity agreement.