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OIG - Processing of Hotline tips

OIG - Processing of Hotline tips

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Published by: Govtfraudlawyer on Mar 22, 2011
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Report Template Update: 04-03-08
Department of Health and Human Services
OFFICE OFIN
 
SPECTOR GENERAL
CMS’
S
P
ROCESSING OF
C
OMPLAINTS
R
ECEIVED
T
HROUGH THE
1-800-HHS-TIPS
 
H
OTLINE
 
Daniel R. Levinson
 Inspector GeneralMarch 2011OEI-07-09-00020
 
 I N T R O D U C T I O N
Report Template Update: 04-03-08
OEI-07-09-00020 CMS’
S
P
ROCESSING OF
C
OMPLA INTS
R
ECEIVED
T
HROUGH
1-800-HHS-TIPS
i
 
M M A R YE X E C U T I V E S U
 
E X E C U T I V E S U M M A R Y
OBJECTIVE
 
To assess the Centers for Medicare & Medicaid Services’ (CMS)processing of complaints received through the 1-800-HHS-TIPS hotline.
BACKGROUND
Many Offices of Inspector General (OIG) operate hotlines to respond tocitizen and employee allegations of fraud, waste, or abuse in Federalprograms. The Department of Health & Human Services (HHS) OIGmaintains such a hotline (1-800-HHS-TIPS), for individuals to provideinformation that may assist in combating fraud, waste, or abuse in HHSprograms (e.g., Medicare, Medicaid, child support enforcement, andHead Start). Individuals may call the hotline or send their writtenconcerns by email, postal mail, or fax.We obtained a copy of the hotline complaint data in CMS’s informationsystem as of March 2009. We identified 1,427 complaints that OIGforwarded to CMS in the first 6 months of 2008. From these, weselected a simple random sample of 120 complaints. We telephonedstaff at each contractor assigned to the sampled complaints to inquireabout what initial research the contractor performed to validate eachcomplaint; how and when the contractor contacted the complainant; andwhat outcomes (e.g., recouping an overpayment from the provider)resulted from the contractor’s actions on the complaint. We alsoconducted structured telephone interviews with contractor staff, CMScentral office staff, and CMS regional office staff about the complaintprocess. Finally, to check the status of complaints 1 year after weinitially received the hotline complaint data, in March 2010 we obtaineda copy of the hotline complaint data in CMS’s information system.
FINDINGS
At least 1 year after receiving complaints through the1
-
800
-
HHS
-
TIPS hotline, CMS had resolved the majority of them,but 12 percent remained unresolved.
CMS has no requirementsregarding the length of time within which contractors should resolvecomplaints. Our period of review allowed at least 1 year to elapse afterCMS received the complaints from OIG. As of March 2010, interviewswith contractors and a review of data in CMS’s information systemconfirmed that CMS resolved or closed administratively 88 percent of complaints received during the first 6 months of 2008. (Complaints are
 
 E X E C U T I V E S U M M A R YE X E C U T I V E S U M M A R Y
Report Template Update: 04-03-08
OEI-07-09-00020 CMS’
S
P
ROCESSING OF
C
OMPLA INTS
R
ECEIVED
T
HROUGH
1-800-HHS-TIPS
ii
closed administratively if they are below the dollar-amount thresholdrequired for research or if the information in the complaint isinsufficient to conduct further work.) Overall, 32 percent of complaintswere confirmed as services billed in error. Eleven percent of complaintsinvolved allegations of fraud. Contractors closed 11 percent of complaints administratively. For another 32 percent, contractorsresearched complaints and found no problems. Two percent of complaints were referred to another agency. CMS had not resolved12 percent of the complaints it received during our period of review.
Long timeframes and inefficient processes delay starting work oncomplaints.
For 58 percent of complaints, contractors reported startingwork within 30 days of CMS’s receipt of the complaints from OIG, butfor 29 percent of complaints, contractors took more than 4 months tostart work. Included in the latter group are complaints that contractorswere unaware had been assigned to them (22 percent of all complaints).Only following our inquiry did the contractors begin work on thesecomplaints. CMS and contractor staff described processes thatcontribute to delays in transmitting complaints from the CMS centraloffice to contractor staff. Such delays add to the time that it takes toresolve complaints.
Lack of guidance and an inadequate information system hindercomplaint processing.
Some CMS and contractor staff reported theneed for written guidance defining their roles and responsibilities forprocessing hotline complaints. Although CMS provides some guidanceto contractors, some CMS and contractor staff stated that guidance islacking for processing complaints from receipt through resolution. Nowritten procedures for processing complaints exist at the level of theCMS central office; however, staff from two CMS regional officesreported developing standard operating procedures for handlingcomplaints. Most contractors have developed internal policies andprocedures for handling complaints; however, some contractors desiredguidance from CMS. In addition, the status of complaints cannot betracked in CMS’s information system.

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