Who will watch the watchers? OIG-HHS reviews contractors' handling of CMS hotline tips

by Ben Vernia | March 27th, 2011

On March 18, the Office of Inspector General of HHS issued a report on its review of the handling of tips reported to the Center for Medicare and Medicaid Services (CMS) via its well-publicized telephone hotline for tips on fraud, waste and abuse. Although the OIG-HHS operates the hotline, it forwards the information it receives to CMS for handling. According to the OIG-HHS:

Long timeframes and inefficient processes delay starting work on complaints. Contractors reported starting work on 58 percent of complaints within 30 days of CMS’s receipt of the complaints from OIG, but for 29 percent of complaints, contractors took more than 4 months to start work. Some CMS and contractor staff described processes that contribute to delays in transmitting complaints from the CMS central office to contractor staff. Such delays add to the time that it takes to resolve complaints. Finally, lack of guidance and an inadequate information system hinder complaint processing. Although CMS provides some guidance to contractors, some CMS and contractor staff stated that guidance is lacking for processing complaints from receipt through resolution. In addition, the status of complaints cannot be tracked in CMS’s information system.

We recommended that CMS (1) issue written guidance to its own staff and contractor staff for processing hotline complaints and (2) upgrade its information system for processing complaints.

In its written comments on the report, CMS concurred with our recommendations. CMS stated that it will create written guidance that defines the specific roles and responsibilities for CMS and its contractor staff to achieve greater clarity in administration of its database (i.e., its information system). Where they are not already established, CMS will establish timeframes for assigning, researching, and resolving complaints. CMS stated that it is revising its national contractor list to include contact names and contract numbers associated with the contractors. CMS stated that it is upgrading and updating the database with the following features: auditing mechanisms to track user activity, contractor assignments, and status of complaints; and the capacity to alert CMS when complaints have not been assigned. CMS stated that it will work with OIG to establish an electronic method to deliver hardcopy evidence received from complainants concurrently with the electronic complaint.

Having an effective tip line is a key element in Corporate Integrity Agreements the OIG-HHS negotiates with companies in settlement discussions in health care fraud cases.

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