Department of Health & Human Services OIG

When Congress established average sales price (ASP) as the basis for reimbursement for Medicare Part B drugs (generally, drugs that are injected or infused in physicians’ offices or hospital outpatient settings), it also provided a mechanism for monitoring market prices and limiting potentially...

Effective in 2018, the Medicare program changed the way it sets payment rates for clinical diagnostic laboratory tests (lab tests). CMS replaced the previous payment rates with new rates based on private payer data collected from labs. This is the first reform in 3 decades to Medicare's payment...

From January 1, 2016, through May 31, 2018 (audit period), Medicare paid $1.5 billion for knee, back, and ankle-foot braces (selected orthotic braces) provided to Medicare beneficiaries. Prior OIG audits and evaluations found that some suppliers of durable medical equipment, prosthetics, orthotics...

Under the Medicare home health prospective payment system (PPS), the Centers for Medicare & Medicaid Services pays home health agencies (HHAs) a standardized payment for each 60-day episode of care that a beneficiary receives. The PPS payment covers intermittent skilled nursing and home health aide...

From July 1, 2016, through December 31, 2018 (audit period), Medicare paid approximately $4 billion for orthotic braces provided to Medicare beneficiaries. Prior OIG audits and evaluations found that some suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) billed...

Prior OIG audits identified Medicare overpayments to hospitals that did not comply with Medicare's post-acute-care transfer policy (transfer policy). CMS generally concurred with our recommendations, but subsequent analysis that we conducted indicated that CMS's system edits were still not properly...

Nurse staffing is a key contributor to the quality of care provided in nursing homes. This review, initiated before the COVID-19 pandemic emerged, focuses on staffing data from 2018. However, the 2020 pandemic reinforces the importance of adequate staffing for nursing homes, as inadequate staffing...

The Social Security Act requires that each Medicare administrative contractor (MAC) have its information security program evaluated annually by an independent entity. The Centers for Medicare & Medicaid Services (CMS) contracted with Guidehouse, LLP (Guidehouse), to evaluate information security...