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What triggers an HHS OIG investigation?

The United States Department of Health and Human Services (HHS) Office of Inspector General (OIG) ensures HHS programs run smoothly. This agency holds those who abuse the program accountable for their wrongdoing by, when necessary, pursuing criminal charges.

How does the agency know when an investigation is needed?

In most cases, the agency begins an investigation after it receives a complaint. The agency generally receives complaints from a whistleblower. A whistleblower is one who has inside information that supports an allegation of fraudulent conduct. This could be a nurse, fellow medical practitioner or administrative assistant.

Once it receives a complaint, the OIG will conduct a preliminary inquiry based on the information provided within the complaint. A more thorough investigation may result after the agency completes the preliminary review. This initial inquiry generally includes a review of the following:

  • Jurisdiction. First, the agency will review the allegation to ensure it covers a regulation that is under the jurisdiction of the OIG. An example includes allegations a health care provider violated the False Claims Act.
  • Severity. The OIG will next review the impact of the allegation on the health and safety of the public as well as the impact on other federal programs.
  • Collaboration. The HHS OIG may reach out to other federal agencies to assist in the investigation.

The agency may call for a more thorough investigation if the findings gathered during this preliminary investigation support the claims made in the complaint.

What action is recommended if a health care facility or individual receives notification of an OIG investigation?

It is wise to take the matter seriously. The investigation can trigger a review from medical licensing boards and may lead to criminal charges. Those who are in this situation have options. An attorney experienced in health care law matters can review the claims and begin building a defense to better ensure a favorable outcome.

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