On June 2, 2025, the Department of Health and Human Services Office of Inspector General (HHS-OIG) announced the release of its Spring 2025 Semiannual Report to Congress. Covering the period from October 1, 2024, to March 31, 2025, the report is the first to be issued by HHS-OIG during this administration.
Because the period covered encompasses the prior administration, the report may provide limited insight into the priorities and operations of HHS-OIG in the current administration. But it indicates that HHS-OIG has remained active in seeking to combat healthcare fraud. Like prior semiannual reports, the report here touts HHS-OIG’s investigative and audit receivables, in this case totaling approximately $4 billion over the relevant period. The report also provides a new metric, explaining that HHS-OIG had identified $12.65 billion of “funds that HHS could use more efficiently if it took action to implement” HHS-OIG recommendations.1 The report highlights that, over the period at issue, HHS-OIG completed 946 criminal, civil and administrative investigations of fraud and abuse; excluded 1,503 individuals and entities from further participation in federally funded healthcare programs; made 1,209 criminal referrals; and pursued 395 civil actions.2
One noteworthy aspect of the report is its focus on Medicare Advantage, the portion of the Medicare program administered by private insurers that receive payments from the Centers for Medicare and Medicaid Services on a capitated risk-adjusted basis. In 2024, Medicare Advantage accounted for more than half of all Medicare spending, totaling over $450 billion.3 Medicare Advantage has been an ongoing focus of False Claims Act enforcement by the Department of Justice (DOJ) for a number of years. The report confirms that HHS-OIG is also focused on Medicare Advantage.
The report’s introduction notes that “OIG audits, evaluations, and investigations consistently identify a high risk of fraud, waste, and abuse in the Medicare Advantage risk adjustment program, which provides higher payments to Medicare Advantage plans for sicker enrollees.”4 In particular, the introduction highlights the risk of inaccurate diagnoses and improper payments resulting from health risk assessments (HRAs) and “HRA-linked chart reviews” conducted by Medicare Advantage organizations.5 It also references the $98 million resolution by Independent Health of “alleged violations of the False Claims Act from submitting or causing the submission of invalid diagnosis codes to Medicare”—a case in which DOJ alleged improper upcoding by a vendor that was engaged by various plans to conduct chart reviews and query physicians for additional diagnoses.6
The body of the report also contains a number of references to Medicare Advantage. The report again cites HRAs, pointing to HHS-OIG’s recommendation that CMS restrict Medicare Advantage organizations’ ability to use diagnoses from “in-home” HRAs or chart reviews that are linked to in-home HRAs to increase future risk-adjustment payments.7 And it reports the results of three audits by HHS-OIG of “high-risk” diagnosis codes submitted by Medicare Advantage plans.8
In addition to describing the Independent Health settlement as a significant enforcement action,9 HHS-OIG’s report features another recent False Claims Act settlement—resolving alleged kickbacks for referrals of Medicare Advantage enrollees.10 That resolution, by MMM Holdings, is discussed along with a “Special Fraud Alert” relating to Medicare Advantage marketing programs involving what HHS-OIG characterized as “questionable payments.”11
The focus on Medicare Advantage by HHS-OIG is just one more indication that the industry remains a potential target for investigations by both DOJ and HHS-OIG. As the Medicare Advantage program continues to expand, Medicare Advantage organizations as well as providers and vendors that participate in the program should remain vigilant and continue to invest in compliance measures.
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