HHS-OIG Strategic Plan 2020 - 2025 HHS Office of Inspector General HHSOIG_35675060-dd6d-11ed-9291-a1f00483ea00Department of Health & Human ServicesChristi A. GrimmPrincipal Deputy Inspector GeneralDrive positive change in HHS programs and in the lives of the people served by these programs_356752e0-dd6d-11ed-9291-a1f00483ea00To provide objective oversight to promote the economy, efficiency, effectiveness, and integrity of HHS programs, as well as the health and welfare of the people they serve _35675466-dd6d-11ed-9291-a1f00483ea00ImpactInnovationPeople-FocusFraud, Waste & AbuseFight Fraud, Waste & Abuse_356755ba-dd6d-11ed-9291-a1f00483ea001OIG’s first goal is to fight fraud, waste, and abuse in HHS programs. To do this, OIG conducts investigations, audits, evaluations, and enforcement actions; makes recommendations to protect the fiscal integrity of HHS programs and help ensure that beneficiaries have access to the services they need; and promotes compliance with program rules and requirements.Prevention, Detection & DeterrencePrevent, detect, and deter fraud, waste, and abuse_356756fa-dd6d-11ed-9291-a1f00483ea001.1Fraud, waste, and abuse divert needed program resources to inappropriate, unauthorized, or illegal purposes. OIG aggressively pursues those who defraud HHS-funded programs; assists those who seek guidance to improve compliance; and makes recommendations for the Department to apply a robust program integrity strategy to protect current and future HHS programs. ^^ OIG’s audits and evaluations address program integrity risks within HHS programs and frequently result in changes in policy and legislation, along with monetary savings. Our investigations result in prosecutions and civil and administrative actions against those who commit fraud. Moreover, OIG combines proactive data analysis, risk assessments of emerging issues, field intelligence, and state-ofthe-art investigative techniques to combat fraud, waste, and abuse. We use advanced data analytics to more effectively assess risk across HHS programs, provider types, and geographic locations, and to efficiently deploy resources and further our oversight efforts. OIG will also build on our detection capabilities by leveraging artificial intelligence (AI) and machine learning to better predict the potential for fraud, waste, and abuse._1d91bca8-dd83-11ed-96b8-4af175babdf6PLACEHOLDER_1[To be determined]Financial Stewardship & PaymentsFoster sound financial stewardship and reduction of improper payments_35675844-dd6d-11ed-9291-a1f00483ea001.2MedicareMedicaidChildren’s Health Insurance Program (CHIP)The Department’s responsible stewardship of funds is paramount to ensuring that HHS beneficiaries and the American public get the true benefit of the substantial financial investment in HHS programs. Due to their size, HHS programs account for some of the largest estimated improper payments in the Federal Government. Medicare and Medicaid, including the Children’s Health Insurance Program (CHIP), accounted for $106.3 billion, or 99.7 percent, of the $106.7 billion in estimated improper payments that HHS reported in its FY 2019 Agency Financial Report. Furthermore, strong HHS oversight of grant programs and contracts identifies and helps to prevent significant improper payments and payments for unallowable costs. Although not all improper payments constitute fraud, all improper payments pose a risk to the financial security of Federal programs. Reducing improper payments is critical to protecting the financial security of HHS programs. ^^ OIG has long been at the forefront of measuring, monitoring, and recommending actions to prevent improper payments. OIG further focuses on recommendations to reduce wasteful spending. In addition to reviewing and reporting on HHS’s annual improper payment information, OIG’s audits, evaluations, and investigations identify improper payments for specific services and items, assess internal control and payment vulnerabilities, and make recommendations to prevent future improper payments and improve program efficiency. Administering grant programs and contracts requires HHS to implement internal controls to help ensure that program goals are met and funds are used appropriately. OIG prioritizes work on billing and payment errors, efficient expenditures, effective program administration, and grant and contract oversight. In addition, we help to ensure the integrity of grant application and selection processes, as well as to protect intellectual property and research integrity. We also review HHS’s annual financial statement audits and error rate reports and conduct targeted reviews to identify improper payments to be recovered and recommend management improvements. _1d91bfaa-dd83-11ed-96b8-4af175babdf6PLACEHOLDER_2[To be determined]MedicareSafeguard the Medicare Trust Funds_356759ac-dd6d-11ed-9291-a1f00483ea001.2.1Medicare BeneficiariesMedicare TrusteesHospital Insurance Trust FundCMSMedicare Strike ForceSafeguarding the Medicare Trust Funds ~ OIG continues to prioritize the fiscal integrity of Medicare funds. The Medicare program, administered by CMS, consists of four parts covering fee-for-service healthcare, managed care, and outpatient prescription drugs for eligible beneficiaries. The Medicare program faces significant challenges with respect to solvency and spending. The most recent annual Medicare Trustees’ Report found, for example, that the Hospital Insurance Trust Fund, which funds Medicare Part A, will be able to fund full benefits only until 2026, and that total Medicare costs will grow from approximately 3.7% of Gross Domestic Product (GDP) in 2018 to 5.9% of GDP by 2038. Overall estimates of waste in the United States healthcare system range upwards of 30% of healthcare spending. To control Medicare costs, it is imperative that Medicare funds be spent to furnish covered services of appropriate quality for eligible beneficiaries, at appropriate rates, and in accordance with program rules. ^^ Going forward, OIG will build on its significant body of oversight work focused on proper spending of Medicare funds, including, for example, payment accuracy, eligibility determinations, and efficacy of payment policies. OIG identifies misspent funds for recovery by CMS and vigorously investigates and engages in enforcement actions against those who defraud Medicare, including through continued leadership and participation in the Medicare Strike Force. OIG also promotes economy and efficiency by identifying potential savings including ensuring that Medicare is a prudent purchaser of healthcare and pays appropriately in different settings. OIG uses data analytics and other methods to identify program areas with especially high rates of improper payments, as well as geographic areas or service lines with high incidence of suspected fraud, waste and abuse. OIG identifies inefficiencies that result in wasteful spending and makes recommendations to improve systemic weaknesses and promote effective program administration and contractor oversight. Other areas for which OIG will provide strategic oversight include emergency preparedness and response affecting Medicare beneficiaries, Medicare Advantage, prescription drug spending, and the transition to value-based care._1d91c158-dd83-11ed-96b8-4af175babdf6PLACEHOLDER_3[To be determined]MedicaidStrengthen Medicaid protections against fraud, waste and abuse_35675b0a-dd6d-11ed-9291-a1f00483ea001.2.2Medicaid BeneficiariesStatesState Medicaid Fraud Control Units (MFCUs)North DakotaPuerto RicoU.S. Virgin IslandsStrengthening Medicaid protections against fraud, waste and abuse ~ OIG conducts reviews across a range of Medicaid topic areas including the reliability and completeness of national Medicaid data, reducing improper payments, the role of Medicaid managed care organizations, and health and safety for Medicaid beneficiaries. OIG audits have identified substantial improper payments to providers across a variety of Medicaid services. In addition, we have found that States are not always correctly determining eligibility of individuals to receive Medicaid benefits, resulting in potential improper payments. For FY 2019, CMS resumed the Medicaid eligibility component measurement, resulting in a significant increase in the Medicaid improper payment rate. Moving forward, OIG’s recommendations to address problems with Medicaid eligibility determinations will be instrumental to the reduction of the Medicaid improper payment rate. ^^ A key component in addressing Medicaid fraud is OIG’s work with State Medicaid Fraud Control Units (MFCUs). OIG administers the grant program that funds MFCUs, partners with MFCUs in fraud investigations and strike force operations and supports the MFCU role in protecting vulnerable residents of health facilities against patient abuse and neglect. OIG has supported MFCUs’ success in many ways. OIG streamlined its regulations, supported MFCU’s efforts to use data mining to identify leads, certified new Units in North Dakota, Puerto Rico, and the U.S. Virgin Islands, and conducted extensive training for the MFCUs. These activities are part of a larger strategic vision OIG has developed to drive MCFU effectiveness and to encourage MFCUs continued success. This strategic vision includes OIG efforts to increase the use of data, expand the MFCU program to better align with a growing and evolving Medicaid program, improve MFCU training, and increase collaboration between MFCUs and OIG. 1.2.2.1IndictmentsRate_1d91c2de-dd83-11ed-96b8-4af175babdf6PLACEHOLDER_4Improvement of Medicaid Fraud Control Unit indictment ratesStatusImproved[To be determined]1.2.2.2ConvictionsRate_1d91c46e-dd83-11ed-96b8-4af175babdf6PLACEHOLDER_5Improvement of Medicaid Fraud Control Unit conviction rates StatusImproved[To be determined]Misspent FundsHold wrongdoers accountable and recover misspent public funds_35675c72-dd6d-11ed-9291-a1f00483ea001.3Healthcare Fraud and Abuse Control Program (HCFAC)DOJMedicare Fraud Strike Force TeamsOIG works to hold wrongdoers accountable and recover misspent public funds, both independently and in cooperation with Federal and State partners. With support of the Healthcare Fraud and Abuse Control Program (HCFAC) funding, OIG partners with DOJ and HHS agencies on healthcare fraud enforcement activities such as the Medicare Fraud Strike Force teams. These teams harness data analytics and the combined resources of Federal, State, and local law enforcement entities to prevent and combat healthcare fraud, waste, and abuse. ^^ OIG uses our administrative civil monetary penalty and exclusion authorities to complement criminal and civil actions to hold fraud perpetrators accountable and recover stolen funds. We protect HHS programs, beneficiaries, and recipients by excluding individuals and entities from Federally funded healthcare programs based on certain convictions and other criteria established in the Social Security Act. Additionally, we enforce OIG’s civil monetary penalties and exclusions authorities through administrative litigation and settlements. Further, OIG uses a risk-based analysis to determine how to best leverage the exclusion authority to protect HHS programs and beneficiaries when resolving False Claims Act cases. Based on the risks presented, we may seek exclusion, provide an administrative release, close the exclusion case, or require the settling entity to enter into a Corporate Integrity Agreement, which requires compliance controls and reporting to OIG._1d91c5fe-dd83-11ed-96b8-4af175babdf6PLACEHOLDER_6[To be determined]Quality, Safety & ValuePromote Quality, Safety & Value_35675e66-dd6d-11ed-9291-a1f00483ea002OIG’s second goal is to promote quality, safety, and value in HHS programs, which provide critical services to diverse populations across a broad range of care settings. OIG is committed to providing oversight that helps HHS improve its programs and ensure that eligible beneficiaries receive appropriate services and are not subjected to abuse or neglect.HHS-Funded ServicesFoster quality, safety, and value of HHS-funded services_35675fce-dd6d-11ed-9291-a1f00483ea002.1Medicare ProgramElderly AmericansDisabled AmericansChildren’s Health Insurance ProgramAmerican IndiansAlaska NativesChildren in Temporary SheltersChildren in Foster CareFamilies with Childcare NeedsPeople with DisabilitiesVulnerable PopulationsUnaccompanied Alien Children (UAC) ProgramStatesOIG’s work helps to ensure that beneficiaries have access to care and that care meets quality and safety standards across HHS’ health and human services programs. For example, HHS operates the Medicare Program serving 60 million elderly or disabled Americans. In partnership with the States, HHS operates the Medicaid and Children’s Health Insurance Programs serving 75 million and 7 million beneficiaries, respectively. HHS also operates programs that serve American Indians and Alaska Natives; children in temporary shelters and foster care; families with childcare needs; people living with disabilities, and many others. ^^ OIG’s oversight work fosters safe, high quality care in services furnished to vulnerable populations. We build on oversight successes, such as our work examining hospice care, personal care services, adverse events in healthcare facilities, the Unaccompanied Alien Children (UAC) program, prescription drug programs, nursing home care, and care in group homes and assisted living facilities. For example, OIG has identified alarming rates of adverse events in hospitals, nursing homes, and other settings, resulting in substantial changes to HHS standards. ^^ OIG provides oversight, recommendations, and training to promote high quality of care for HHS beneficiaries by working both independently and in key partnerships with HHS partners and States. We focus on ensuring that the people served by HHS programs receive safe, quality services to which they are entitled. We also focus on ensuring that taxpayer funds are used to deliver high-value services_1d91c78e-dd83-11ed-96b8-4af175babdf6PLACEHOLDER_7[To be determined]Home/Community SettingsPromote patient safety and accuracy of payments in home and community settings_35676154-dd6d-11ed-9291-a1f00483ea002.1.1PatientsMedicaid Personal Care ServicesCMSMedicaid Fraud Control UnitsDOJAdministration for Community LivingHHS Office of Civil RightsPromoting patient safety and accuracy of payments in home and community settings ~ OIG conducts oversight work aimed at reducing improper payments for services in noninstitutional settings, such as home health, hospice, and group homes. OIG has identified program integrity for home and community-based services as a top management challenge for HHS. We have issued more than 30 audits and evaluations, recommending the recovery of over $700 million and improvements to service delivery. OIG seeks to both reduce fraud, waste, and abuse and enhance program integrity in home and community settings through outreach, education, audits, evaluations, inspections, investigations, and administrative enforcement. OIG also seeks to foster quality and safety of services provided in home and community settings during disease outbreaks and other emergencies. ^^ Another key oversight area involves OIG’s work in Medicaid Personal Care Services (PCS) -- services that help Medicaid beneficiaries with everyday tasks in their home. OIG has identified systemic problems related to the design and delivery of Medicaid PCS, as well as instances of patient harm. Over the past 6 years, OIG has opened more than 200 investigations involving fraud and patient harm and neglect in the PCS. ^^ Moving forward, OIG remains committed to program integrity in home and community-based services and ensuring beneficiary health and safety. OIG will continue to collaborate with CMS and partner with other oversight agencies like Medicaid Fraud Control Units, DOJ, the Administration for Community Living, and the HHS Office of Civil Rights to achieve that goal. 2.1.1.1Critical IncidentsPercentage_1d91c932-dd83-11ed-96b8-4af175babdf6PLACEHOLDER_8Reduction in the percentage of unreported critical incidents involving individuals with developmental disabilities residing in group homes StatusReduced[To be determined]Prescription DrugsIdentify opportunities to lower prescription drug spending for patients and programs_35676302-dd6d-11ed-9291-a1f00483ea002.1.2PatientsIdentifying opportunities to lower prescription drug spending for patients and programs ~ OIG’s commitment to providing oversight that promotes the economy and efficiency of HHS programs extends to spending for prescription drugs and biologics. OIG is focused on identifying opportunities for programs to lower prescription drug spending. Increases in prescription drug prices have contributed to the growth in total prescription drug spending for patients and programs. HHS programs accounted for 43 percent ($143 billion) of the total U.S. prescription drug expenditures in 2018. Increased costs may limit patients’ ability to afford needed prescription drugs, in some cases causing patients to skip doses of medication or forgo purchasing it altogether. OIG has a long history of assessing policies for reimbursement of prescription drugs. OIG's reports and enforcement work helped pave the way for legislative changes in the reimbursement methodology for most drugs under Medicare Part B and the resulting programmatic changes that saved the Federal Government billions of dollars. Historically, OIG has focused its oversight on payment accuracy, ensuring that HHS programs and beneficiaries do not overpay for prescription drugs. OIG is dedicated to building on this body of work and finding opportunities to enhance our oversight of spending on prescription drugs and biologics. Ultimately, OIG aims to inform HHS efforts to promote drug affordability so that cost is not a barrier to patients receiving needed medications. _1d91cafe-dd83-11ed-96b8-4af175babdf6PLACEHOLDER_9[To be determined]Health & SafetyPromote public health and safety _356764c4-dd6d-11ed-9291-a1f00483ea002.2Food and Drug AdministrationCenters for Disease Control and PreventionAssistant Secretary for Preparedness and ResponseOIG promotes public health and safety by recommending improvements to HHS programs that address public health and safety and emergency preparedness. For example, OIG conducts critical oversight of programs administered by the Food and Drug Administration, the Centers for Disease Control and Prevention, and the Assistant Secretary for Preparedness and Response. HHS is the lead Federal department responsible for providing medical support and coordination during public health emergencies, such as disease outbreaks. ^^ OIG’s work also helps ensure that hospitals and nursing homes are prepared to respond to public health emergencies caused by communicable diseases and natural disasters, and that the food supply, drugs, and devices are safe and secure. Prior OIG work identified gaps in emergency preparedness and response planning for healthcare facilities during disasters and pandemics. Disease outbreaks, such as the COVID-19 pandemic, pose an ongoing challenge and demonstrate HHS’s need to rapidly detect, diagnose, assess, and respond to these threats. OIG will assess the effectiveness and efficiency of preparedness and response efforts. We will also regularly engage with stakeholders and work with leadership from across HHS on issues that have public health and safety implications. _1d91cce8-dd83-11ed-96b8-4af175babdf6PLACEHOLDER_10[To be determined]Drug AbuseProtect beneficiaries from prescription drug abuse, including opioids_35676686-dd6d-11ed-9291-a1f00483ea002.2.1Protecting beneficiaries from prescription drug abuse, including opioids ~ OIG prioritizes enforcement and oversight activities that protect beneficiaries from prescription drug abuse, with a focus on addressing the opioid epidemic. OIG's efforts in this space fall in three areas: (1) identifying opportunities to improve the efficiency and effectiveness of HHS programs, (2) identifying and holding accountable those engaged in fraud, and (3) empowering partners through data sharing and education. In addition, OIG helps enable its Federal, State, and private sector partners through referrals and sharing our data analysis methods. ^^ Moving forward, we plan to advance our efforts to reduce substance use disorder by pivoting from utilization control to treatment access and enhancing our fight against fraud in treatment programs. We will continuously review and shift our approach as warranted to reflect recent developments in the opioid epidemic; agency and HHS program responses to the epidemic; current law and proposed egislation; and new data sources, analytic capabilities and investigative techniques. We are also expanding the scope of our efforts to include the treatment of opioid use disorders. To help ensure that beneficiaries have access to treatment, we are identifying barriers to access and engaging in enforcement to make sure HHS funds are not diverted from legitimate services to fraudulent service providers. Further, we share information, as appropriate, with HHS Operating Divisions about law enforcement efforts to facilitate the co-deployment of public health resources so that law enforcement activities do not disrupt beneficiaries’ access to needed opioids or treatment.2.2.1.1Questionable PrescribersNumber_1d91cefa-dd83-11ed-96b8-4af175babdf6PLACEHOLDER_11Reduction of Part D prescribers whom OIG identified as having questionable prescribing practicesStatusReduced2020-01-012020-12-31[To be reported]2020-01-012020-12-31[To be reported]2021-01-012021-12-31[To be reported]2022-01-012022-12-31[To be reported]2023-01-012023-12-31[To be reported]2024-01-012024-12-31[To be reported]2025-01-012025-12-31401 prescribers in Calendar Year (CY) 2017 baseline Baseline4012017-01-012017-12-31HHS ProgramsIdentify opportunities to improve the efficiency and effectiveness of HHS programs_35676848-dd6d-11ed-9291-a1f00483ea002.2.2.1_1d91d116-dd83-11ed-96b8-4af175babdf6PLACEHOLDER_12[To be determined]FraudIdentify and hold accountable those engaged in fraud_35676a00-dd6d-11ed-9291-a1f00483ea002.2.2.2_1d91d31e-dd83-11ed-96b8-4af175babdf6PLACEHOLDER_13[To be determined]Data & EducationEmpower partners through data sharing and education_35676bae-dd6d-11ed-9291-a1f00483ea002.2.2.3_1d91d54e-dd83-11ed-96b8-4af175babdf6PLACEHOLDER_14[To be determined]HHS programsEnsure health and safety for children served by HHS programs_35676d84-dd6d-11ed-9291-a1f00483ea002.2.2HHS ProgramsChildrenEnsuring health and safety for children served by HHS programs ~ Keeping children safe is critically important to OIG. HHS programs provide needed health and human services to children through programs such as the UAC program, foster care, Head Start, and the Child Care and Development Fund (CCDF). To better ensure the health and safety of children served by HHS grants, OIG uses a multidisciplinary approach to oversight. For example, evaluators, auditors, investigators and lawyers all collaborated to conduct extensive reviews of the UAC program. We regularly meet with HHS Operating Division leadership. For example, we met with ACF to gain insight on State efforts and challenges related to the CCDF program. These interactions facilitate enhanced working relationships, increase the exchange of information, and provide OIG with valuable information that informs our oversight efforts to address the needs of vulnerable populations. ^^ Ensuring that Federal funds for these programs serve their intended purposes and are not mismanaged or misappropriated is crucial. OIG is prioritizing oversight work that identifies ways in which HHS can improve program integrity for child welfare programs. We focus on internal controls; program effectiveness; and prevention of fraud, waste, and abuse. This initiative includes a focus on the CCDF, the UAC program, including the emergency preparedness at UAC facilities, and other child welfare programs.2.2.2.1Intrastate Background ChecksNumber_1d91d788-dd83-11ed-96b8-4af175babdf6PLACEHOLDER_15Increase in the number of States and territories requiring Child Care and Development Fund (CCDF) providers to conduct all required intrastate criminal background checks at least once every 5 yearsStatusIncreased[To be determined]2.2.2.2Interstate Background ChecksNumber_1d91d9c2-dd83-11ed-96b8-4af175babdf6PLACEHOLDER_16Increase in the number of States and territories requiring CCDF providers to conduct all required interstate criminal background checks at least once every 5 years StatusIncrease[To be determined]PerformanceSupport high-performing health and human services programs_3567716c-dd6d-11ed-9291-a1f00483ea002.3Vulnerable BeneficiariesChildrenUnaccompanied ChildrenChildren in Foster CarePeople with DisabilitiesOIG conducts oversight to support a high-performing healthcare system to foster better health outcomes and lower costs. We have made recommendations to HHS to improve quality and achieve greater value, including better patient and health outcomes. The Department continues to enact reforms in Medicare and Medicaid that come with an array of operational and program integrity challenges, as well as promising opportunities for better health outcomes, lower costs, improved transparency and choices for consumers, and reduced administrative burden on providers. HHS has introduced, and is continuing to introduce, a range of innovative payment and delivery models, including accountable care organizations, medical homes, bundled payment models, primary care models, and others. ^^ OIG work has long demonstrated a range of challenges in both CMS and other HHS programs, from flaws in program design and administration (e.g., improper payments, misaligned program incentives, and confusing or insufficient program guidance), to deficiencies in how providers deliver care to beneficiaries (e.g., poor quality and unsafe care or inappropriate utilization), to gaps in provider enrollment systems and available data needed for proper oversight. Moreover, OIG work has identified problems in ensuring that eligible beneficiaries have adequate access to covered services in both Medicare and Medicaid fee-for-service and managed care. OIG will conduct audits and evaluations of value-based healthcare and undertake enforcement actions in instances of substandard care, where appropriate. ^^ Further, we will make recommendations to the Department to protect vulnerable beneficiaries in the Department’s human services programs and ensure that those programs’ funds are used efficiently to achieve their intended purposes. This includes HHS-funded child care services, as well as services furnished to unaccompanied children, children in foster care, and people with disabilities._1d91dbe8-dd83-11ed-96b8-4af175babdf6PLACEHOLDER_17[To be determined]Excellence & InnovationAdvance Excellence & Innovation_3567732e-dd6d-11ed-9291-a1f00483ea003Advancing excellence and innovation requires investment and commitment in our people, processes, and data. OIG is committed to building an innovative, agile, continuous-learning organization that can respond quickly to changing oversight needs. We maximize value by improving efficiency and effectiveness; promote the secure and effective use of data and technology; and encourage the Department to implement our recommendations.Efficiency & EffectivenessMaximize value by improving efficiency and effectiveness_35677522-dd6d-11ed-9291-a1f00483ea003.1Within OIG, we make operational improvements that optimize our performance and results. We routinely identify opportunities to create efficiencies and streamline processes—from prioritization of our work, management processes, data management, analytics, human resources, budget, and facilities. By streamlining day-to-day operations as much as possible, OIG can ensure that we are leaner and more responsive and maximize our resources to deliver results that advance our mission. ^^ OIG is planning technology enhancements that will automate time-consuming tasks, allowing OIG staff to increase productivity and efficiency and develop more impactful reports and investigations. We are using data visualization to better aid our audiences in understanding critical information. We are using new tools to strengthen internal coordination and collaboration and instituting new internal governance methods, including data governance. We focus on human-centered design—for our website, for our reports, for our tools—to achieve greater impact. ^^ OIG embraces continuous innovation. We encourage taking measured risks because we understand that for innovation to work, we must embrace change. We are adopting three goals established by Office of Management and Budget (OMB) for Enterprise Risk Management (ERM): (1) promote and facilitate a risk-aware culture while developing and refining new strategies and policies as needed for continued improvement and ERM implementation, (2) promote integrated strategy-setting with performance and cost management practices that are supported by quality data that OIG can rely on to manage risk in creating, preserving, and realizing value, and (3) drive resource prioritization and allocation by leveraging risk informed decisions. Our goal is to apply risk management at the enterprise level, where risks and opportunities discussions are embedded in strategic planning, resource allocation, processes, and decision making._1d91df6c-dd83-11ed-96b8-4af175babdf6PLACEHOLDER_18[To be determined]HealthcareEnsure HHS managed care and non-traditional healthcare models produce value_356776ee-dd6d-11ed-9291-a1f00483ea003.1.1Ensuring HHS managed care and non-traditional healthcare models produce value ~ The healthcare system and CMS’s programs are changing rapidly. OIG is focusing on the transition to innovative, value-based, consumer-empowered care. HHS continues to enact reforms in Medicare and Medicaid to promote quality, efficiency, and value of care. These reforms come with an array of operational and program integrity challenges, as well as promising opportunities for better health outcomes, lower costs, improved transparency and choices for consumers, and reduced administrative burden on providers. OIG has identified three elements of this transition that are particularly critical to achieve better value, quality, and improved outcomes. These are (1) aligning program incentives with improved health outcomes, (2) strengthening program integrity, and (3) delivering on the promise of innovative technology. Program integrity must be part of planning and implementation of value-based care and payment within HHS and by industry stakeholders. ^^ OIG will undertake oversight work to ensure that value-based programs, including managed care, benefit patients, drive efficiency, and include appropriate safeguards against fraud, waste, and abuse. OIG’s work will address familiar and emergent risks. OIG work has identified troubling fraud in managed care; OIG will be alert to similar problems in value-based care in fee-for-service programs. Value-based care models are expected increasingly to promote care in home and community settings, often preferred by patients, through home visits by practitioners and care managers, remote monitoring, and other technologies. OIG work in areas such as hospice care, home health, and personal care services consistently demonstrates that patients may be particularly vulnerable to fraud and abuse in home and community settings._1d91e1ba-dd83-11ed-96b8-4af175babdf6PLACEHOLDER_19[To be determined]Incentives & OutcomesAlign program incentives with improved health outcomes_356778ce-dd6d-11ed-9291-a1f00483ea003.1.1.1_1d91e41c-dd83-11ed-96b8-4af175babdf6PLACEHOLDER_20[To be determined]Program IntegrityStrengthen program integrity_35677afe-dd6d-11ed-9291-a1f00483ea003.1.1.2Program integrity must be part of planning and implementation of value-based care and payment within HHS and by industry stakeholders._1d91e746-dd83-11ed-96b8-4af175babdf6PLACEHOLDER_21[To be determined]TechnologyDeliver on the promise of innovative technology _35677cf2-dd6d-11ed-9291-a1f00483ea003.1.1.3_1d91e9a8-dd83-11ed-96b8-4af175babdf6PLACEHOLDER_22[To be determined]Data & TechnologyPromote secure and effective use of data and technology_35677edc-dd6d-11ed-9291-a1f00483ea003.2The Department’s programs are becoming increasingly integrated through greater networking and automation. In addition, emerging technologies like machine learning and AI have the potential to transform how HHS operates its programs. As a result, effective oversight will depend on our ability to deploy data and IT solutions that have the right capabilities and allow OIG to be adaptable in a rapidly changing technology environment. We arm our experts with the best available data and technology, in order to effectively analyze problems in HHS programs and propose practical solutions. We will modernize our IT infrastructure to deliver high-quality, timely, actionable data and technology to frontline staff throughout OIG. OIG’s strategic investments in cloud computing and network modernization are serving as models for transformation for all of HHS. ^^ To adapt and respond to new priorities, it is essential that we develop and deploy IT that rapidly handles large and diverse data sets. We are using cutting-edge data tools that enable analysts to explore, transform, and enrich raw data into clean and structured formats. We are integrating data sets and tools where appropriate and providing data at our users’ fingertips. We will continue to find ways to leverage data assets and continue to expand access or gain real-time access to additional Departmental data. Robust data and technology solutions enable maximum effectiveness, strengthen our ability to work with partners, and improve the business processes of our enterprise automated systems._1d91ec14-dd83-11ed-96b8-4af175babdf6PLACEHOLDER_23[To be determined]CybersecurityCombat cybersecurity threats within HHS and healthcare_356780f8-dd6d-11ed-9291-a1f00483ea003.2.1Combatting cybersecurity threats within HHS and healthcare ~ OIG is focused on cybersecurity oversight of HHS agencies and programs. Cyberattacks aimed to destroy, alter, or steal sensitive information threaten HHS, its Operating Divisions, and healthcare providers daily. Cybersecurity attacks can threaten HHS’s mission critical operations during national public health emergencies. The security of HHS information technology (IT) systems and the personal information and data collected and maintained by HHS programs is critically important to the health and well-being of the American people. OIG has been ramping up its oversight work focused on combatting cybersecurity threats within HHS and the healthcare system. Such cybersecurity threats range from the hacking and manipulation of medical devices, such as pacemakers and continuous infusion pumps, to that of healthcare facilities and major infrastructure systems. Other examples include risks to national security when permitting foreign principal investigators to access U.S. genomic data. OIG performs cybersecurity audits of HHS agencies and programs, including but not limited to penetration and indicators of compromise testing, incident response and contingency controls assessments. Additionally, representatives from OIG’s information technology team, Computer Crimes Unit, and cybersecurity audit team have partnered to bring awareness to situations, such as distributed denial-of-service attacks, and have made recommendations for improvement to the Department, some of which remain unimplemented. ^^ Further, OIG will continue to conduct investigations that may involve espionage and foreign threats. To ensure HHS safety protocols remain relevant in the continuously changing technological landscape, OIG is concentrating its efforts on risk management, resiliency, and IT controls. We will expand our cyber reviews and conduct advanced penetration testing to identify exploitable vulnerabilities in HHS agency systems and will conduct broad evaluations of HHS cybersecurityrelated programs. OIG’s cybersecurity work identifies risks and vulnerabilities not yet enumerated by HHS during the normal course of operating its systems and recommends corrective actions to enable the Department to enhance its security posture and maintain the American public’s trust over its most sensitive information._1d91ee6c-dd83-11ed-96b8-4af175babdf6PLACEHOLDER_24[To be determined]TechnologyLeverage technology as it intersects with HHS programs_3567830a-dd6d-11ed-9291-a1f00483ea003.2.2Office of the National Coordinator for Health Information TechnologyOIG will coordinate with HHS agencies, including the Office of the National Coordinator for Health Information Technology, with respect to oversight of health information and other technologies.Leveraging technology as it intersects with HHS programs ~ OIG anticipates substantial growth in its oversight of existing and new technology used to deliver health and human services. Leveraging digital and health technology to foster efficient, high-quality care is critical to a value-driven health and human services system, as is ensuring the appropriate flow of complete, accurate, timely, and secure information. Also critical is the effective use of technology, such as telemedicine and data monitoring systems, during and after disease outbreaks and natural disasters. HHS faces challenges in achieving an integrated healthcare system to support better coordinated and value-based care in which patients’ data—including conventional healthcare data and newer types of data related to social determinants, demographics, and personal trackers—flow freely across provider settings, with appropriate privacy and security protections. Health-related applications (apps) and technologies, such as telemedicine, are proliferating and becoming integrated with the delivery of better coordinated and value-based care. To achieve the promise of technology, beneficiaries must be able to choose reliable and trustworthy apps and technologies. In many cases, new technologies and apps are being developed by individuals and entities—often engineers or scientists—unschooled in the complex regulations governing healthcare and unaware of the range of program integrity risks their inventions may face. These new participants in the healthcare ecosystem will need education, guidance, and appropriate oversight. If done right, empowering patients with appropriate information to make their own informed choices can improve the efficiency of the healthcare system and the care they receive. ^^ In addition, AI and machine learning are introducing radically different paradigms that will require fresh thinking about compliance and fraud prevention. Relatedly, HHS will need to assess how it can use AI, machine learning, and other technologies to foster value and quality of care in Medicare, Medicaid, and other HHS programs._1d91f0b0-dd83-11ed-96b8-4af175babdf6PLACEHOLDER_25[To be determined]RecommendationsEncourage implementation of OIG recommendations _3567851c-dd6d-11ed-9291-a1f00483ea003.3We drive positive change by rigorously following up with the Department on implementation of our recommendations. We will create processes and systems that better enable streamlined communication about outstanding recommendations and progress made. OIG has multiple communication procedures for engaging with key stakeholders on recommendation followup. OIG plans to strengthen our processes by implementing new technologies, such as an integrated and modernized audit and evaluation recommendation tracking system to streamline our current processes and enhance collaboration with internal and external stakeholders. The goal is better, more timely understanding of findings and solutions and reduction in the average time for implementing recommendations. We will also explore ways to improve public transparency about OIG recommendations and their implementation status._1d91f326-dd83-11ed-96b8-4af175babdf6PLACEHOLDER_26[To be determined]_1d91f5a6-dd83-11ed-96b8-4af175babdf62019-10-012025-09-302023-04-18https://oig.hhs.gov/documents/root/7/OIG-Strategic-Plan-2020-2025.pdf_1d91f812-dd83-11ed-96b8-4af175babdf6OwenAmburOwen.Ambur@verizon.net