HHS-OIG Offers Medicare and Medicaid Managed Care Strategic Plan and Website Reflecting Agency Oversight Strategy

The number of individuals receiving government health care benefits through managed care programs has been on a steady upward trajectory over the last two decades, with a rapid increase in enrollment in such programs in recent years. Indeed, in 2022, 50% of Medicare enrollees received their benefits through Medicare Advantage organizations (MAOs) and more than 80% of Medicaid enrollees received at least one component of care through managed care.¹

The prevalence of this evolving benefit delivery model has changed fundamental aspects of underlying health care programs and transformed how the United States covers and pays for health care for approximately 100 million individuals.² The dollars flowing through these managed care programs is vast and, not surprisingly, has resulted in increased scrutiny and new concerns from a regulatory oversight and program integrity perspective. We see this scrutiny daily: in Congressional hearings, new CMS regulations, HHS-OIG audits, and a spate of government and whistleblower enforcement actions.

The growth, complexity, and cost of these managed care programs—and a concern that Medicare beneficiaries may not be getting the full measure of their benefit—has led the HHS-OIG to designate oversight of managed care as a “priority area” and to issue a strategic plan tailored to the unique attributes of managed care programs.³

The OIG’s Strategic Plan for Oversight of Managed Care for Medicare and Medicaid, issued on August 29, 2023, is designed to align the agency’s managed care audits, evaluations, investigations, and enforcement actions, and serves as a roadmap for how the agency views the managed care landscape.  Recognizing that “managed care oversight and enforcement is among the most complex work that the OIG performs,”⁴ the agency lays out three goals in its Strategic Plan:

• to promote access to care for people enrolled in managed care;

• to provide comprehensive financial oversight; and

• to promote data accuracy and encourage data-driven decisions.⁵

To advance these goals, the HHS-OIG intends to focus on four areas, which track the “life cycle” of the managed care plans’ involvement in the Medicare and Medicaid programs: (i) plan establishment and contracting, (ii) enrollment, (iii) payment, and (iv) delivery of services to members. In the Strategic Plan, the agency lays out its principal concerns from a regulatory and program integrity risk perspective related to each of these topic areas.

To highlight the work the HHS-OIG and the DOJ are doing in this area, the HHS-OIG has created a managed care webpage that consolidates, in one place, access to a variety of materials focused on managed Medicare and Medicaid, including (i) OIG managed care audit, evaluation and inspection reports; (ii) OIG work plan items; (iii) OIG speeches and Congressional testimony; (iv) civil and criminal fraud enforcement actions and settlements, and (v) analyses of top government management challenges and unimplemented recommendations in the Medicare and Medicaid managed care context.

This robust webpage is frequently updated and serves as a useful resource for lawyers practicing in this area. 

1. US Dep’t of Health & Human Servs. Office of Inspector General, Managed Care, https://oig.hhs.gov/reports-and-publications/featured-topics/managed-care/?hero=managed-care-ft. ↩︎
2. Id. ↩︎
3. Id. ↩︎
4. HHS-OIG, HHS-OIG Strategic Plan: Oversight of Managed Care for Medicare and Medicaid (Aug. 2023), p. 4, https://oig.hhs.gov/reports-and-publications/featured-topics/managed-care/Strategic_Plan_Managed_Care.pdf. ↩︎
5. Id. ↩︎