Department of Defense: Eating Disorders in the Military

What GAO Found

The Department of Defense (DOD) screens for eating disorders for all applicants entering into the military but does not specifically screen servicemembers for eating disorders after entrance. However, after joining the military, servicemembers receive annual health screenings, and medical personnel may be able to diagnose eating disorders during in-person physical exams. Service branch behavioral health specialists told GAO that DOD medical personnel are trained to notice signs of eating disorders, such as changes in vital signs and emaciated appearance. DOD is examining ways to improve its screening of eating disorders in the military and recently expanded the available research funding for eating disorders in its Peer-Reviewed Medical Research Program (PRMRP).

DOD provides health care services to approximately 9.5 million eligible beneficiaries, including services to treat those diagnosed with eating disorders, through TRICARE, DOD’s regionally structured health care system. Servicemembers can obtain these services at military treatment facilities—referred to as direct care—or receive care purchased from civilian providers—referred to as purchased care. DOD officials told us that the specialized level of care necessary to treat eating disorders is available to TRICARE beneficiaries through purchased care, rather than direct care. The Defense Health Agency (DHA), which oversees the TRICARE program, uses two contractors to develop regional provider networks.

According to the two TRICARE contractors’ data for purchased care, as of spring 2020, there were 166 eating disorder facilities located in 32 states throughout the country and the District of Columbia. The facilities vary by geographic location, population served, and level of treatment provided:

  • Geography: About half of the 166 facilities (79) are located in the following five states: California (24), Florida (18), Illinois (15), Texas (13), and Virginia (nine). 
  • Population: Of the 166 eating disorder facilities, over three-quarters provide treatment to both adult (132 facilities) and child and adolescent (132 facilities) populations.
  • Level of Treatment: Most facilities provide inpatient hospitalization programs, which are for serious cases requiring medical stabilization (81 facilities); partial hospitalization, which are day programs providing treatment 5 to 7 days a week (133 facilities); or intensive outpatient programs, which are treatment programs providing therapy 2 to 6 days a week (107 facilities). About one-fifth of the facilities (35) provide residential treatment services, which are living accommodations providing intensive therapy and 24-hour supervision.

TRICARE contractors have met with some challenges entering into contracts with eating disorder treatment facilities in certain areas of the country, according to DHA officials and both contractors. However, both contractors told GAO they consider it their responsibility to ensure beneficiaries receive the care they need regardless of the location of the facility. No access-to-care complaints related to eating disorder treatment were reported by TRICARE beneficiaries, according to the most recent DHA data for years 2018 through 2019.

Why GAO Did This Study

Eating disorders are complex conditions affecting millions of Americans and involve dangerous eating behaviors, such as the restriction of food intake. They can have a severe impact on heart, stomach, and brain functionality, and they significantly raise the risk of mortality. Many with eating disorders also experience co-occurring conditions such as depression. Research has yielded a range of estimates of the number of servicemembers with an eating disorder, due to differences in research methods. For example, a 2018 DOD study concluded that servicemembers likely experienced eating disorders at rates that are comparable to rates in the general population, while other survey-based research suggested the number of servicemembers with eating disorders may be higher than those with a medical diagnoses of such disorders. The potential effects that eating disorders can have on the health and combat readiness of servicemembers and their dependents underscores the importance of screening and treating this population.

GAO was asked to provide information on eating disorders among servicemembers and their dependents. To describe how DOD screens for eating disorders among servicemembers, GAO reviewed DOD policies related to health screening and interviewed behavioral health specialists from the military branches. To understand approaches and challenges with implementing screening in a military environment, any planned or ongoing DOD-sponsored research related to this topic, and available eating disorder treatment, GAO interviewed representatives from the Eating Disorder Coalition, Uniformed Services University of Health Sciences, and the University of Kansas. To describe how DOD provides eating disorder treatment to servicemembers and their dependents, GAO interviewed DHA officials and TRICARE contractors and reviewed the TRICARE policy manual to identify the types of eating disorder diagnoses and treatments that are covered through direct and purchased care. GAO received data from the two TRICARE contractors related to the availability of eating disorder treatment services as of spring 2020.

For more information, contact Sharon Silas at (202) 512-7114 or Silass@gao.gov.

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    GAO began 42 new audits that involved the Department of Defense (DOD) in the third quarter of fiscal year 2020. Of the 42 requested entrance conferences (i.e., initial meetings between agency officials and GAO staff) for those audits, DOD scheduled 41 within 14 days of notification and held all 42 entrance conferences within 30 days of notification. Scheduling was delayed for one entrance conference, which was scheduled 21 days after notification, because DOD and GAO were working to reach agreement on the primary action officer, which is the appropriate office or component within the department that coordinates DOD's response to the audit. The entrance conference was held 8 days after it was scheduled. Entrance conferences allow GAO to communicate its audit objectives and enable agencies to assign key personnel to support the audit work. GAO's agency protocols govern GAO's relationships with audited agencies. These protocols assist GAO in scheduling entrance conferences with key agency officials within 14 days of receiving notice of a new audit. The ability of the Congress to conduct effective oversight of federal agencies is enhanced through the timely completion of GAO audits. In past years, DOD experienced difficulty meeting the protocol target for the timely facilitation of entrance conferences. In Senate Report 116-48 accompanying a bill for the National Defense Authorization Act for Fiscal Year 2020, the Senate Armed Services Committee included a provision for GAO to review DOD's scheduling and holding of entrance conferences. In this report, GAO's agency protocols govern GAO's relationships with audited agencies. These protocols assist GAO in scheduling entrance conferences with key agency officials within 14 days of receiving notice of a new audit. The ability of the Congress to conduct effective oversight of federal agencies is enhanced through the timely completion of GAO audits. In past years, DOD experienced difficulty meeting the protocol target for the timely facilitation of entrance conferences. In Senate Report 116-48 accompanying a bill for the National Defense Authorization Act for Fiscal Year 2020, the Senate Armed Services Committee included a provision for GAO to review DOD's scheduling and holding of entrance conferences. In this report, GAO evaluates the extent to which DOD scheduled entrance conferences within 14 days of receiving notice of a new audit, consistent with GAO's agency protocols, and held those conferences within 30 days. This is the third of four quarterly reports that GAO will produce on this topic for fiscal year 2020. In the first two quarterly reports, GAO found that DOD had improved its ability to meet the protocol target. GAO analyzed data on GAO audits involving DOD and initiated in the third quarter of fiscal year 2020 (April 1, 2020, through June 30, 2020). Specifically, GAO identified the number of notification letters requesting entrance conferences that were sent to DOD during that time period. GAO determined the number of days between when DOD received the notification letter for each new audit and when DOD scheduled the entrance conference and assessed whether DOD scheduled entrance conferences within 14 days of notification, which is the time frame identified in GAO's agency protocols. GAO also determined the date that each requested entrance conference was held by collecting this information from the relevant GAO team for each audit and assessed whether DOD held entrance conferences for new audits within 30 days of notification, which was the time frame identified in the mandate for this review For more information, contact Elizabeth Field at (202) 512-2775 or Fielde1@gao.gov.
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  • Government Auditing Standards: 2018 Revision Technical Update April 2021 (Supersedes GAO-18-568G)
    In U.S GAO News
    The Yellow Book provides standards and guidance for auditors and audit organizations, outlining the requirements for audit reports, professional qualifications for auditors, and audit organization quality control. Auditors of federal, state, and local government programs use these standards to perform their audits and produce their reports. Effective Date The 2018 revision of the Yellow Book is effective for financial audits, attestation engagements, and reviews of financial statements for periods ending on or after June 30, 2020, and for performance audits beginning on or after July 1, 2019. Early implementation is not permitted. The technical updates to the 2018 revision of the Yellow Book are effective upon issuance. Revision Process Yellow Book revisions undergo an extensive, deliberative process, including public comments and input from the Comptroller General's Advisory Council on Government Auditing Standards. GAO considered all comments and input in finalizing revisions to the standards. For more information, contact James R. Dalkin at (202) 512-9535 or yellowbook@gao.gov. Visit our Yellow Book website for more information on applicable updates and alerts.
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  • Doctor Sentenced to Prison for Role in Unlawful Distribution of Controlled Substances
    In Crime News
    An Ohio physician was sentenced to 40 months in prison today for his role in illegally distributing controlled substances.
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  • Justice Department Files Suit Against Dallas, Texas, Towing Company for Unlawfully Selling Servicemember-Owned Vehicles
    In Crime News
    The Justice Department today filed a lawsuit in the Northern District of Texas alleging that Dallas-based towing company United Tows LLC violated the Servicemembers Civil Relief Act (SCRA), by unlawfully auctioning off vehicles owned by SCRA-protected servicemembers. 
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  • Attorney General Merrick B. Garland Announces Investigation of the City of Minneapolis, Minnesota, and the Minneapolis Police Department
    In Crime News
    Attorney General Merrick B. Garland announced today the Justice Department has opened a pattern or practice investigation into the City of Minneapolis (the City) and the Minneapolis Police Department (MPD). The investigation will assess all types of force used by MPD officers, including uses of force involving individuals with behavioral health disabilities and uses of force against individuals engaged in activities protected by the First Amendment. The investigation will also assess whether MPD engages in discriminatory policing. As part of the investigation the Justice Department will conduct a comprehensive review of MPD policies, training and supervision. The department will also examine MPD’s systems of accountability, including complaint intake, investigation, review, disposition and discipline. The Department of Justice will also reach out to community groups and members of the public to learn about their experiences with MPD. “The investigation I am announcing today will assess whether the Minneapolis Police Department engages in a pattern or practice of using excessive force, including during protests,” said Attorney General Garland. “Building trust between community and law enforcement will take time and effort by all of us, but we undertake this task with determination and urgency, knowing that change cannot wait.” This morning, Department of Justice officials informed Minneapolis Mayor Jacob Frey, MPD Chief Medaria Arradondo, City Attorney Jim Rowader, City Coordinator Mark Ruff, and City Council President Lisa Bender of the investigation. The department will continue to work closely with both the City and MPD as the investigation progresses. “One of the Civil Rights Division’s highest priorities is to ensure that every person in this country benefits from public safety systems that are lawful, responsive, transparent and nondiscriminatory,” said Principal Deputy Assistant Attorney General Pamela S. Karlan for the Justice Department's Civil Rights Division. “It is essential that police departments across the country use their law enforcement authority, including the authority to use force, in a manner that respects civil rights and the sanctity of human life.” “People throughout the city of Minneapolis want a public safety system that protects and serves all members of our community,” said Acting U.S. Attorney W. Anders Folk for the District of Minnesota. “This investigation by the Department of Justice provides a vital step to restore and build trust in the Minneapolis Police Department and its officers.” The investigation is being conducted pursuant to the Violent Crime Control and Law Enforcement Act of 1994, which prohibits state and local governments from engaging in a pattern or practice of conduct by law enforcement officers that deprives individuals of rights protected by the Constitution or federal law. The Act allows the Department of Justice to remedy such misconduct through civil litigation. The department will be assessing law enforcement practices under the First, Fourth and Fourteenth Amendments to the U.S. Constitution, as well as under the Safe Streets Act of 1968, Title VI of the Civil Rights Act of 1964 and Title II of the Americans with Disabilities Act. The Special Litigation Section of the Department of Justice Civil Rights Division, in Washington, D.C., and the U.S. Attorney’s Office for the District of Minnesota, in Minneapolis, are jointly conducting this investigation. Individuals with relevant information are encouraged to contact the Department of Justice via email at Community.Minneapolis@usdoj.gov or by phone at 866-432-0268. Individuals can also report civil rights violations regarding this or other matters using the Civil Rights Division’s new reporting portal, available at civilrights.justice.gov. Additional information about the Civil Rights Division is available on its website at www.justice.gov/crt. Additional information about the U.S. Attorney’s Office for the District of Minnesota is available on its website at https://www.justice.gov/usao-mn.
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  • Individual Arrested and Charged with Operating Notorious Darknet Cryptocurrency “Mixer”
    In Crime News
    A dual Russian-Swedish national was arrested Tuesday at Los Angeles International Airport on criminal charges related to his alleged operation of the longest-running bitcoin money laundering service on the darknet.
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  • Office of the Historian, Foreign Service Institute Release of Foreign Relations of the United States, 1969–1976, Volume E–15, Part 2, Documents on Western Europe, 1973–1976, Second, Revised Edition
    In Crime Control and Security News
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  • OECD Working Group on Bribery Issues Report Commending United States for Maintaining Leading Role in the Fight Against Transnational Corruption
    In Crime News
    The Working Group on Bribery of the Organisation for Economic Co-operation and Development (OECD Working Group) issued its Phase 4 Report of the United States today, announced the U.S. Departments of Justice, Commerce, State, and the Securities and Exchange Commission (SEC).
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  • West Tennessee Psychiatrist Sentenced for Unlawfully Distributing Opioids
    In Crime News
    A west Tennessee psychiatrist was sentenced today to 48 months in prison followed by three years of supervised release for unlawfully distributing opioids.
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  • Small Business Contracting: Better Documentation and Reporting Needed on Procurement Center Representatives
    In U.S GAO News
    The Small Business Administration (SBA) does not maintain complete documentation to support data on the activities of procurement center representatives (PCR), which is information used to oversee PCRs and assess their performance. PCRs are responsible for helping small businesses gain access to federal contracting and subcontracting opportunities—for example, by making set-aside recommendations to federal agency contracting officers. SBA area offices generate a monthly report that summarizes data on PCRs' activities and accomplishments, and SBA procedures require PCRs to maintain these reports and the supporting documentation. GAO found that they do not consistently do either. According to SBA officials, in some cases the supporting documentation, which PCRs store on their individual computers or in their offices, either was destroyed or was not maintained after PCRs left their positions. Officials told GAO that SBA recently implemented a new database and established a policy requiring the monthly reports to be maintained in the database. However, SBA has not established a centralized means of maintaining the supporting documentation. A central repository for PCRs to store their supporting documentation would provide greater assurance that the documentation is maintained as required and help SBA verify the accuracy of the data PCRs report on their activities. SBA assigns PCRs to buying activities, divisions in federal agencies that purchase goods and services based on geographic coverage and other factors. Specifically, PCRs are assigned within one of six regional areas to ensure geographic coverage, at specific federal agencies, and at buying activities that have significant opportunities for small business contracting. However, SBA has not submitted required reports to Congress on its rationale for assigning PCRs to cover buying activities. The Small Business Act, as amended, requires that SBA submit a report (1) identifying each area for which SBA has assigned a PCR, (2) explaining why SBA selected the areas for assignment, and (3) describing the activities performed by PCRs. SBA was required to submit the first report to Congress by December 26, 2010, and subsequent reports every 3 years thereafter. SBA officials told GAO they were not aware of the reporting requirement. As a result, Congress lacks the information these reports were intended to provide, information that could be useful for its oversight of PCRs. The Small Business Act establishes tools to enhance procurement opportunities for small businesses, such as set-asides and requirements that large contractors set goals for using small business subcontractors. SBA's PCRs advocate for the inclusion of small businesses during the procurement process. GAO was asked to examine how PCRs help small businesses gain access to federal contracting and subcontracting opportunities. This report addresses, among other objectives, (1) documentation SBA maintains on the activities of PCRs and (2) how SBA assigns PCRs to cover buying activities and its requirement to report to Congress on these assignments. GAO reviewed SBA policies and procedures, data on PCR assignments, and selected data reported by PCRs and related documentation. GAO also interviewed agency officials. GAO recommends that SBA (1) develop a central repository for PCRs to store the supporting documentation for the data they report on their activities and (2) ensure that it submits required reports to Congress on PCRs' assignments and activities. SBA concurred with both recommendations. For more information, contact William B. Shear at (202) 512-8678 or shearw@gao.gov.
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  • Probation Official Charged with Child Pornography Offenses
    In Crime News
    A Pennsylvania man made his initial appearance today after being charged in an indictment with multiple child pornography offenses.
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  • District Court Enters Permanent Injunction Shutting Down Technical-Support Fraud Scheme
    In Crime News
    A federal court entered an order of permanent injunction against an individual and five companies in a case against a large-scale technical-support fraud scheme alleged to have defrauded hundreds of elderly and vulnerable U.S. victims, the Department of Justice announced today. 
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  • United States Files Suit Against California Skilled Nursing Chain and its Owner for Allegedly Paying Illegal Kickbacks to Physicians
    In Crime News
    The United States filed a complaint in the U.S. District Court for the Central District of California yesterday under the False Claims Act against Paksn Inc.; Prema Thekkek, one of its owners; and seven skilled nursing facilities (SNFs) owned by Thekkek and/or operated by Paksn. Those seven SNFs are Bay Point Healthcare Center, Gateway Care & Rehabilitation Center, Hayward Convalescent Hospital, Hilltop Care & Rehabilitation Center, Martinez Convalescent Hospital, Park Central Care & Rehabilitation Hospital, and Yuba Skilled Nursing Center.
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  • Secretary Antony J. Blinken On CNN’s Fareed Zakaria GPS with Fareed Zakaria
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  • Justice Department Issues Favorable Business Review Letter to Institute of International Finance for Sovereign Debt Information Sharing Principles
    In Crime News
    The Department of Justice’s Antitrust Division announced today that it has completed its review of the proposal by the Institute of International Finance (IIF) to promulgate voluntary guidelines, called the Principles for Debt Transparency (Principles), allowing for public disclosure of information regarding the issuance of sovereign debt. Based on the representations in IIF’s letter request, including its description of certain safeguards, the department has concluded that the principles are unlikely to harm competition. Therefore, the department does not presently intend to challenge IIF’s proposed principles.
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  • Attorney General Merrick Garland Recognizes Individuals and Organizations for Service to Crime Victims
    In Crime News
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  • Department of Justice Forecasts an Increase in Counter Unmanned Aerial Systems (C-UAS) Protection Activities and Criminal Enforcement Actions
    In Crime News
    The Department of Justice (DOJ) today announced the protection activities undertaken by the FBI to counter the threat posed by Unmanned Aircraft Systems (UAS) at certain National Special Security Events (NSSEs), Special Events Assessment Rating (SEAR) events, and select mass gatherings throughout the country over the past fiscal year. DOJ and the FBI are publicizing protection activities in an effort to deter careless and criminal UAS operators in light of an anticipated increase in enforcement activity in response to the misuse of UAS.
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  • Accelerating Innovation in Diagnostic Testing for Lyme Disease: HHS Request for Information (RFI)
    In Human Health, Resources and Services
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  • Jacksonville Woman Pleads Guilty to Attempting to Illegally Exporting Maritime Raiding Craft and Engines to China
    In Crime News
    Yang Yang (34, Jacksonville) has pleaded guilty to conspiring to submit false export information through the federal government’s Automated Export System and to fraudulently export to China maritime raiding craft and engines in violation of United States (U.S.) law, and also to attempting to fraudulently export that equipment in violation of U.S. law. Yang faces a maximum penalty of 15 years in federal prison. A sentencing date has not yet been set.
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  • Introductory Remarks of Deputy Attorney General at Announcement of Civil Antitrust Lawsuit Filed Against Google
    In Crime News
    This morning, the Department of Justice and eleven states filed an antitrust civil lawsuit against Google, for unlawfully maintaining a monopoly in general search services and search advertising in violation of section two of the Sherman Act.
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  • Former Drug Enforcement Administration Special Agent and Task Force Officer Convicted of Conspiracy and Conversion of Property
    In Crime News
    A former U.S. Drug Enforcement Administration (DEA) special agent and a former DEA task force officer were convicted Tuesday by a federal jury in New Orleans, Louisiana, in connection with a long-running scheme to steal personal property and money from individuals who had been arrested.
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  • DHS Office of Inspector General: Preliminary Observations on Long-Standing Management and Operational Challenges
    In U.S GAO News
    What GAO Found GAO's preliminary work has identified a number of management and operational challenges, including frequent leadership turnover, since fiscal year 2015 that have impeded the overall effectiveness of the Department of Homeland Security (DHS) Office of Inspector General (OIG). DHS OIG senior leaders have acknowledged that these challenges have contributed to organizational weaknesses, and have taken steps to begin addressing some of them. GAO's preliminary work has identified issues in the following areas, among others: Strategic planning: DHS OIG has not consistently developed strategic plans, which are a necessary input for developing the organization's other guiding documents and governance framework. Specifically, DHS OIG has operated for 4 of the past 6 years without a strategic plan, and the plan it adopted for fiscal years 2018–2019 included some, but not all, of the elements considered standard for federal entities. In 2020, DHS OIG contracted with a nonprofit academy of government experts to develop a strategic plan for fiscal years 2021–2025, with expected delivery in June 2021. Quality assurance: Internal and external reviews have reported on concerns about quality assurance in some of DHS OIG's work. In 2017 and 2018, after an internal review found that some reports issued by DHS OIG may not have adhered to the professional standards cited, DHS OIG retracted 13 audit reports that had been issued over a 5-year period. In 2018, an external review determined that DHS OIG needed to improve its system of quality control. Though DHS OIG concurred with all of the recommendations from that external review, it did not fully implement them. In addition, DHS OIG has not established roles and responsibilities for an organization-wide quality assurance program. Moreover, GAO's preliminary work indicates that current staff allocations may limit DHS OIG's quality assurance reviews to focusing on audit work and not on the other types of work it produces, including inspections, evaluations, special reviews, and management alerts. Timeliness: DHS OIG project time frames for work from its offices of Audits and Special Reviews and Evaluations have increased over the 4 fiscal years GAO assessed. For example, in fiscal year 2017, 79 of 102 Office of Audits projects were completed in 1 year or less and eight of 102 took more than 18 months. In fiscal year 2020, seven of 67 reports were completed in 1 year or less and more than half (35 of 67) took more than 18 months. In addition, DHS OIG has not assessed time frames for work completed by these offices, though timeliness in reporting is a key element of effective oversight and DHS OIG staff considered it an organizational weakness. GAO will complete its evaluation of these and other management and operational areas, and will issue a final report in the coming months. Why GAO Did This Study DHS OIG has a critical role in providing independent and objective oversight of DHS, which encompasses multiple operational and support components. OIGs are expected to maintain high standards of professionalism and integrity in light of their mission, according to quality standards developed by the community of federal Inspectors General. However, DHS OIG has faced a number of challenges that have affected its ability to carry out its oversight mission effectively. This statement is based on GAO's draft report on DHS OIG's management and operations, which is currently at the agency for comment. It provides preliminary observations on DHS OIG's strategic planning processes; quality assurance processes; and reporting time frames for work from DHS OIG's offices of Audits and Special Reviews and Evaluations. To develop these preliminary observations, GAO reviewed relevant federal laws and quality standards for federal OIGs as well as DHS OIG documentation, including organizational policies; internal communications such as emails and memoranda; and DHS OIG's semiannual reports to Congress and published reports. GAO also analyzed DHS OIG project data from fiscal years 2015 through 2020, and interviewed DHS OIG leaders and other staff.
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  • Secretary Michael R. Pompeo Remarks at the Florida Family Policy Council Dinner Gala: Respecting Life in America’s Foreign Policy
    In Crime Control and Security News
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  • Ohio Treatment Facilities and Corporate Parent Agree to Pay $10.25 Million to Resolve False Claims Act Allegations of Kickbacks to Patients and Unnecessary Admissions
    In Crime News
    Oglethorpe Inc. and its three Ohio facilities, Cambridge Behavioral Hospital, Ridgeview Behavioral Hospital, and The Woods at Parkside, will pay $10.25 million to resolve alleged violations of the False Claims Act for improperly providing free long-distance transportation to patients and admitting patients at Cambridge and Ridgeview who did not require inpatient psychiatric treatment, resulting in the submission of false claims to the Medicare program. 
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