Kusserow on Compliance: OIG recommendations for Medicare fraud prevention

Gary Cantrell, Deputy Inspector General for Investigations for the HHS Office of the Inspector General (OIG), provided testimony before the House Ways and Means Subcommittee on Oversight on the OIG’s efforts to combat fraud in the Medicare program as reported in the “2015 Report on Unimplemented OIG Recommendations.” He presented several high priority OIG recommendations to prevent fraud from occurring by making improvements that address vulnerabilities and better safeguard the Medicare program and its beneficiaries. All of these recommendations were included in the recently released OIG’s “Compendium of Unimplemented Recommendations,” issued earlier this month. The highlighted recommendations included the following:

  • To address prescription drug abuse, CMS should move to restrict certain Part D beneficiaries to a limited number of pharmacies or prescribers. This practice, known as “lock-in,” is currently used by some state Medicaid programs and could help reduce inappropriate drug utilization by Part D.
  • To improve Medicare Part C and D fraud reporting, CMS should require Medicare Part C (Medicare Advantage or MA) and Part D plan sponsors to report fraud and abuse. Oversight of Part C and Part D is hampered by a lack of accurate, timely, and complete data on fraud and abuse incidents.
  • To help curb inappropriate home health care, CMS should enhance its oversight mechanisms to improve compliance with the home health “face-to-face” requirement. Home health agencies (HHAs) are required to obtain documentation from the provider, who must certify that a Medicare beneficiary who needs home health care had a face-to-face encounter with the provider. This safeguard is intended to reduce inappropriate payments for home health care, but OIG found high rates of noncompliance in this area.
  • If CMS would remove Social Security numbers from Medicare cards, it would help guard the personal health information of Medicare beneficiaries from fraudulent use of the numbers. Experts in the health care program integrity field advise that medical identity theft is a prevalent and increasing crime that is closely linked to Medicare fraud and additional safeguards are needed to protect the identities of beneficiaries.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2015 Strategic Management Services, LLC. Published with permission.