Kusserow on Compliance: OIG work planning driven by CMS program mandates

The HHS Office of Inspector General (OIG) Mid-Year Update to the OIG Work Plan for fiscal year (FY) 2015 described ongoing OIG audits, evaluations, and certain legal and investigative initiatives, as well as removed items that have been completed, postponed, or canceled. The report explained that the OIG work planning is a dynamic process and adjustments are made throughout the year to meet priorities and to anticipate and respond to emerging issues within the constraints of available resources. Priorities are set as a result of assessing relative risks confronting the more than 100 HHS programs and in identifying areas most in need of attention. The agency then allocates its available resources accordingly. A number of factors are considered in generating specific task work for any given period including:

  • Legal, regulatory, and other mandates;
  • Requests by Congress, HHS management, or the Office of Management and Budget;
  • Top management and performance challenges facing HHS;
  • Work generated by partner organizations;
  • Management’s actions in response to recommendations from previous reviews; and
  • Timeliness of issues.

It should be noted however that the entire process is distorted by funding requirements, which direct more than three quarters of their resources be devoted to the Medicare and Medicaid program. As such, the OIG Work Plan devotes most of its resources to reducing Medicare Parts A and B and ensuring quality, including quality in nursing home, hospice care, and home- and community-based care. As a result, the overarching OIG planning efforts reflected in the current fiscal year and beyond involve the following:

Quality of care: Planned work will examine settings in which the OIG has identified gaps in program safeguards intended to ensure medical necessity, patient safety, and quality of care. It will also continue its focus on access to care, including beneficiary access to durable medical equipment prosthetics, orthotics, and supplies (DMEPOS) in the context of new programs involving competitive bidding.

Appropriate payments: Planning is ongoing to expand OIG’s portfolio examining inefficient payment policies or practices, including comparison among government programs to identify instances when Medicare paid significantly different amounts for the same or similar services or when less efficient payment methodologies were used. Planning is ongoing for work addressing Medicare costs incurred because of deficiencies in services or defective medical devices, as well as noncompliance or other vulnerabilities in care settings with high payment error rates.

Oversight of payment and delivery reform: Planning is underway to expand OIG’s work addressing changes to Medicare programs designed to improve efficiency and quality of care and to promote program integrity and transparency. OIG will consider work examining the transition from volume- to value-based payments and the soundness and effectiveness of the payment structures, care coordination, and administration of these new payment models. Work expected to begin in 2015 and beyond includes examinations of data and metrics to document and measure quality and performance.

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.