Kusserow on Compliance: OIG November 2017 Work Plan update

This year, the OIG is updating its annual Work Plan during the year, rather than annually. The OIG’s Work Plan sets forth various audits and evaluations that are underway or planned during the fiscal year and beyond. The updates will include the addition of newly initiated Work Plan items; removal of completed items. In conducting its work, the OIG assesses relative risks in HHS programs and operations to identify those areas most in need of attention. In evaluating potential projects to undertake, the OIG considers a number of factors, including mandates set forth in laws, regulations, or other directives; requests by Congress, HHS management, or the Office of Management and Budget; top management and performance challenges facing HHS; work performed by other oversight organizations (e.g., GAO); management’s actions to implement OIG recommendations from previous reviews; and potential for positive impact. In addition to working on projects that often result in audits, reviews, and reports, the OIG also engages in a number of legal and investigative activities that are separately reported.

New projects

  1. Use of Funds by Medicaid Managed Care Organizations (MCOs). In 2015, Federal Medicaid managed care payments were approximately $161.8 billion, which was more than 40 percent of the $349.8 billion in total Federal expenditures for Medicaid. States continue to expand their use of managed care. To deliver services to Medicaid managed care enrollees, states contract with MCOs and make monthly capitation payments to those plans to provide enrollees with Medicaid-covered services. Appropriately set capitation rates help to ensure that adequate payments are made to provide services to beneficiaries. OIG auditors plan to examine how Medicaid funds received by MCOs are used to provide services to enrollees with results reported in 2019.


  1. Opioids in Medicaid: Concerns about Extreme Use and Questionable Prescribing in Selected States. The OIG Office of Evaluation and Inspection will focus on the problem of opioid abuse and overdose deaths that have reached crisis levels in the United States, with more than 33,000 Americans dying from it annually. These issues are of particular concern for Medicaid beneficiaries because they are more likely to have chronic conditions and comorbidities that require pain relief. Especially affected are beneficiaries who qualify through a disability. The OIG plans to identify beneficiaries who received extreme amounts of opioids through Medicaid and those cases that appear to involve doctor shopping or pharmacy shopping, as well as prescribers associated with these beneficiaries. This review will provide baseline data about beneficiaries receiving extreme amounts of opioids and prescribers with questionable patterns for opioids in Medicaid.


  1. Medicaid Services Delivered Using Telecommunication Systems. Medicaid pays for telemedicine, telehealth, and telemonitoring services delivered through a range of interactive video, audio or data transmission (telecommunications). Medicaid programs are seeing a significant increase in claims for these services and expect this trend to continue. OIG auditors will over the next year or two determine whether selected states’ Medicaid payments for services delivered using telecommunication systems were allowable in accord with Medicaid requirements.

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 © 2017 Strategic Management Services, LLC. Published with permission.