Kusserow on Compliance: July/August 2018 Work Plan updates

The Office of Inspector General’s (OIG) work planning process is dynamic and adjustments are made throughout the year to meet priorities and to anticipate and respond to emerging issues with the resources available. Effective June, 2017, the OIG has been updating its Work Plan monthly. The following are the updates posted for July and August 2018:

  1. 3-Dimensional Conformal Radiation Therapy (3D-CRT). 3D-CRT is a radiation therapy technique that allows doctors to sculpt radiation beams to the shape of a patient’s tumor provided in two treatment phases: planning and delivery. Hospitals bill Medicare for developing a 3D-CRT treatment plan using Current Procedural Terminology code 77295. Automated prepayment edits prevent additional payments for separately billed radiation planning services if they are billed on the same date of service as the 3D-CRT treatment plan. However, Medicare allows additional payments if they are billed on a different date of service (e.g., 1 day before). For a form of radiation similar to 3D-CRT, Medicare requirements prohibit payments for separately billed radiation planning services when they are billed on a different date of service. OIG auditors will determine the extent of potential savings to Medicare if it had implemented the same requirements for 3D-CRT planning services.


  1. Identification of HHS Cybersecurity Vulnerabilities. The OIG will perform a series of IT audits at the HHS Operating Divisions in an effort to identify cybersecurity vulnerabilities and possible compromise of the HHS Office of the Secretary and its OPDIVs’ systems and networks.


  1. HRSA’s Oversight of Funds for Access Increases in Mental Health and Substance Abuse Services (AIMS). The Health Resources and Services Administration (HRSA) administers AIMS grants and last year HRSA awarded $200 million in AIMS grants to 1,178 health centers nation-wide intended to expand access for existing Health Center Program grant recipients to mental health and substance abuse services, focusing on the treatment, prevention, and awareness of opioid abuse. The OIG will review HRSA’s internal controls to determine whether they are suitable for (1) awarding AIMS grants and (2) monitoring AIMS grant recipients.


  1. Increased Payments For Transfer Claims With Outliers. While the transfer rule reduces the Diagnosis Related Group (DRG), Disproportionate Share Hospital (DSH), and Indirect Medical Education (IME) payments on a Medicare beneficiary’s claim, the methodology for calculating cost outlier payments can result in such payments being higher than what would have been paid in a nontransfer context. Under the transfer rule, CMS reduces the DRG payment by applying a graduated per diem payment on the Medicare claim of the hospital transferring the patient to another setting early in the patient’s hospital stay. Because DSH and IME payments are determined as a percentage of the reduced DRG payment, they are also reduced. By contrast, by reducing the threshold above which a claim qualifies as an outlier, the application of the outlier methodology at 42 CFR Sec. 412.80(b) can result in an increase in the outlier payment in transfer cases. The plans to produce a report describing the extent to which additional Medicare outlier payments negate the reduction in DRG, DSH, and IME payments of transfer claims.


  1. Review of Post-Operative Services Provided in the Global Surgery Period. Section 523 of Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires CMS to collect data on post-operative services included in global surgeries and requires OIG to audit and verify a sample of the data collected. The OIG will review a sample of global surgeries to determine the number of post-operative services documented in the medical records and compare it to the number of post-operative services reported in the data collected by CMS. The OIG plans to verify the accuracy of the number of post-operative visits reported to CMS by physicians and determine whether global surgery fees reflected the actual number of post-operative services that physicians provided to beneficiaries during the global surgery period


  1. SAMHSA’s Oversight of Accreditation Bodies for Opioid Treatment Programs. The Substance Abuse and Mental Health Services Administration (SAMHSA) estimates that 2.5 million people have an opioid use disorder related to prescription pain relievers and/or heroin. Medication-Assisted Treatment (MAT), provided by opioid treatment programs (OTPs), is a significant component of the treatment protocols for opioid use disorder and plays a large role in combating the opioid epidemic in the United States. SAMHSA issued final regulations to establish an oversight system for the treatment of substance use disorders with MAT. These regulations (42 CFR Part 8) established procedures for an entity to become an approved accreditation body, which evaluates OTPs and ensures SAMHSA’s opioid dependency treatment standards are met. The OIG plans to determine whether SAMHSA’s oversight of accreditation bodies complied with Federal requirements; and will include SAMHSA-approved accrediting bodies that have accredited OTPs


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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