Kusserow on Compliance: OIG summarizes investigative accomplishments from last three years

The OIG testified before the House Committee on Ways and Means and reported that in the last 3 fiscal years, its investigations have resulted in more than $10.8 billion in investigative receivables (dollars ordered or agreed to be paid to Government programs as a result of criminal, civil, or administrative judgments or settlements); 2,650 criminal actions; 2,211 civil actions; and 10,991 program exclusions. Much of this work involving the Medicare and Medicaid programs is funded by the Health Care Fraud and Abuse Control Program (HCFAC).  The HCFAC provides funding resources to the Department of Justice (DOJ), HHS, and OIG, which are often used collaboratively to fight health care fraud, waste, and abuse. Since its inception in 1997, the HCFAC has returned more than $31 billion to the Medicare trust fund.

The OIG is a lead participant in the DOJ led Medicare Fraud Strike Force, which combines the resources of Federal, state, and local law enforcement entities to fight health care fraud across the country. The Strike Force operates in nine geographic hot spots, including Miami, Florida; Los Angeles, California; Detroit, Michigan; southern Texas; Brooklyn, New York; southern Louisiana; Tampa, Florida; Chicago, Illinois; and Dallas, Texas. Strike Force teams are led by the DOJ, includes the FBI and the OIG, along with state and local law enforcement. In 2017 alone Strike Force teams accounted for over 2,000 criminal actions with about 3,000 indictments, and accounted for monetary results of around $3 billion. Since its inception in March 2007, the Strike Force has charged more than 3,000 defendants who collectively billed the Medicare program more than $10.8 billion.

The OIG also collaborates with state Medicaid Fraud Control Units (MFCUs) to detect and investigate fraud, waste, and abuse in state Medicaid programs, as well as private sector stakeholders to enhance the relevance and impact of its work to combat health care fraud, as demonstrated by its leadership in the Healthcare Fraud Prevention Partnership (HFPP) and collaboration with the National Health Care Anti-Fraud Association (NHCAA). The OIG strives to cultivate a culture of compliance in the health care industry through various educational efforts, such as Pharmacy Diversion Awareness Conferences, public outreach, and consumer education.

 

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.

Connect with Richard Kusserow on Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

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

Medicaid and CHIP are catching uncovered kids, the ACA helps

Due to high rates of Medicaid and Children’s Health Insurance Program (CHIP) coverage for young children, only 3.3 percent of children ages three and younger were uninsured in 2016. Coverage of both young children (age three and younger) and their parents increased under the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) in 2014 and 2015—a trend that continued in 2016. According to an Urban Institute report, young children and their families continued to rely on Medicaid and CHIP in 2016, with 48.5 percent of young children covered by Medicaid or CHIP. In comparison, only 42 percent of older children were covered by the programs.

Trends. Nearly half of young children and one-fifth of the parents of young children were covered by Medicaid and CHIP in 2015 as well. The high incidence of Medicaid and CHIP coverage is partly due to higher incidence of family characteristics among parents of younger children, including lower incomes, younger parents, and mixed immigration status.

Variance. Despite high overall levels of coverage, the prevalence of health insurance coverage for young children and their families continued to vary across state lines. Uninsurance rates were below 2 percent in 12 states but above 8 percent in three states—Alaska, Wyoming, and North Dakota. Additionally, the expansion of state Medicaid programs under the ACA continues to be a significant source of variation in state uninsurance levels for the parents of young children. For example, an estimated 8.7 percent of parents of young children in expansion states were uninsured in 2016, whereas 18 percent of parents of young children were uninsured in nonexpansion states.

Kusserow on Compliance: Physicians must comply with sharing patient information

Under the electronic health records (EHR) metric, The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (P.L. 114-10) requires attestations from doctors that they are not knowingly and willfully limiting or restricting their EHR’s ability to share information with providers that may have different record systems.  CMS has issued new guidance reminding providers of their responsibilities to promptly share medical information with patients and other clinicians, or else face financial penalties. The targets are providers participating in the Merit-based Incentive Payment System (MIPS) to comply with MACRA. The notice stated physicians will need to attest that they are not engaged in information blocking and that they give patients their data in a timely fashion. Many physicians and medical practices use vendors for their information management systems. They will now have to ensure their vendors enable them to comply with the information sharing mandates.

Under MIPS, providers become eligible for either bonus payments or penalties based on their performance, including evidence of quality improvement, cost reduction or maintaining current levels of spending; efficient use of EHRs; and clinical improvement activities such as later office hours and greater use of care coordination. The Prevention of Information Blocking Attestation has three related statements for MIPS eligible clinicians:

  1. They did not knowingly and willfully take action to limit or restrict the compatibility or interoperability of Certified EHR Technology (CEHRT).
  2. They implemented technologies, standards, policies, practices, and agreements reasonably calculated to ensure the CEHRT was connected and compliance with applicable law and standards for timely access by patients to their data and other health care providers.
  3. They responded in good faith and in a timely manner to request to retrieve or exchange EHR from patients and other health care providers.

CMS also stated that physicians would not be held accountable for things outside of their control, but must get adequate assurances from their vendors that they are able to comply with the information sharing requirements. On the other hand, physicians must take care that they don’t violate the HIPAA Privacy law for patient Protected Health Information (PHI).

 

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.

Connect with Richard Kusserow on Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

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

MACPAC suggests Congress authorize states to mandate managed care

Congress should amend Section 1932(a)(2) of the Social Security Act (SSA) to allow states to require all beneficiaries to enroll in Medicaid managed care programs under state plan authority, without a waiver, according to the Medicaid and CHIP Payment and Access Commission (MACPAC).

Other recommendations

During its January session, MACPAC approved the managed care recommendation, which will be added to the commission’s draft March 2018 report to Congress alongside two December 2017 recommendations that Congress (1) extend Section 1915(b) waiver approvals from two to five years; and (2) revise Section 1915(c) waivers to waive freedom of choice and allow selective contracting.

Concerns

Other concerns raised by MACPAC in December 2017 included: (1) whether the managed care recommendation should include long-term services and supports; (2) the adequacy of protections for vulnerable beneficiaries under state plan authority; and (3) that the recommendation to allow mandatory managed care enrollment requires oversight of states and plans to ensure beneficiary needs are met.