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.

Kusserow on Compliance: OIG reports investigative results for first half of 2015

The Office of Inspector General (OIG) mission is to provide independent and objective oversight that promotes economy, efficiency, and effectiveness in the programs and operations of HHS. It investigates allegations of fraud, waste, and abuse in all of the Department’s programs and is mandated to report to Congress semi-annually on the progress of meeting these mission goals. On June 1, 2015, the OIG released its first half of fiscal year (FY) 2015’s report, which included the following statistical results from investigations:

• Expected recoveries of over $1.8 billion ($544.7 million in audit receivables and $1.26 billion in investigative receivables that includes $142 million in areas such as the states’ shares of Medicaid restitution);
• 486 criminal actions against individuals/entities engaged in crimes against HHS programs;
• 326 civil actions, civil monetary penalties settlements, and administrative recoveries related to provider self-disclosure matters;
• 1,735 individuals and entities excluded from participation in federal health care programs.

The largest body of work in the report involved the investigation of matters related to the Medicare and Medicaid programs, such as: (1) patient harm; (2) billing for services not rendered, medically unnecessary services, or services more extensive than those actually provided; (3) illegal billing, sale, diversion, and off-label marketing of prescription drugs; and (4) solicitation and receipt of kickbacks, including illegal payments to patients for involvement in fraud schemes and illegal referral arrangements between physicians and medical companies. The OIG also investigated cases involving organized criminal activity, medical identity theft, and fraudulent medical schemes that are established for the sole purpose of stealing Medicare dollars. Those who participate in these schemes may face heavy fines, jail time, and exclusion from participating in federal health care programs. The OIG took special note to highlight common criminal fraud scheme case types that occurred in the following areas:

• controlled and non-controlled prescription drugs;
• home health agencies and personal care services;
• ambulance transportation;
• durable medical equipment (DME); and
• diagnostic radiology and laboratory testing.

It also cited the results from the Health Care Fraud Prevention and Enforcement Action Team (HEAT) started in 2009 by HHS and the Department of Justice (DOJ) to strengthen programs and invest in new resources and technologies to prevent and combat health care fraud, waste, and abuse. HEAT continued to identify those who seek to defraud Medicare and Medicaid. The Medicare Fraud Strike Force, which operates in nine major cities and is a key component of HEAT, coordinates law enforcement operations conducted jointly by federal, state, and local law enforcement entities that prosecute health care fraud. During the first half of FY 2015, the efforts of this team resulted in the filing of charges against 69 individuals or entities, 124 criminal actions, and $163 million in investigative receivables. As part of the endeavors, the team refers credible allegations of fraud to CMS so that it can suspend payments to the suspected perpetrators, thereby immediately preventing losses from claims by Strike Force targets.

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.

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

 

Kusserow on Compliance: Breaking News: HHS OIG posts its mid-year Work Plan update

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The Office of Inspector General (OIG) has posted a mid-year update on its Fiscal Year 2015 Work Plan, effective May 2015. It is worth reviewing, as it describes audits, evaluations, and certain legal and investigative initiatives that are ongoing, as well as those deleted, completed, postponed, or canceled. The OIG has added 20 new items that have been started since October 2014. For each project in the revised Work Plan, the agency included the subject, primary objective, criteria related to the topic, identification code for the review, and when it expects reports to be issued for the review. The update also forecasted areas for which it anticipates planning and/or beginning work in the upcoming fiscal year and beyond. These broader areas of focus are based on the results of OIG’s past work and have been identified as significant management and performance challenges facing HHS.

The OIG intends to continue reviews of the appropriateness of Medicare and Medicaid payments with possible additional work on the efficiency and effectiveness of payment policies and practices in inpatient and outpatient settings, for prescription drugs, and in managed care. Other areas it has under consideration include: (1) the integrity of the food, drug, and medical device supply chains; (2) security of electronic data; (3) use and exchange of health information technology; and (4) emergency preparedness and response efforts. It also plans to continue to focus on emerging payment, eligibility, management, and information technology systems security vulnerabilities in health care reform programs, such as the Health Insurance Marketplaces, as well as care quality and access in Medicare and Medicaid.

Among the new reviews schedule for Medicare and Medicaid program are the following:

  • Medicare outpatient payments for intensity-modulated radiation therapy (IMRT);
  • Hospital preparedness and response to high-risk infectious diseases;
  • Competitive bidding on beneficiary access to durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS);
  • Payments for the top 25 clinical diagnostic laboratory tests charged to Medicare;
  • Inpatient rehabilitation facility prospective payment system (IRF PPS) compliance, including required documentation to support claims paid by Medicare;
  • Accountable care organization (ACO) Medicare Shared Savings Program (MSSP) use of electronic health records (EHRs) to achieve their care coordination goals;
  • Medicare Part D billing trends, including changes in billing for commonly used opioid drugs;
  • States’ reporting of their federal share of Medicaid rebate collections;
  • Determinations of whether generic drug prices increased more than inflation for urban consumers;
  • Drug manufacturers’ treatment of sales of generics in their calculation of average manufacturer price (AMP) for the Medicaid drug rebate program; and
  • State submissions of Transformed Medicaid Statistical Information System (T-MSIS) data.

The OIG makes it clear that the Work Plan is constantly being updated and changed according to needs and circumstances and as such it does not provide status reports on the progress of the reviews, however it does periodically update the Work Plan.

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