Kusserow on Compliance: OIG reports top unimplemented recommendations

The HHS Office of Inspector General (OIG) Top Unimplemented Recommendations: Solutions to Reduce Fraud, Waste, and Abuse in HHS Programs is an annual OIG publication. These recommendations, if implemented, are ones that would most positively impact HHS programs in terms of cost savings, program effectiveness and efficiency, and public health and safety. All were derived from audits and evaluations issued through December 31, 2019, which predated the COVID-19 public health emergency. Fourteen of the 25 were related to Medicare and Medicaid. The recommendations called for CMS to:

  1. Take actions to ensure that incidents of potential abuse or neglect of Medicare beneficiaries are identified and reported.
  2. Reevaluate the inpatient rehabilitation facility payment system, which could include seeking legislative authority to make any changes necessary to more closely align inpatient rehabilitation facility payment rates and costs.
  3. Seek legislative authority to comprehensively reform the hospital wage index system.
  4. Seek legislative authority to implement least costly alternative policies for Part B drugs under appropriate circumstances.
  5. Provide consumers with additional information about hospices’ performance via Hospice Compare.
  6. Continue to work with the Accredited Standards Committee X12 to ensure that medical device-specific information is included on claim forms and require hospitals to use certain condition codes for reporting device replacement procedures.
  7. Analyze the potential impacts of counting time spent as an outpatient toward the three-night requirement for skilled nursing facility (SNF) services so that beneficiaries receiving similar hospital care have similar access to these services.
  8. Provide targeted oversight of Medicare Advantage organizations (MAOs) that had risk adjusted payments resulting from unlinked chart reviews for beneficiaries who had no service records in the 2016 encounter data.
  9. Require MAOs to submit ordering and referring provider identifiers for applicable records in the encounter data.
  10. Develop and execute a strategy to ensure that Part D does not pay for drugs that should be covered by the Part A hospice benefit.
  11. Ensure that States’ reporting of national Medicaid data is complete, accurate, and timely.
  12. Collaborate with partners to develop strategies for improving rates of follow-up care for children treated for attention deficit hyperactivity disorder (ADHD).
  13. Develop policies and procedures to improve the timeliness of recovering Medicaid overpayments and recover uncollected amounts identified by OIG’s audits.
  14. Identify States that have limited availability of behavioral health services and develop strategies and share information to ensure that Medicaid managed care enrollees have timely access to these services.

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 © 2020 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: 2020 DOJ compliance program guidelines on continuous improvement and use of data

The DOJ released an update to its Compliance Guidance, intended to assist prosecutors in making informed decisions about whether a company’s compliance program was effective at the time of an offense. It emphasizes the importance of using data and technology to support compliance efforts, including assisting with continuous updates of a compliance program and assessing the adequacy and effectiveness of it at the time of the offense, charging decision, and case resolution. Many of the changes involve adding questions about a company’s ability to learn from its own experience through, among other things, the use of data and technology. The guidance asks whether companies:

  1. Engage in periodic reviews limited to a “snapshot” in time, or one based on continuous access to operational data across functions?
  2. Incorporated “lessons learned” through a “process for tracking and incorporating into its periodic risk assessment” information acquired both internally and from other similarly situated companies?
  3. Update policies/procedures and if they provide enough data to allow for effective monitoring and testing their effectiveness?
  4. Publish policy documents in a searchable format for easy reference and access?
  5. Can track access to specific policies/procedures to understand which are attracting the most attention from employees?
  6. Have means for employees to ask questions arising out of training?
  7. Have evaluated extent to which training has had an impact on employee behavior or operations?
  8. Engage in continuous ongoing monitoring and improving reporting mechanisms?
  9. Periodically test[s] hotline effectiveness, and track reports from inception to conclusion?
  10. Effectively communicate compliance requirements to employees during compliance education and training?

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 LinkedIn.

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Copyright © 2020 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: OIG response plan—four goals for the COVID-19 Crisis

The HHS Office of Inspector General (OIG) has identified four goals to respond to the COVID-19 Pandemic: protecting people, protecting funds, protecting infrastructure, and promoting effectiveness. The OIG set out its framework in the OIG Strategic Plan: Oversight of COVID-19 Response and Recovery.

PROTECT PEOPLE. The OIG plans for this goal include to: (1) issue guidance on its administrative fraud enforcement authorities related to delivering needed patient care; (2) conduct rapid-cycle reviews of conditions affecting HHS beneficiaries or health care providers; (3) inform/support response efforts; (4) help ensure continuity of HHS operations during the public health emergency; (5) identify and investigate fraud and scams that endanger HHS beneficiaries and the public; (6) alert the public to fraud schemes related to COVID-19; and (7) assess the impacts of HHS programs on the health and safety in the acquisition, management, and distribution of COVID-19 tests and vaccine and treatment research and development.

PROTECT FUNDS. HHS was appropriated $251 billion for COVID-19 response and recovery—to prevent, prepare for, and respond to coronavirus, along with funds from other appropriations. The OIG plans for this  goal include: (1) reviewing of oversight, management, and internal controls for awarding, disbursement, and use of funds; (2) assessing whether recipients met requirements; (3) mitigating major risks that cut across program and agency boundaries; (4) ensuring that intended purposes of funds granted are being used properly; (5) identifying and investigating suspected fraud and exercising OIG’s administrative enforcement authorities; (6) identifying program integrity vulnerabilities and recommend safeguards; and (7) providing alerts to potential fraud risks or schemes to steal funds.

PROTECT INFRASTRUCTURE. Objectives for this goal include: (1) protecting the security and integrity of IT systems and health technology; (2) identifying IT vulnerabilities and incidents, mitigating threats, and restoring IT services; and (3) focusing on identifying and investigating cybersecurity vulnerabilities related to COVID-19 response.

PROMOTE EFFECTIVENESS. The OIG’s plans for this goal include: (1) focusing on COVID-19 efforts to identify successful practices and lessons learned from the emergency preparedness and response; (2) reviewing pandemic preparedness planning to identify how preparedness funding was spent; and (3) assessing COVID-19 impact on HHS programs and beneficiaries, including expanded telehealth in Medicare.

 

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 LinkedIn.

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Copyright © 2020 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: OIG Strategic plan outlines top priorities for 2020 – 2025

 The HHS Office of Inspector General (OIG) has identified seven major initiatives as part of its strategic plan for the period between 2020 and 2025. The initiatives include: (1) fraud and abuse protections; (2) safeguarding the Medicare trust funds; (3) protecting beneficiaries from prescription drug abuse; (4) combating health care cybersecurity threats; (5) promoting patient safety and accuracy of payments in home and community settings; (6) leveraging technology; and (7) ensuring HHS managed care and new health care models produce value.

  1. Fraud and Abuse Protections. OIG audits of national Medicaid data found substantial improper payments to providers for Medicaid Services; states were not always correctly determining lack of eligibility of individuals for Medicaid benefits. These two areas will be a focus for OIG oversight.
  2. Safeguarding the Medicare Trust Funds. The OIG plans to use data analytics to identify program areas and geographic areas of high-risk. It should provide strategic oversight of emergency preparedness and response affecting Medicare beneficiaries, Medicare Advantage, prescription drug spending, and the transition to value-based care.
  3. Protecting Beneficiaries from Prescription Drug Abuse, Including Opioids. The OIG’s efforts will focus on identifying opportunities to improve the efficiency and effectiveness of monitoring and identifying and holding accountable those engaged in fraud and abuse related to prescription drugs. Major efforts will include empowering partners through data sharing and education.
  1. Combatting Health Care Cybersecurity Threats. The OIG will increase efforts to combat cybersecurity threats, including hacking attacks, manipulation of medical devices, and inappropriate access to U.S. genomic data. The OIG will perform more cybersecurity audits of HHS agencies and programs, in partnership with other agencies, to conduct investigations that may involve espionage or foreign threats.
  1. Promoting Patient Safety and Accuracy of Payments in Home and Community Settings. The OIG plans increased efforts to reduce improper payments for services in noninstitutional settings, including home health. The OIG’s plans include outreach, education, audits, evaluations, inspections, investigations, and administrative enforcement.
  1. Leveraging Technology as it Intersects with HHS Programs. The OIG highlights that technology can be used to increase the efficiency, quality, and accessibility of the health care system. The OIG will work with other HHS agencies, patients, and providers to educate and oversee the use of health technology to positively impact providers and patients. The OIG will also assess how it can use Artificial Intelligence to foster value and quality in HHS programs.
  1. Ensuring HHS Managed Care and New Healthcare Models Produce Value. As CMS programs shift to value-based care and payment, the OIG has identified three elements that are critical to achieving better value, quality, and outcomes: (1) aligning program incentives with improved health outcomes; (2) strengthening program integrity; and (3) delivering innovative technology. The OIG will oversee the continued transition to value-based programs and will address and combat any issues of fraud, waste, and abuse.

 

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 LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2020 Strategic Management Services, LLC. Published with permission.