OIG identifies top 10 challenges in fulfilling HHS’ mission

Going into the new year, the HHS Office of Inspector General (OIG) will continue to focus on administration, quality health care, program integrity, and the improvement of electronic health records (EHR) and health information technology (IT). The OIG has identified its top 10 management and performance challenges, and has expressed its commitment to assisting in transitioning between administrations.

Effective administration

The OIG finds effective administration to be a challenge in many areas. The Medicaid program is a particular area of concern due to the 72 million enrollees that the program serves and the expansions implemented under the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148). In particular, CMS needs complete and accurate data about managed care, states need to fully implement all program integrity tools, and corrective action plans to address improper payments must be developed. These issues are representative of the OIG’s challenges in operating the entirety of HHS, which reported total costs of about $1 trillion in fiscal year (FY) 2015. The OIG must continue taking corrective actions, resolving deficiencies, and monitoring contracts. Other particular administrative challenges are grants, the health insurance marketplaces, and Part A and Part B program integrity.

Other issues

The OIG faces several issues within the realm of IT. Cybersecurity has been a growing concern due to the significant increase in the frequency of data breaches. Additionally, despite HHS’ investments in health IT and interoperability, the agency still has steps to take to ensure widespread use and adoption of EHRs and other health IT. The rest of the top challenges focus on serving the population: ensuring that vulnerable populations receive quality care; monitoring food, drug, and medical device safety; and addressing drug abuse in Part D and Medicaid.

Kusserow on Compliance: Self-disclosures to the OIG continue to result in settlements

The HHS Office of Inspector General (OIG) announced an update on self-disclosures reporting that settlements from that process have exceeded $500 million since the inception of the program in 1998. Health care providers, suppliers, or other individuals or entities subject to Civil Monetary Penalties are encouraged to use the OIG Provider Self-Disclosure Protocol, to voluntarily disclose self-discovered evidence of potential fraud. It gives providers the opportunity to avoid the costs and disruptions associated with a government-directed investigation and civil or administrative litigation.

Settlements are posted on the OIG Website that show amounts through this process most often range between a quarter and a half million dollars, with many under $100,000. However there are some significantly larger settlements in the millions of dollars. By far the large settlement came last year with Kroger Co., who agreed to pay $21,523,047 for (1) employment of 14 excluded individuals; and (2) filling prescriptions written by 84 excluded prescribers. It is also a reminder that the most common self disclosure involves parties on the OIG List of Excluded Individuals and Entities (LEIE). The lesson to be learned from this is to ensure ongoing screening of employees, health care professionals, contractors and vendors, as called for by the OIG. However, many times organizations that do screen frequently are not sufficiently trained to identify and confirm those that may appear on the LEIE. Sometimes this is as the result of slightly different spelling of names, transposition of first and surnames, etc. As such, it pays to train people in resolving potential hits, or use a service that will do it for you.

Guidance on the Provider Self-Disclosure Protocol can be found on the OIG website. The “principal purpose” of this program is making available “guidance to health care providers that decide voluntarily to disclose irregularities in their dealings with federal health care programs.” They accept on submissions relevant to the False Claims Act, the anti-kickback statute, and claims pertaining to excluded individuals. The OIG places emphasis on organizations to undergo a full internal investigation before disclosure submission and providing detailed findings to the OIG. Self-disclosure may be submitted online or by written submissions by mail to the OIG.

Disclosure Benefits

  1. No Corporate Integrity Agreement (CIA)
  2. Lower multiplier (1.5 times single damages)
  3. CMS suspending “the obligation to report overpayments” for those self disclosed
  4. Reduced the time a case is pending to less than 12 months.

The OIG leaves it to the provider to ensure the conduct in violation of federal criminal, civil, or administrative laws ended at the time of disclosure, or that corrective action is undertaken within 90 days of submission to the protocol. They must conduct a review to estimate the improper amount received from a federal healthcare program when reporting a submission of improper claims to the protocol. Damage estimation must be either a review of claims submitted or a random sample of affected claims (the random sample must be accompanied by a copy of the sampling plan). This is a critical step and must be done correctly by experts.

Meet Before Self Disclosing

  • Ensure reportable has ended before disclosure.
  • Corrective actions taken to correct underlying problem and prevent future non-compliance.
  • Waiver of any statute of limitations defenses pertaining to OIG administrative actions.
  • “Must acknowledge that the conduct is a potential violation” and “explicitly identify the laws that were potentially violated.”

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 © 2016 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: CMS program integrity reports saving $40B over two years

CMS issued its 2016 mandated annual program integrity report to Congress that addresses activities during fiscal years 2013 and 2014.  The agency reported that its program integrity activities saved Medicare over $39 billion, for a two-year return on investment of $12.4 to 1.  Over 70 percent in aggregate was the result of prevention of improper payments.  Recovery of overpayments represented only about one-fourth of the total savings with Reviews and Audit recoveries of about $5 billion, Recovery Auditor Collections of about $6 billion, and Law Enforcement Referrals of $230 million.  During the same period, CMS had about 1,000 active payment suspensions. Prevention of improper payments continues to increase as CMS proceeds with its proactive approach to program integrity.

The report also addressed the CMS Medicaid Integrity Program.  CMS directed the Audit Medicaid Integrity Contractors (MICs), which identified roughly $50 million in overpayments for recovery by states. Through Audit MIC activities, the states returned the federal share of $11 million to the Treasury. Through the State Medicaid Recovery Audit Programs, the states have recovered a total federal and state share combined amount of about $230 and returned the federal share of $140 million to the Treasury.

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 © 2016 Strategic Management Services, LLC. Published with permission.

Demonstration requires earlier home health documentation in high-risk areas

A new demonstration project will require pre-claim review for home health agencies (HHAs) prior to payment in five states. In an advance release, CMS stated that this demonstration will serve as an anti-fraud tool to prevent improper payments and protect program integrity. CMS assures beneficiaries that they will continue to receive immediate care once services are ordered, but agencies will be required to submit supporting documentation during the provision of care.

Earlier submission

The demonstration will not impose new documentation requirements on HHAs, and does not change the home health service benefit for beneficiaries. HHAs in the participating states (Illinois, Florida, Texas, Michigan, and Massachusetts) will be required to submit all supporting documentation while providing care. Beneficiaries are also permitted to submit documentation for pre-claim review. CMS has established a timeframe of about 10 days for a decision, giving the HHA or the beneficiary an option to submit additional documentation if the agency finds that the original submission is inadequate.

Errors and fraud

HHAs are prone to errors in documentation and present a risk of fraud, abuse, and waste to federal health care programs. The improper payment rate for HHAs was 59 percent in 2015, which can be largely attributed to insufficient documentation. Research indicates that the majority of home health payment errors occur when the narrative portion of the documentation did not sufficiently show that the patient was homebound and in need of home health services. CMS plans to use the demonstration to educate HHAs on what is required, and will allow HHAs to submit documentation as many times as necessary during review.

HHAs are so prone to fraud and abuse that CMS has issued a moratoria preventing new enrollment of home health providers in markets indicating high risk, including Miami, Chicago, Dallas, and Houston (see Home health fraud bigger in Texas; convictions in $376M scheme, Health Law Daily, April 14, 2016; Fighting home health and ambulance fraud by putting providers on a map, Health Law Daily, February 23, 2016). CMS believes that the pre-claim review process will be another tool available to prevent fraud, rather than attempting to reclaim fraudulent payments.