The aim of the Office of Inspector General (OIG) is to protect federal healthcare programs’ integrity as well as their beneficiaries by primarily detecting and preventing fraud, waste, and abuse. These efforts are demonstrated in the HHS OIG Work Plan that identifies different projects that are in progress or planned to be addressed in the near future, as part of the OIG mission.
Monitoring and assessing items included in the Work Plan should be a key component of every healthcare compliance program. This allows healthcare providers and organizations to make timely and necessary changes. Thus, they can be proactive and ensure continued compliance in key risk areas identified by the HHS OIG Work Plan.
Monthly Updates and Structure of the HHS OIG Work Plan
The OIG has replaced annual and semiannual Work Plan publications with updates on a more frequent basis. With a goal of transparency, the OIG updates its Work Plan monthly, by outlining recently added information. The Work Plan development process is dynamic and requires adjustments throughout the year to meet necessary priorities and appropriately respond to developing issues. Projects listed in the Work Plan include the Centers for Medicare & Medicaid Services (CMS), Centers for Disease Control and Prevention (CDC), National Institutes of Health (NIH), and many other administrative health agencies.
The HHS OIG Work Plan is searchable by month of listing, agency, title, and report number. Healthcare providers and organizations can also easily find projects that have recently been issued, and recent final reports.
In order to identify emerging issues, the OIG assesses relative risks in HHS programs and operations. When creating Work Plan items, the OIG considers several factors such as legal mandates, congressional requests, budgetary concerns, and potential for positive impact. Apart from working on projects that often lead to audits, reviews, and reports, the OIG also conducts several legal and investigative activities that are separately reported.Use this step-by-step guide to find out how to develop and keep effective healthcare compliance while staying on top of industry standards, federal, state, and local laws and regulations.
A Summary of the Latest Updates of the HHS OIG Work Plan
Healthcare providers need to pay attention to the latest releases of the Work Plan and address them within their compliance programs, if applicable.
November Updates of the HHS OIG Work Plan
There are 16 new items in the November release of the HHS OIG Work Plan:
- Medicaid Concurrent Eligibility
If a Medicaid beneficiary changes their residency to a new state, they cannot maintain concurrent Medicaid eligibility in another state, and Managed Care Organizations (MCOs) would not receive payment for each beneficiary from the previous state. OIG will review if states made capitation payments on behalf of beneficiaries who established residency in another state.
- Additional Programming Code for Toolkit: Using Data Analysis to Calculate Opioid Levels and Identify Patients at Risk of Misuse or Overdose
Last year, HHS OIG released an important resource in addressing the opioid crisis. The toolkit provides detailed steps for analyzing patients’ opioid levels and identifying patients who are at risk of opioid misuse or overdose.
- Audit of HHS Information Technology Recovery Readiness
HHS is responsible for having effective contingency plans in place to ensure meeting its mission in the event of a disaster or major disruption. Therefore, effective contingency planning for information technology systems is necessary.
- Review of Office of Refugee Resettlement’s Awarding of a No-Bid Contract for the Unaccompanied Alien Children Program
The Office of Refugee Resettlement (ORR) contracted with Comprehensive Health Service (CHS) to operate a temporary influx care facility. OIG will determine whether ORR awarded a contract with CHS in accordance with Federal statutes, regulations, and HHS’s policies and procedures.
- Comparison of Average Sales Prices and Average Manufacturer Prices
Part of the HHS OIG Work Plan is the quarterly memo that summarizes the results of OIGs comparison analysis based on average sales price (ASP) and average manufacturer prices (AMP). It includes data reported for the first quarter of 2020, the second quarter of 2019, the fourth quarter of 2019, and the third quarter of 2019.Get a better understanding of the OIG exclusion list reinstatement process and how to deal with a complicated set of federal and state healthcare laws and regulations.
- Medicare Payments for Stelara
Since 2016, total Medicare Part B payments to physicians for Stelara, an expensive drug used to treat certain autoimmune diseases, have increased substantially. Such a large increase in payments for a drug that would not typically be covered under Part B raises questions about what is driving the growth, including the possibility of improper billing.
- Medicare Part B Drug Payments: Impact of Price Substitutions Based on 2018 Average Sales Prices
Over the past decade, OIG has produced annual reports aggregating the results of mandated quarterly ASP to AMP comparisons. This annual report quantifies the savings to Medicare and offers recommendations to achieve additional savings.
- Review of Background Verification Process at Tribally Operated Health Facilities
The Indian Health Service’s (IHS’s) mission is to partner with American Indians and Alaska Natives to elevate their physical, mental, social, and spiritual health to the highest level. OIG will determine whether the tribally operated health facilities meet Federal and Tribal requirements.
- Excluding Noncovered Versions When Setting Payment for Part B Drugs
One of the items in the November issue of HHS OIG Work Plan is examining the financial costs to Medicare and its beneficiaries of continuing to include noncovered versions when setting Part B amounts in 2017 and 2018.
- Medicare Advantage Organizations’ Collection of Ordering Provider Identifiers
The availability of ordering provider identifiers in the Medicare Advantage (MA) encounter data is essential for using these data to identify and prevent potential fraud, waste, and abuse. OIG will determine the extent to which MA organizations (MAOs) obtain the NPIs of providers who order DMEPOS, clinical laboratory services, imaging services, and home health services for MA enrollees.
- Fiscal Year 2020 OIG Oversight of Medicaid Fraud Control Units
Medicaid Fraud Control Units investigate and prosecute Medicaid provider fraud as well as complaints of patient abuse or neglect in Medicaid-funded facilities and board and care facilities. OIG provides guidance to the MFCUs, assesses their adherence to Federal regulations, policy, and performance standards. It also collects and analyzes performance data.
- Medicaid Fraud Control Units Fiscal Year 2020 Annual Report
The OIG’s annual report analyzes the statistical information that was reported by the MFCUs, and identifies trends in MFCU case results.
- Medicare Advantage Risk-Adjustment Data – Targeted Review of Documentation Supporting Specific Diagnosis Codes
Payments to Medicare Advantage (MA) organizations are risk-adjusted on the basis of the health status of each beneficiary. OIG will perform a targeted review of the medical record documentation to ensure that it supports the diagnoses that MA organizations submitted to CMS and to determine whether the diagnoses complied with Federal requirements.Find out how to prevent civil monetary penalties and other fines by voluntary disclosing potential fraud that involve federal health care programs.
October Updates of the HHS OIG Work Plan
There are 6 items in the October release of the HHS OIG Work Plan:
- Review of Hospice Inpatient and Aggregate Cap Calculations
Hospice care can provide great comfort to beneficiaries, families, and caregivers at the end of a beneficiary’s life. Medicare administrative contractors (MACs) oversee the cap process and hospices must file their self-determined aggregate cap determination notice with their MAC no later than 5 months after the end of the cap year and remit any overpayment due at that time.
- Medicare Part B Payments for Speech-Language Pathology
Medicare payments for a beneficiary’s combined physical therapy and speech therapy are subject to an annual therapy spending threshold. When a spending threshold is met, the provider must append the KX modifier. Part of the October HHS OIG Work Plan is determining whether the claims using the KX modifier adhere to Federal requirements.
- Review of Medicare Payments for Power Mobility Device Repairs
Medicare Part B covers medically necessary power mobility devices (PMDs), such as power wheelchairs, and PMD repairs that are reasonable and necessary to make the equipment serviceable. OIG audits Medicare payments for PMD repairs to determine whether suppliers complied with Medicare requirements.
- Review of Medicare Part B Urine Drug Testing Services
Medicare covers treatment services for substance use disorders (SUDs), such as inpatient and outpatient services when they are reasonable and necessary. OIG reviews UDT services for Medicare beneficiaries with SUD-related diagnoses to determine whether those services were in accordance with Medicare requirements.Starting in April 2019, the CMS Presclusion List will be available to all Medicare Advantage plans and Part D sponsors. Find out how this new requirement eases the burden of enrollment.
- Supplier Compliance with Medicare Requirements for Replacement of Positive Airway Pressure Device Supplies
Beneficiaries receiving continuous positive airway pressure or respiratory assist device, collectively known as positive airway pressure (PAP) devices, require the replacement of supplies when they wear out or are exhausted. It is necessary to review claims for frequently replaced PAP device supplies at selected suppliers to determine whether documentation requirements for medical necessity, frequency of replacement, and other Medicare requirements are met.
- An Assessment of the U.S. Food and Drug Administration’s Postmarket Surveillance of Medical Devices
As the information that the U.S. Food and Drug Administration (FDA) receives about medical device safety and effectiveness is increasingly gathered in the postmarket setting, FDA’s postmarket safety surveillance system can effectively identify and act on safety signals. As part of the HHS OIG Work Plan for October, OIG assesses and describes how FDA’s surveillance system identifies and tracks safety concerns, and assesses FDA’s response to those concerns.
September Updates of the HHS OIG Work Plan
There are 3 items in the September release of the HHS OIG Work Plan:
- ORR-Funded Facilities’ Efforts to Ensure Health and Safety of Unaccompanied Children
The Unaccompanied Alien Children (UAC) program, operated by the Office of Refugee Resettlement (ORR), provides temporary shelter, care, and other related services to unaccompanied children in its custody. OIG identifies vulnerabilities in facilities’ efforts to protect children in their care from harm and to provide needed physical and mental health services, including efforts to address trauma. OIG also explores the challenges facilities face, including challenges presented by external factors such as HHS policies and management decisions.
- Sufficiency and Implementation of Indian Health Service Patient Abuse Policies
Implementation and sufficiency of patient abuse policies and procedures for IHS hospitals is another issue in the HHS OIG Work Plan. Indian Health Services (IHS) provides healthcare services to hundreds of federally recognized tribes in 7 areas with 25 acute-care hospitals. After the controversy surrounding a recent patient abuse conviction of a former physician – Stanley Patrick Weber, MD, IHS adopted new policies in regard to patient care and abuse.
- Specialty Drug Coverage and Reimbursement in Medicaid
Since there is no standard definition for specialty drugs in each state, and Medicaid spending for these items has increased, reviewing state definitions for Medicaid specialty drugs and their strategies to manage drug costs was part of the HHS OIG Work Plan.
How to Make Use of the HHS OIG Work Plan
Following the law, ethical standards, and the OIG requirements is a critical element of every successful healthcare compliance program. The HHS OIG Work Plan summarizes new and ongoing reviews and activities that the OIG plans to pursue. Hence, there is no better approach for healthcare organizations than to use the Work Plan when evaluating possible risks and creating compliance plans.
Due to monthly updates, it is prudent for healthcare organizations and providers to regularly monitor the Work Plan in order to identify whether any newly added items may be of particular importance to them. Such practice would allow them to ascertain the OIG’s areas of interest and enforcement priorities, and to review and update policies and procedures in accordance with this. Apart from using the HHS OIG Work Plan to stay abreast of possible investigations and audits, healthcare organizations should consider outsourcing healthcare compliance activities. Integrating technology results in increased workflow efficiencies and reduced organizational risk as well as higher standards when it comes to protecting patients and their data. Such an approach combined with regular monitoring of the HHS OIG Work Plan leads to a well-managed compliance program and ensures that healthcare organizations stay out of trouble.