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Recent Industry News

Department of HHS OIG

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The Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently issued five updates to its 2017 OIG Active Work Plan (“Work Plan”).  The November updates include five new Work Plan items.  The Work Plan outlines ongoing and planned audits and evaluations for the fiscal year and beyond.  In June 2017, the OIG announced that it would begin issuing monthly adjustments to the Work Plan, rather than issuing semi-annual updates. The monthly updates add new items and remove completed tasks from the Work Plan.  A monthly update schedule ensures that the Work Plan closely aligns with the OIG’s work planning process.

The OIG assesses relative risks in HHS programs and operations to identify those areas most in need of attention.  The OIG considers several factors when creating Work Plan items, including legal mandates, congressional requests, budgetary concerns, potential for positive impact, and others.  In addition to projects that often result in audits, reviews, and reports, the OIG also engages in a number of separately reported legal and investigative activities.

November additions to the 2017 Work Plan include the following:

  1. Use of Funds by Medicaid Managed Care Organizations (MCOs).
  • The OIG plans to examine how MCOs use Medicaid funds to provide services to enrollees. The review comes in response to states’ expanded use of managed care services.  Specifically, the OIG may look at capitation rates to ensure that state payments to MCOs are adequate to provide the paid services to beneficiaries.
  1. Opioids in Medicaid: Concerns about Extreme Use and Questionable Prescribing in Selected States.
  • The OIG plans to examine beneficiaries who received high quantities of opioids through Medicaid and cases that appear to use doctor and/or pharmacy shopping. The review comes in response to the opioid abuse and overdose crisis.  Specifically, the OIG seeks to establish baseline data about affected beneficiaries and prescribers with patterns of abnormal opioid distributions in Medicaid.
  1. Medicare Claims on Which Hospitals Billed for Severe Malnutrition.
  • The OIG plans to examine provider compliance with Medicare billing requirements for inpatient treatment of severe malnutrition. Treating and billing for severe malnutrition, which is classified as a major complication or co-morbidity, can result in higher coded Diagnosis Related Groups, and therefore higher Medicare payments.
  1. Medicaid Services Delivered Using Telecommunication Systems.
  • The OIG plans to review Medicaid payments for services delivered through telecommunication systems. Medicaid, in limited circumstances, pays for telemedicine, telehealth, and telemonitoring services, which are provided via interactive video, audio, or data transmission.  Claims for these services have risen significantly.   The OIG plans to examine whether these claims are permitted in accordance with Medicaid requirements.
  1. Data Briefs Regarding Financial Relationships Reported to the Federal Open Payments Program.
  • The OIG plans to analyze data from 2015 Open Payments to determine the volume and nature of financial interests held by physicians. In addition, the OIG seeks to review the amount of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) ordered by these “interested” physicians.  The OIG will draw this information from reported payments under the Physician Payments Sunshine Act (PPSA).  The PPSA requires manufactures to disclose payments to physicians and teaching hospitals.

The OIG Work Plan is available at:

https://oig.hhs.gov/reports-and-publications/workplan/index.asp.

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