Recent Industry News
The Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently issued six updates to its OIG Active Work Plan (“Work Plan”). The Work Plan outlines ongoing and planned audits and evaluations for the fiscal year and beyond. In 2017, the OIG began releasing its Work Plan projects on an ongoing basis, as opposed to providing biannual updates. The new format includes an ongoing list of “Active Work Plan Items”, which includes newly initiated Work Plan items and notifications of completed items. 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, the potential for positive impact, and others. In addition to working on projects that often lead to audits, reviews, and reports, the OIG also engages in a number of legal and investigative activities that are separately reported.
January additions to the OIG Work Plan include the following:
- Financial Impact of Health Risk Assessments and Chart Reviews on Risk Scores in Medicare Advantage.
- Payments to Medicare Advantage (MA) organizations are risk-adjusted, based on beneficiary information, to determine which MA organizations have higher expected costs. Health risk assessments and chart reviews are an integral part of this process. The OIG seeks to determine which diagnoses solely generated by these means correlate with high and low-risk scores and payments.
2. OIG Toolkit to Identify Patients at Risk of Opioid Misuse.
- The OIG released a data brief in 2017 entitled “Opioids in Medicare Part D: Concerns About Extreme Use and Questionable Prescribing,” which found that 500,000 Part D beneficiaries received high amounts of opioids in 2016, and roughly 90,000 were at serious risk of a drug overdose or misuse. The OIG plans to release a toolkit which should enable stakeholders to address the epidemic using patient-level opioid data.
3. Potential Abuse and Neglect of Medicare Beneficiaries.
- Elderly patients in both inpatient and outpatient settings experience abuse, neglect, and exploitation, although the Elder Justice Act recognizes that they have the right to be free from such treatment. The OIG seeks to analyze diagnoses to address problems with quality of care reporting and investigation of abuse or neglect at group homes, skilled nursing facilities, and nursing homes.
4. Questionable Billing for Off-the-Shelf Orthotic Devices.
- Three “off-the-shelf” orthotic devices have seen claims increase by 97 percent, with allowed charges increasing by 116 percent in 2016. A Medicare Administrative Contractor (MAC) identified high improper payments associated with the devices, citing medical necessity as a top concern. The OIG plans to review whether these devices have been supplied without an encounter with the referring physician, prior to the claim.
5. State Monitoring of Sub-recipients to Ensure Program Integrity Within the Child Care Development Fund Block Grant Program.
- The Child Care Development Fund provides subsidies for the child care expenses of low-income families, with funding roughly totaling $5.8 billion in FY 2017. Due to the program’s susceptibility to improper payments, the OIG seeks to study how states monitor sub-recipients of these funds to ensure program integrity.
6. State Use of the Automated Child Welfare Information System to Monitor Medication Prescribed to Children in Foster Care.
- Psychotropic medications treat mental health disorders such as schizophrenia, depression, bipolar disorder, anxiety disorders, and attention-deficit/hyperactivity disorder (ADHD), and may be prescribed to children in foster care. The Statewide Automated Child Welfare Information System (SACWIS) is a case management system that can be used to monitor psychotropic prescriptions for foster care children. The OIG seeks to review states’ use of the system.