The United States Department of Health and Human Services ("HHS") Office of Inspector General ("OIG") released its Fiscal Year 2017 Work Plan ("2017 Plan") on November 10. OIG releases a work plan annually to identify the new and ongoing investigative, enforcement, and compliance activities that it will undertake during that fiscal year ("FY"). Takeaways from OIG's Work PlanHealthcare organizations are well-advised to review their internal audit and compliance plans on a regular basis, and the 2017 Plan is a valuable resource in that effort insofar as the Plan outlines where OIG will focus its investigative resources. New initiatives indicate OIG's impending priorities, and audit and compliance continuing initiatives emphasize OIG's continued—and potentially heightened—interest in certain areas. OIG's stated priorities (including the degree of specificity of OIG's focus) can help an organization shape its compliance program for the coming year. While the 2017 Plan covers a lot of territory, healthcare organizations should pay particular attention to those priorities involving hyperbaric oxygen therapy services, pharmaceutical and device pricing and reimbursement, and a renewed focus on post-acute care services. OIG has noted that its work plan is an ongoing and evolving process, and the 2017 Plan may be updated throughout the year. The new administration will also likely have an effect on HHS and OIG priorities. Initiatives for FY 2017As explained below, the 2017 Plan includes many new initiatives, including review of incorrect medical assistance days claimed by hospitals, a focus on skilled nursing facilities ("SNF") and several post-acute reviews, and attention to prescription drugs including pricing and 340B rebates. The 2017 Plan also contains reviews of hyperbaric oxygen therapy billing and services, new laboratory payment structures, drug waste, managed care organization and provider compliance with federal billing requirements. This Update summarizes new initiatives and highlights of the 2017 Plan. Medicare Parts A and BOIG notes that its Medicare oversight efforts have been focused on identifying and offering recommendations to reduce improper payments, prevent and deter fraud, and foster economical payment policies. The 2017 Plan notes that OIG's future planning efforts will include additional oversight of hospice care, SNF compliance with admission requirements, and evaluation of the Centers for Medicare and Medicaid Services ("CMS") Fraud Prevention System. Hospitals and Institutional ProvidersThe 2017 Plan contains several new initiatives for hospitals and institutional providers as well as continuing initiatives:
In FY 2017, OIG will also continue its review of outpatient outlier payments for short-stay claims, provider-based reimbursement, reconciliations of outlier payments, hospitals' use of outpatient and inpatient stays under the two-midnight rule, adverse events in post-acute care, and potentially avoidable hospitalizations of dual eligible nursing facility residents. Medical Equipment and SuppliesOIG will continue to study competitive bidding and payments and compliance for specific items, including orthotic braces, osteogenesis stimulators, power mobility devices, and nebulizer machines. OIG will add review of other items, including durable medical equipment, prosthetics, orthotics and supplies, along with mail-order diabetic testing strips and positive airway pressure device supplies. Other Providers and SuppliersThe 2017 Plan outlines five new enforcement priorities among other revised and continuing reviews:
Continuing in FY 2017, OIG will review financial interests reported under the open payments program, high use of sleep-testing procedures, outpatient physical therapy, chiropractic services, quality oversight of the ambulatory surgical centers, anesthesia services, and prolonged services. OIG will also continue to monitor payments for Medicare services, supplies, and durable medical equipment, prosthetics/orthotics and supplies referred or ordered by physicians. Prescription DrugsThe 2017 Plan contains two new initiatives for FY 2017:
OIG will also continue to review the difference between average sales prices and average manufacturer prices of Part B drugs as well as Part B payments for immunosuppressive drugs billed with specific modifiers. Part A and B Management Issues
Medicare Parts C and DThe 2017 Plan contains a number of new and revised initiatives for FY 2017. Most of the OIG initiatives focus on CMS administration and oversight of Parts C and D. However, these items are often the source of increased CMS scrutiny on plans and vendors (e.g., first-tier, downstream, and related entities).
OIG also plans to continue its audits and reviews of conflicts of interest in Medicare prescription drug decisions, access by dual eligible beneficiaries to drugs under Part D, and review CMS oversight of Medicare Eligibility Verification transactions (E1 transactions) processed by contractors. MedicaidOIG's focus on the Medicaid program for FY 2017 continues OIG's interest on fraud, waste, and abuse as Medicaid continues to expand and long-term initiatives address new payment and delivery models, state financing mechanisms, drug diversion and abuse, and Medicaid managed care. As with Part C and D, a number of OIG priorities for FY 2017 focus on state and CMS management and administration. However, providers may see increased state and CMS interest related to these initiatives.
Also continuing for FY 2017 is OIG review of adult day health care services, room-and-board costs associated with the Home and Community Based Services waiver program, benefits and challenges of Express Lane Eligibility, provider compliance with Medicaid billing requirements for billing required dental services for children, payments for Community First Choice services and required institutional level of care and financial eligibility criteria, rate of and reasons for transfer from group homes or nursing facilities to hospital emergency departments, state Medicaid agency (and contractors) HIPAA breach notification procedures, and reimbursement made to managed long-term care plans. OIG will also continue to perform onsite reviews of MFCUs. Health Insurance Marketplaces OIG will continue its review of health insurance marketplaces and related programs (e.g., financial assistance payments and premium stabilization programs) in FY 2017. Specifically, OIG reports that it will focus on payment accuracy, eligibility, management and administration, IT security risks, and consumer fraud. For FY 2017, OIG will focus on the following to facilitate the health insurance marketplace: a revised review of CMS oversight and issuer compliance in ensuring data integrity for the risk adjustment program, HHS Establishment Grants, accuracy of financial assistance payments for individual enrollees, inconsistencies in marketplace applicant data, and a revised review of CMS monitoring activities for the Consumer Operated and Oriented Plan. Electronic Health RecordsThe 2017 Plan includes a continued focus on compliance with the Health Information Technology for Economic and Clinical Health Act ("HITECH") and the EHR incentive programs HITECH established. The 2017 Plan notes that more than $30 billion in incentives have been paid thorough the Medicare and Medicaid EHR incentive programs; improper incentive payments is the primary risk to the programs, and these programs may be at greater risk of improper payments because of the complex requirements. For FY 2017, OIG will review past Medicare EHR incentive program payments to look for errors and will assess CMS's plans to oversee incentive payments for the program. OIG will also continue to assess whether eligible providers and hospitals have successfully implemented appropriate technical capabilities to fulfill meaningful use objectives. OIG notes that it will perform audits throughout the year to ensure that entities receiving incentive payments are complying with the objectives. CMS-Related Legal and Investigative ActivitiesIn the 2017 Plan, OIG notes that it will continue to leverage its authority under the False Claims Act, Civil Monetary Penalties statute, the Anti-Kickback statute, and the Stark law, among other statutes and regulations, to combat fraud against federal health care programs. The 2017 Plan specifically indicates a focus on health care fraud schemes related to:
Other HHS-Related ReviewsOIG reports that it will continue to address Department-wide matters, such as financial statements, financial accounting, information systems management, and other departmental issues. One such Department-wide initiative for FY 2017 includes a review of CMS Action on Comprehensive Error Rate Testing ("CERT") Data. OIG reports that the national error rate for Medicare fee-for-service payments is at around 12.1% with improper payments of approximately $43.3 billion. OIG plans to review CERT data to identify patterns to reduce payment errors and determine whether CMS took action to target error-prone providers. |
Office of Inspector General's Work Plan Outlines 2017 Priorities
Thursday, December 1, 2016
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