Health Reform WK-EDGE Updated OIG work plan puts renewed vigor into fraud prevention
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Tuesday, June 21, 2016

Updated OIG work plan puts renewed vigor into fraud prevention

By Patricia K. Ruiz, J.D.

The HHS Office of Inspector General (OIG) updated its fiscal year (FY) 2016 work plan, increasing focus on preventing fraud and abuse in Medicare, Medicaid, and the health insurance exchanges. The mid-year update summarizes new and ongoing reviews and activities that the OIG plans to pursue with respect to HHS programs and operations during FY 2016 and beyond. Specifically, the update removes items that have been completed, postponed, or canceled, and includes new items that have been started since October 2015’s Work Plan (see OIG has 2016 Work Plan in hand, predicts oversight done right, November 4, 2015) (OIG Fiscal Year Work Plan: Mid-Year Update, Fiscal Year 2016, June 7, 2016).

Updated work plan. Planning work is a dynamic process, and the OIG often makes adjustments throughout the year to meet priorities and to anticipate and respond to emerging issues. The OIG assesses relative risks in HHS programs and operations to identify the areas most needing attention, which allows it to set priorities for the sequence and proportion of resources allocated. The OIG considers factors such as mandatory requirements for OIG reviews set forth in laws, regulations, and other directives, requests made or concerns raised by Congress, HHS, or the Office of Management and Budget (OMB), top management and performance challenges facing HHS, work performed by other oversight organizations, HHS’s actions to implement recommendations from previous reviews, and potential positive impact.

2015 top management and performance challenges facing HHS. The top challenges facing HHS include: (1) protecting an expanding Medicaid program from fraud, waste, and abuse; (2) fighting fraud, waste, and abuse in Parts A and B; (3) the meaningful and secure exchange and use of electronic information and health information technology; (4) administration of grants, contracts, and financial and administrative management systems; (5) ensuring appropriate use of prescription drugs; (6) ensuring quality in nursing home, hospice, and home- and community-based care; (7) implementing, operating, and overseeing the health insurance marketplaces; (8) reforming delivery and payment in health care programs; (9) effectively operating public health and human services programs; and (10) ensuring the safety of food, drugs, and medical devices.

Medicare Parts A and B. In its updated work plan, the OIG focused its Medicare oversight efforts on identifying and offering recommendations to reduce improper payments, prevent and deter fraud, and foster economical payment policies. These efforts include additional oversight of hospice care, including certification surveys and worker license requirements, and oversight of SNF compliance with patient admission requirements. The OIG will also evaluate CMS’ Fraud Prevention System.

Medicare Parts C and D. Part D administration depends on the coordination and information sharing between federal and state government agencies, drug plan sponsors, contractors, health care providers, and third-party payers. For its updated work plan, the OIG is adding significant focus to price increases for brand-name and generic drugs under Part D.

Medicaid. The OIG stated that protecting an expanding Medicaid program from fraud, waste and abuse is becoming increasingly urgent as the program grows in spending and the number of people it serves. The OIG predicts that additional Medicaid work for FY 2016 will examine new payment and delivery models; Medicaid managed care; state financing mechanisms focusing on compliance with upper payment limits; drug diversion and abuse; and states’ lock-in programs to restrict beneficiaries to a limited number of pharmacies and prescribers to reduce prescription drug abuse. The OIG also expects to examine beneficiary access to and program integrity of mental and behavioral health services. It will also expand its examination of the quality and safety of care provided in a variety of home- and community-based settings, including Medicaid personal care services.

Health insurance marketplace. The OIG oversees proper expenditure of taxpayer funds and the efficient and effective operation of the health insurance marketplace and related programs. The implementation, operation, and oversight of the marketplaces are among the most challenging areas for the OIG. The OIG continues to focus its marketplace oversight on payment accuracy, eligibility, management and administration, and security.

Electronic health records. The Congressional Budget Office estimated that from 2011 through 2019, spending on the Medicare and Medicaid EHR incentive programs will total $30 billion, with the Medicaid EHR incentive program accounting for more than one-third of the total. The GAO has identified improper incentive payments as the biggest risk to the EHR incentive programs. These programs may be at greater risk because they are new and have complex requirements.

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