Office of Inspector Releases Fiscal Year 2015 Work Plan
Fiscal Year 2015 Work Plan (“Work Plan”) in late 2014. This Work Plan provides an annual overview of OIG’s planned areas of focus and enforcement with respect to HHS’ reviews, programs and operations.
FY 2014 Accomplishments
The Work Plan details some of the accomplishments that arose as a result of its FY 2014 Work Plan including, but not limited to, the following:
- Expected recoveries of over $4.9 billion in receivables (which include $834.7 million in audit receivables and $4.14 billion in investigative receivables);
- Identified roughly $15.7 billion in savings on the basis of prior-period legislative, regulatory or administrative actions supported by OIG recommendations;
- 4,017 individuals and entities excluded from participating in Federal Health Care programs; and
- 971 criminal actions against individuals or entities that engaged in crimes against HHS programs.
Continuation of Certain FY 2014 Work Plan Initiatives
In addition to many new initiatives, the 2015 Work Plan also addresses the following matters that, while initiated in previous years, will continue to be studied throughout FY 2015:
- Medical Equipment and Supplies – The OIG will continue to study competitive bidding, payments and compliance for specific medical equipment and supplies.
- Prescription Drug Initiative – The OIG will continue to study the 340B Program evaluating the payments for outpatient drugs and the administration of drugs and clinical uses of Part B drugs.
- Centers for Medicare & Medicaid Services (“CMS”) – Related Legal and Investigative Activities – The OIG will aim to leverage its authority under the False Claims Act, Civil Monetary Penalties status and Anti-Kickback and Stark rules in order to combat fraud against federal healthcare programs.
- Public Health Reviews – The OIG will continue to work with public health agencies to ensure that certain agencies are effectively managed and adequately prepared to respond to public health emergencies.
Areas of Focus for FY 2015 Initiatives
OIG indicates in the Work Plan that it plans to focus on issues such as emerging payment, eligibility, management, IT security vulnerabilities, care quality and access in Medicare and Medicaid and public health and human service programs in the coming year. Below are some areas of focus that have been expanded upon.
Affordable Care Act (“ACA”) Reviews
According to the Work Plan “OIG is committed in FY 2015 to initiating at least 5-10 additional reviews addressing ACA programs. These reviews could focus on emerging marketplace issues, including, for example, potential vulnerabilities that may arise in connection with the second open enrollment period; implementation of additional marketplace functionality, such as the redetermination process; or the premium stabilization programs. They could also focus on other ACA areas, including Medicaid expansion, new Medicare payment and delivery models, or new grant programs.”
OIG intends to focus on the following areas with respect to ACA provisions:
- Marketplaces, Financial Assistance Payments and Market Stabilization Payments – OIG will focus on reviewing proper expenditure of taxpayer funds. The review will aim to assess the accuracy of payments to quality health plan issuers for advanced premium tax credits and cost sharing reductions, accuracy of advance premium tax credits and cost sharing reductions for individual enrollees and CMS internal controls for generating, reviewing and approving premium tax credits.
- Eligibility – OIG will assess the effectiveness and efficiency of marketplace eligibility and enrollment, which includes enrollment safeguards, eligibility verifications and inconsistencies in the federally facilitated marketplace data.
- Security – OIG will also review the information system security of HealthCare.gov. OIG will conduct vulnerability scans and review whether information security controls for state-based marketplaces have been implemented in accordance with Federal requirements and recognized industry best practices.
Accountable Care Organizations (“ACO”)
OIG plans to continue the risk assessment of the Pioneer ACO Model. According to the Work Plan “An ACO is a group of providers and suppliers of services (e.g., hospitals and physicians and others involved in patient care) that will work together to coordinate care for the Medicare fee-for-service beneficiaries they serve. The Centers for Medicare & Medicaid Innovation was created to test innovative care and service delivery models and is administering the Pioneer ACO Model.”
Hospitals & Two Midnight Rule
Hospitals will continue to be major areas of focus for OIG. There are currently 22 substantive areas under review; with OIG intending to focus on billing and payment reviews of hospitals as well as quality of care issues. More specifically, OIG plans to review the impact of the new admission criteria on hospital billing, Medicare payments and beneficiary copayments. The new “Two Midnight Rule” which took effect in FY 2014 will continue to be reviewed so that the OIG can determine its impact on billing. It was further noted that OIG plans to issue a report in 2016 on the impact of the new inpatient criteria on hospital billing.
Medicare Part C and Part D
OIG plans to continue its audits and reviews of Part C Medicare Advantage and Part D compliance. These initiatives will focus on data integrity of encounter and risk adjustment data, sponsor compliance with Part D requirements and oversight of conflicts of interest in Medicare prescription drug determinations. Additionally, OIG will assess Part D billing and payment compliance.
Medicaid
OIG also plans to focus on Medicaid programs, with an intense focus on fraud, waste and abuse of these programs. OIG aims to address the following areas related to Medicaid:
- Medicaid Prescription Drug reviews;
- Billing and Payment – OIG will continue to assess compliance with respect to State and Federal programs and review payments for adult day care services. A determination will be made as to whether Medicaid payments for medical equipment and supplies should be reduced;
- State Claims for Federal Reimbursement – OIG will study two new initiatives: Community First Choice State plan option and Balancing Inventive Program. These are both new programs under the ACA that will provide support services to individuals who qualify for institutional care and provide State enhanced funding for Medicaid long-term services and support; and
- Medicaid Eligibility Determinations – OIG will work to evaluate and make a determination as to the extent to which states have made inaccurate eligibility determinations. OIG will calculate the error rate and determine the amount of payments associated with beneficiaries who received incorrect eligibility determinations.
Conclusion
The Work Plan can prove to be a valuable resource to organizations, including hospitals, healthcare systems, physician practices and others. The items addressed in the Work Plan list the areas of interest to OIG. Organizations can use the Work Plan as a means to become compliant in areas that may create exposure.
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The information contained herein is not necessarily all inclusive, does not constitute legal or any other advice, and should not be relied upon without first consulting with appropriate qualified professionals for your individual facts and circumstances.
