The U.S. Department of Health and Human Services Office of Inspector General (OIG) issues an annual work plan summarizing the health program reviews planned by OIG for the upcoming year. Its Fiscal Year 2016 Work Plan provides important information and guidance to healthcare executives. Here are some of the key takeaways.
The work plan states that OIG expects recoveries from providers and health plans of more than $3 billion for 2015. Further, the legislative, regulatory and administrative actions OIG supported saved approximately $20.6 billion last year.
OIG reviews resulted in the exclusion of 4,112 individuals and entities from participation in federal healthcare programs; 925 criminal actions; and 682 civil actions, including false claims and unjust-enrichment cases.
In June 2015, OIG participated in the largest national healthcare fraud intervention in its history, resulting in more than 240 subjects being charged with defrauding Medicare and Medicaid.
OIG will expand its focus on delivery system reform and the effectiveness of alternate payment models, coordinated care programs and value-based care purchasing.
Data analytics will be used to identify additional issues for further analysis and scrutiny.
As more attention is directed to addressing the rising cost of healthcare, reviews and enforcement actions can be expected to increase.
Next: New areas the OIG will review
New areas the OIG will review include:
- Federal government recoveries from managed care plans not meeting medical loss ratio requirements.
- Methodologies for assigning managed care organizations accurate federal medical assistance percentages.
- State treatment of specialty drug payments, including pharmacy reimbursement amounts.
Medicare Parts C and D
- Medicare Advantage provider networks in Puerto Rico to determine if they provide access to appropriate medical care from credentialed providers in accordance with federal requirements.
- Part D beneficiaries prescribed drugs with severe drug interactions.
- Medicare Eligibility Verification transactions submitted by pharmacies to determine eligibility for the Part D program.
- CMS’s oversight of Part D pharmacies.
- Growth in pharmacy reimbursement for brand-name drugs under Part D between 2010 and 2014.
Affordable Care Act (ACA)
- Examination of the loan award selection process, financial condition, and other factors relating to the Consumer Operated and Oriented Plan, CO-OP, loan program.
- Expenditures of ACA Marketplace Establishment Grants for contractor services claimed by marketplace grantees.
Medicare Parts A and B:
- Billings for replacement of medical devices implanted in inpatient or outpatient procedures.
- Outpatient claims billed during inpatient stays.
- Validation of data reported for hospital value-based purchasing and acquired condition reduction programs.
- Skilled nursing facility therapy services payments.
- Medical necessity for orthotic braces.
- Overutilization of ventilators for beneficiaries with non-life-threatening conditions.
- Quality oversight of ambulatory surgery centers.
- Overutilization of durable medical equipment.
- Documentation of necessity for physician home visits.
- Payments for prolonged evaluation and management services.
- Payments to histocompatibility laboratories.
- Accountable care organizations that have been successful in the Medicare Shared Savings Program over the past three years.
- Procedures to prevent Medicare services from being rendered to incarcerated beneficiaries and individuals not lawfully present in the United States.
- Management of ICD-10 implementation.
Deborah Dorman-Rodriguez is a Partner at Freeborn & Peters LLP, and is the leader of the Firm's Healthcare Practice Group.
David Kaufman is a Partner at Freeborn & Peters LLP, and serves as a key member of the Firm's Healthcare Practice Group.