OIG Outlines Top Ten Oversight and Compliance Priorities

COVID-19 fraud, telehealth oversight, modernizing program integrity and compliance and implementing value-based care are among the top ten priorities for the U.S. Department of Health and Human Services Office of the Inspector General.

Principal Deputy Inspector General Christi Grimm outlined the top ten list during the HCCA 25th Annual Compliance Institute last month.

She noted that OIG surveyed administrators at more than 300 hospitals around the country to identify the challenges they have faced during the pandemic and heard four core challenges:

  • Balancing providing health care for complex, resource-intensive COVID patients with efforts to resume routine care for their communities.
  • Staffing challenges related to burnout and competition for workers.
  • Vaccination efforts that were positive steps towards recovery, but pose staffing, logistical, and patient access challenges.
  • The strain on hospital finances.

For all of its negatives, the pandemic also has pushed the healthcare industry to speed up much needed changes which Grimm said will make it easier for healthcare professionals to access and use information that supports their work.

To that end, here is the OIG’s top ten list:

Overseeing COVID-19 Relief and Response: Risk assessment and data analytics will be used to identify, monitor, and target potential fraud, waste, and abuse affecting HHS programs and beneficiaries, and to promote the effectiveness of HHS’s COVID-19 relief and response programs.

Realizing the Potential of Telehealth: The pandemic has resulted in the skyrocketing use of telehealth which has proven to improve access to healthcare, resulting in better care coordination and health outcomes. OIG will provide telehealth oversight and enforcement in a transparent and timely manner to ensure that its potential is realized without compromising program integrity.

“It is important that new policies and technologies with potential to improve care and enhance convenience achieve these goals and are not compromised by fraud, abuse, or misuse,” said Grimm

Ensuring Quality of Care and Patient Safety in Nursing Homes: Nursing home patients were among those hardest hit by COVID, underscoring the vulnerability of patients in these settings. OIG is focused on protecting residents from abuse, neglect, and failures of care, improving state oversight, and improving quality of care monitoring.

Advancing Health Equities: COVID-19 further pulled back the curtain on the stark racial and socioeconomic divides for communities of color. OIG will seek to identify where HHS programs can do better to achieve equity in health and human services, including areas such as quality of care, access to care, and health outcomes.

Modernizing Program Integrity and Compliance Information: OIG is considering how to modernize OIG guidance, compliance resources, and data sharing practices for OIG’s List of Excluded Individuals and Entities.

“Modernized LEIE information will mean that data are easier to access through compliance software and apps that use APIs, and can support the development of new tools and approaches to compliance,” Grimm said

Combating the Substance Use Disorder Epidemic: Early data indicates that substance use disorder and overdoses have increased during the pandemic. OIG will continue its oversight and enforcement work related to substance use disorder, including partnering with public health agencies to ensure that patients can be connected with appropriate treatment after law enforcement actions.

Prioritizing Cybersecurity: For OIG, cybersecurity is a fraud, waste, and abuse issue, which makes it a compliance issue, too.  Increased involvement by the compliance community can help address this persistent problem.

Information Blocking Enforcement: OIG issued a proposed rule in April 2020 regarding OIG’s information blocking enforcement.  Enforcement will not begin until after OIG publishes an information blocking final rule. OIG’s information blocking rule does not apply to healthcare providers. Healthcare providers that info block are subject to appropriate disincentives that will be established in future regulatory action by HHS.

Implementing Value-Based Care: Value-based models often raise program integrity risks that differ from those in traditional, fee-for-service models. Effective program integrity safeguards for new payment and care delivery models will be key to the success of value-based care. A good source for guidance is OIG’s new safe harbor final rule, which provides flexibility for beneficial innovation and better coordinated patient care while incorporating protections for patients and Federal health care programs. 

Strengthening Managed Care Program Integrity: OIG has identified weaknesses in managed care organization (MCO) efforts to identify fraud, waste, and abuse.  Additional OIG focus areas include accuracy of risk adjustment; MCO provisions of services including behavioral health services; encounter data quality; and MCO denials of care.

The Health Law Offices of Anthony C. Vitale keeps abreast of rules and regulations coming out of OIG and can assist clients in a number of ways in making sure they are compliant. For more information call 305-358-4500 or email info@vitalehealthlaw.com.

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