OIG WorkPlan Update for December Includes Six New Initiatives

The HHS Office of the Inspector General continues to update its Work Plan each month and ended the year in December with six new initiatives, two of which focus on the opioid epidemic and how to better monitor and prevent drug abuse.

Status Update on States’ Efforts on Medicaid-Provider Enrollment

OIG will determine just how far states have gotten toward their goal of completing fingerprint-based criminal background checks and site visits. In addition, it will ask states and CMS about the challenges that have prevented states from completing fingerprint-based criminal background checks and site visits of those providers enrolled in the Medicaid program.

OIG noted that it previously found many states had yet to complete these background checks and site visits. Although CMS has agreed that it needs to comply, instead it has continued to extend the deadline for completion. OIG noted that this opens the program to potential fraud and abuse.

Review of CMS Systems Used to Pay Medicare Advantage Organizations

OIG will review the continuity of data maintained on current Medicare Part C systems. Specifically, it will review instances in which CMS made an increased payment to a Medicare Advantage organization for a hierarchical condition category (HCC) and determine whether CMS’s systems properly contained a requisite diagnosis code that mapped to that HCC. HCC is a risk-coding payment model that is the basis for CMS to reimburse Medicare Advantage plans. As CMS transitions to a new data system to make these payments, OIG will conduct analysis to inform both use of current systems and the transition to a new system.

State Compliance with Requirements for Reporting and Monitoring Critical Incidents

OIG will review additional state Medicaid agencies to determine whether the selected states follow the requirements for reporting and monitoring critical incidents. Its work will focus on Medicaid beneficiaries living in both community-based settings and nursing facilities. During prior audits, OIG found that some states did not always comply with federal and state requirements for reporting and monitoring critical incidents such as abuse and neglect.

Paper Check Medicaid Payments Made to Mailbox-Rental Store Addresses

OIG will determine if Medicaid payments issued by paper checks and sent to providers with mailbox-rental locations were for unallowable services. Providers can choose to be paid by electronic fund transfer or paper check. A report by the Government Accountability Office (GAO) identified potential issues with Medicare-provider addresses and found that payments made to a provider with a mailbox-rental store, vacant, or invalid practice address increase the potential risk of fraud, waste, or abuse. OIG will determine whether similar problems exist within the Medicaid program.

Prescription Opioid Drug Abuse and Misuse Prevention – Prescription Drug Monitoring Programs

OIG will identify actions state agencies that have taken using federal funds to enhance prescription drug monitoring programs (PDMPs) to achieve program goals — improving safe prescribing practices and preventing prescription drug abuse and misuse. OIG also will determine whether state agencies complied with federal requirements. This series of audits includes states that have had a high number of overdose deaths, a significant increase in the rate of drug overdose deaths, or received HHS funding to enhance their drug monitoring programs.

Impact of the Indian Health Service’s Delivery of Information Technology/Information Security Services and Opioid Prescribing Practices

OIG will analyze and compare information technology/information security (IT/IS) operations and opioid prescribing practices at five Indian Health Service (HIS) hospitals to determine whether (1) IHS’s decentralized management structure has affected its ability to deliver adequate IT/IS services in accordance with Federal requirements and (2) hospitals prescribed and dispensed opioids in accordance with IHS policies and procedures. This is a concern, because IHS has a decentralized management structure with the area offices responsible for overseeing 26 hospitals, 59 health centers and 32 health stations, some of which are in remote areas. OIG has found that hospitals with limited cybersecurity resources struggle to implement information technology improvements and update the IHS electronic heath record system.

Healthcare providers should review these monthly updates and use them to update policies and procedures. If you have any questions or concerns, the Health Law Offices of Anthony C. Vitale can assist. Contact us for additional information at 305-358-4500 or send us an email to info@vitalehealthlaw.com and let’s discuss how we might be able to help.