The U.S. Department of Health and Human Services (HHS), Office of Inspector General (OIG) has released its Work Plan for FY 2009. The OIG Work Plan is released annually, and identifies priority areas for OIG review/investigation that the agency believes are HHS’ most vulnerable programs and activities, with the goal to improve HHS agency efficiency and effectiveness. Most of the projects described in the Work Plan focus on familiar themes, such as quality of care, transparency, reimbursement, minimum data set (MDS), antipsychotic drugs and durable medical equipment (DME) to name a few – all of which have already been identified in press and OIG enforcement actions. There is mention of some newer themes too; however, such as “never events” and medical identity theft.
In the 2009 OIG Work Plan the agency categorizes its plans for reviews/investigations under two headings: 1) Centers for Medicare & Medicaid Services (CMS), which describe reviews related to Medicare, Medicaid, information systems controls, Gulf Coast hurricane response, State Children’s Health Insurance Program (SCHIP) and related investigations; and 2) Public Health and Human Services Programs and Departmentwide issues, which describe reviews related to agencies, such as the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), the National Institutes of Health (NIH), the Administration for Children and Families (ACF) and the Administration on Aging (AoA). This section also describes issues, such as financial accounting and information systems management.
The OIG Work Plan focuses on a number of areas critical to long term care providers, but especially relevant are many of the upcoming CMS’ reviews/investigations including, but not limited to:
- Serious Medical Errors (Never Events) - OIG will review the incidences of and payments for serious medical errors, known as “never events,” in the Medicare population. Recent law requires OIG to conduct a study of never events, examining types of events and payments by any party; the extent to which the Medicare program paid, denied payment, or recouped payment for services furnished in connection with such events; and the extent to which beneficiaries paid for such services. OIG also is required to review CMS’s administrative processes regarding detecting and paying for never events. OIG will conduct a series of reviews to address the requirements of this mandate. More specifically, it will review key issues, policies, and practices regarding never events in hospitals. AHCA is watching this issue carefully in hospitals to determine spill over into nursing facilities.
- Skilled Nursing Facility (SNF) Consolidated Billing – OIG will review Medicare Part B claims submitted by suppliers for items, supplies, or services provided to beneficiaries during Part A Medicare-covered SNF stays. Pursuant to the current law, the supplier must bill and receive payment from SNF, rather than from Medicare, for these items or services. Prior work has identified significant improper claims submission and reimbursement in this area, and the OIG is continuing work to identify additional overpayments. OIG also will determine whether edits in CMS’s main claims-processing system, the Common Working File (CWF), are effective in detecting and preventing improper payments.
- Accuracy of Coding for Medicare SNF Resource Utilization Groups’ Claims – OIG will review a national sample of Medicare claims submitted by SNFs to determine the extent to which Resource Utilization Groups (RUGs) included on SNF claims for Medicare reimbursement are accurate and supported by the residents’ medical records. Medicare pays for Part A-covered SNF stays based upon a PPS that includes a case-mix adjustment based upon RUGs. A 2006 OIG report found that 22 percent of claims were upcoded, representing $542 million in potential overpayments for FY 2002. As part of the OIG’s follow-up work, it also will identify methods to improve the accuracy of payments to SNFs.
- Part B Services in Nursing Homes: Mental Health Needs and Psychotherapy Services – OIG will review Medicare Part B payments for psychotherapy services provided to nursing home residents during noncovered Medicare Part A SNF stays. Pursuant to regulations, certified nursing homes are required to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. A previous OIG review found that approximately 31 percent of outpatient claims for Part B mental health services allowed by Medicare did not meet coverage guidelines, resulting in $185 million in inappropriate payments. OIG will determine the medical necessity of services, appropriateness of coding, and adequacy of nursing home documentation.
- Calculation of Medicare Benefit Days – OIG will review whether SNFs submit no-pay bills as required. No-pay bills are submitted to Medicare without a request for reimbursement to track beneficiaries’ benefit periods. Medicare allows up to 100 days of SNF services per spell of illness. A spell of illness begins on the first day on which SNF services are provided and ends after those services have not been utilized for 60 days. The Medicare Claims Processing Manual requires that a SNF submit a bill for a beneficiary that has started a spell of illness under the SNF Part A benefit for every month of the related stay even though no benefits may be payable. A SNF provider also must submit no-pay bills for a beneficiary who has previously received Medicare-covered skilled care and subsequently dropped to a noncovered level of service but continues to reside in a Medicare-certified area of a facility. OIG will review whether failure to submit no-pay bills contributes to inappropriate calculations of SNF eligibility periods. OIG also will examine CMS’s oversight mechanisms in place to ensure that no-pay bills are submitted by SNFs.
- Oversight of Nursing Home Minimum Data Set Data (MDS) – OIG will review CMS’s oversight of MDS data submitted by nursing homes certified to participate in Medicare or Medicaid. The law requires nursing homes to conduct accurate comprehensive assessments for residents using a resident assessment instrument that includes the MDS. Regulations specify the requirements of the assessment instrument. MDS data includes the residents’ physical and cognitive functioning, health status and diagnoses, preferences, and life care wishes. CMS implemented a SNF PPS based on MDS data in July 1998 and began posting MDS-based quality performance information on its Nursing Home Compare Web site in 2002. OIG will review CMS’s processes for ensuring that nursing homes submit accurate and complete MDS data.
- Nursing Home Residents Aged 65 or Older Who Received Antipsychotic Drugs –OIG will review the extent to which nursing home residents aged 65 or older received selected antipsychotic drugs in the absence of conditions approved by the Food and Drug Administration (FDA). The law requires SNFs to respect certain rights of patients, including the right to be free from chemical restraints administered for discipline or convenience. The regulation defines safeguards to protect nursing home residents from being prescribed unnecessary drugs. OIG will examine Medicare Part D and Part B program reimbursements for selected antipsychotic drugs received by elderly nursing home residents and the extent to which these drugs were prescribed and paid for in accordance with Federal regulations.
- Medicare Hospice Care for Nursing Home Residents: Services and Appropriate Payments – OIG will review the nature and extent of hospice services that are provided to Medicare beneficiaries who reside in nursing facilities and assess the appropriateness of payments for these services. The law governs hospice care in the Medicare program. Medicare hospice spending doubled from $3.5 billion to $7 billion from 2001 to 2004, with the growth associated mostly with nursing home residents. A previous OIG review found that hospice beneficiaries in nursing facilities received nearly 46 percent fewer nursing and aid services than hospice beneficiaries residing at home. By conducting a medical record review of hospice services provided to selected beneficiaries, OIG plans to assess beneficiaries’ plans of care and determine whether the services that they receive are consistent with their plans of care and whether payments are appropriate.
Durable Medical Equipment and Suppliers:
- Part B Services in Nursing Homes: Overview - OIG will review the extent of Part B services provided to nursing home residents whose stays are not paid for under Medicare’s Part A SNF benefit. Unlike services provided during a Part A SNF stay, which are billed to Medicare directly by the SNF in accordance with consolidated billing requirements, Part B services are provided and billed directly by suppliers and other providers. In repealing consolidated billing provisions that would have applied to non-Part A SNF stays, Congress directed OIG to monitor these services for abuse. This review will determine the extent of Part B services provided to nursing home residents during 2006 and assess patterns of billing among nursing homes and providers. As a follow-up to this study, OIG also plans a number of in-depth reviews on specific Part B services, such as those associated with DME and enteral nutrition therapy (ENT). OIG believes these reviews will identify inappropriate payments and aberrant billing patterns by providers and suppliers.
- Part B Services in Nursing Homes: Enteral Nutrition Therapy (ENT) - We will review Part B ENT, commonly called tube feeding, to determine the appropriateness of payments for associated services. OIG believes that the review will specifically assess the medical necessity, adequacy of documentation, and coding accuracy of claims submitted for Medicare beneficiaries during a nursing home stay that is not covered under the Part A SNF benefit. The law authorizes Medicare Part B coverage of ENT under a prosthetic device benefit provision for beneficiaries residing at home or in nursing facilities when the stays are not covered by Medicare Part A. We will assess the appropriateness of payments for claims for ENT.
- Part B Pricing of Enteral Nutrients for Nursing Homes - OIG will review Part B pricing of enteral nutrients used in ENT. Medicare covers enteral nutrients for beneficiaries who cannot swallow because of permanent or severe medical problems. The law authorizes Medicare Part B coverage of enteral nutrients under the prosthetic device benefit provision for beneficiaries residing at home or in nursing facilities when the stays are not covered by Medicare Part A. Past OIG work found that Medicare reimbursement for enteral nutrients substantially exceeded prices commonly available to purchasers, such as nursing homes. OIG will compare Medicare’s fee schedule for enteral nutrients to prices available to nursing homes.
- Part B Services in Nursing Homes: Durable Medical Equipment - OIG will review Medicare Part B DME payments allowed for items or supplies provided to beneficiaries in nursing homes. The law authorizes Medicare payments for DME claims, but the nursing home is specifically excluded from qualifying as a beneficiary’s home for DME payment purposes when the nursing home is engaged primarily in providing skilled nursing care or rehabilitation services. A previous OIG report found that $210 million was potentially inappropriately paid for DME for beneficiaries residing in nursing homes. OIG will review Medicare claims data to determine the extent of inappropriate Medicare Part B DME payments made on behalf of Medicare beneficiaries during nursing home stays not covered by Medicare Part A.
- Medicare Part B Payments for Home Blood-Glucose-Testing Supplies - OIG will review Medicare Part B payments made for home blood glucose test strips and lancet supplies. The law provides that Medicare will not pay for items or services that are “not reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member.” The Local Medical Review Policies (LMRP) or local coverage determinations, whichever are applicable, issued by the four DME MACs require that the physician’s order for each item billed to Medicare include certain elements and be retained by the supplier to support billing for those services. Further, the LMRP require that suppliers add a modifier to identify when the patient is insulin-treated or noninsulin-treated. The amount of supplies allowable for Medicare reimbursement differs depending on the applicable modifier. OIG will determine the appropriateness of Medicare Part B payments to DME suppliers for home blood glucose test strips and lancet supplies.
- Medicare Payments for Power Wheelchairs - OIG will review documentation supporting claims for power wheelchairs paid for by Medicare and determine whether Medicare beneficiaries received the required face-to-face examinations from the referring practitioners prior to receipt of power wheelchairs, in accordance with the law. DME is defined as including power-operated wheelchairs. In 2003, Medicare payments for power wheelchairs peaked at $1.2 billion. In 2004, as a result of expanded CMS program integrity initiatives, power wheelchair spending decreased to $850 million. However, Medicare payments for power wheelchairs increased again in 2005 to approximately $920 million. OIG will determine the appropriateness of Medicare payments for power wheelchairs.
Other Reviews Related to Part A and Part B:
- Ambulance Services Used to Transport End Stage Renal Disease (ESRD) Beneficiaries - OIG will review the extent to which ambulance services are used to transport ESRD beneficiaries to and from dialysis facilities. CMS’s Medicare Benefit Policy Manual describes coverage of ambulance services to and from renal dialysis facilities for ESRD patients who require dialysis. Furthermore, the law requires the HHS Secretary to develop a report on a bundled Prospective Payment System (PPS) for ESRD services. The bundled PPS for ESRD services generally does not provide for ambulance services. In calendar year 2005, payments for ambulance services between beneficiaries’ residences and hospital-based or freestanding ESRD facilities were approximately $262 million. OIG will examine factors such as the percentage of the population using ambulance services, the feasibility of freestanding facilities to contract with ambulance suppliers and the coverage policies of other health insurance programs.
- Medical Identity Theft in Medicare – OIG will review CMS’s activities designed to deter medical identity theft in Medicare. The law establishes the Medicare Integrity Program in an effort to combat fraud, waste, and abuse in the Medicare program. In 2007, the Department of Justice (DOJ) and the Federal Trade Commission (FTC) reported identity theft as one of the fastest growing crimes, with data showing annual monetary losses in the billions of dollars. Early detection and notification of medical identity theft could deter or limit the impact of Medicare fraud. We will review CMS’s medical identify theft deterrence measures, including its outreach to beneficiaries.
Medicare Part A and Part B Contractor Operations:
- Medicare and Medicaid Data Match Project - OIG will review CMS’s oversight and monitoring of the Medicare and Medicaid Data Match Project (Medi-Medi) contractors to determine whether they are meeting contractual requirements outlined in the Medi-Medi task orders. The Medi-Medi Project was initiated in 2001 by CMS in partnership with the State of California and continues, pursuant to the law, to improve coordination of Medicare and Medicaid program integrity efforts. The objective of the project is to match Medicare and Medicaid data to proactively identify program vulnerabilities and potential fraud and abuse that may have gone undetected by reviewing Medicare and Medicaid program data individually. As of 2007, there were 10 active Medi-Medi Task Orders in the states of California, Texas, Washington, Pennsylvania, North Carolina, New Jersey, New York, Florida, Ohio, and Illinois. Federal regulations provide policies and establish responsibilities for agencies recording and maintaining contractor performance information.
- Accuracy and Completeness of the National Provider Identifier (NPI) - OIG will review the accuracy and completeness of NPIs, which are unique identification numbers for health care providers. CMS regulations require that, beginning May 23, 2007 (May 23, 2008, for small health plans), NPIs be used in lieu of legacy provider identifiers when submitting claims. Providers failing to obtain their NPIs risk losing their ability to receive payment for services provided to Medicare and Medicaid beneficiaries. By May 23, 2008, all Medicare providers had to include their NPIs when submitting claims. We will determine whether CMS has met program goals for implementation of NPIs.
- Recovery Audit Contractors (RACs): Reducing Medicare Improper Payments - OIG will review CMS’s oversight and monitoring of RACs to determine whether they meet contractual requirements outlined in the Task Orders. The RAC program, authorized under the law, is designed to reduce Medicare improper payments through the detection and collection of overpayments, the identification of underpayments, and the implementation of actions that will prevent future improper payments. The law also requires the HHS Secretary to utilize RACs in the Medicare Integrity Program to identify underpayments and overpayments and recoup overpayments associated with services for which payments are made under Medicare Part A or Part B.
- Medicare Contractors’ Use of Payment Suspensions and Other Administrative Sanctions - OIG will review MACs’ and Program Safeguard Contractors’ use of payment suspensions and other administrative sanctions intended to prevent payments to providers and suppliers suspected of fraud. Pursuant to regulations, CMS or its contractors can suspend payments to providers or suppliers based upon the existence of reliable information of an overpayment or fraud. Payment suspensions temporarily stop payment until contractors identify and determine overpayments. We will examine CMS’s oversight and contractors’ implementation of payment suspensions and other administrative sanctions.
- Collection of Medicare Overpayments Referred by Program Safeguard Contractors - OIG will review overpayments that program safeguard contractors referred to claims processors for collection in 2007. The Health Insurance Portability and Accountability Act (HIPAA) established the Medicare Integrity Program, which requires CMS to engage contractors to review Medicare claims, among other things, for possible overpayments. Pursuant to this provision, program safeguard contractors perform investigative work on Medicare payments to detect and deter fraud and abuse. When they identify overpayments that have been made to Medicare providers and beneficiaries, they refer them to Medicare claims processors for collection. OIG will examine the amount of overpayments that Medicare claims processors have collected as a result of overpayment referrals and identify the procedures the program safeguard contractors and claims processors use to identify and track possible fraud and abuse related to the overpayments.
- Handling of Complaints Referred by the 1-8-HHS-TIPS-Hotline - OIG will review CMS’s handling of complaints referred by OIG from callers to 1-800-HHS-TIPS, which is a hotline the OIG operates to receive calls alleging fraud, waste, or mismanagement of HHS programs, such as Medicare. The availability of the hotline is widely publicized on the Internet and in various publications, including CMS’s Medicare & You booklet that is distributed annually to Medicare beneficiaries. In 2007, the hotline referred approximately 4,000 complaints to CMS for assessment and appropriate action. OIG will review CMS’s handling of these referrals, including its research related to the issues of the complaints, corrective actions taken, and communications with the complainants.
- Validation of National Claims History (NCH) File - OIG will review CMS’s NCH file to determine the accuracy and completeness of paid claims and utilization data on Medicare beneficiaries enrolled in Part A or Part B. The data is used by CMS and other outside healthcare organizations for statistical and research purposes related to evaluating and studying the operation and effectiveness of the Medicare program. The information contained in the NCH also is used to support regulatory, reimbursement, and policy functions performed by CMS or by a contractor, consultant, or grantee. The NCH is populated on a daily basis with claims fully adjudicated by the CWF. Prior OIG work determined that contractors do not correctly process canceled claims when a provider remits a check to the Medicare program representing multiple claims. OIG will assess Medicare contractors’ policies and procedures for processing returned funds, canceled claims, and other adjustments that affect the original Medicare claim and which are not always processed through the CWF.
- Potentially Excessive Medicaid Payments for Inpatient and Outpatient Services - OIG will review State controls to detect potentially excessive Medicaid payments to institutional providers for inpatient and outpatient services. The Office of Management and Budget (OMB) states that to be allowable, costs must be necessary and reasonable for the proper and efficient performance and administration of Federal awards. Further, costs must be authorized, or not prohibited, under State or local laws or regulations. The law and regulations provide for the adjustment of quarterly payments to States by CMS to account for overpayments and underpayments made by States to providers. Prior OIG work involving Medicare inpatient and outpatient claims found that many claims resulting in excessive payments to the hospitals were attributable to billing errors on the submitted claims, such as inaccuracies in the diagnosis codes, admission codes, discharge codes, procedure codes, charges, HCPCS codes, and number of units billed. OIG will determine whether similar vulnerabilities exist in State agencies’ controls for detecting potentially excessive Medicaid payments.
Medicaid Home, Community and Nursing Home Care:
- Medicaid Payments to Nursing Homes While Dual-eligible Beneficiaries Received - OIG will review Medicaid payments made to nursing homes for dual-eligible beneficiaries while the beneficiaries were receiving Medicare Part A services (e.g., hospital or SNF stays). The law authorizes States to make payments for nursing facility services for individuals 21 years of age or older. If a State Medicaid program makes full per diem payments to a nursing home for days a beneficiary is not in the nursing home, but in an inpatient hospital, it is paying for services not rendered. A previous OIG review found that some States made full per diem payments for dates that overlapped hospital stays. For selected States, OIG will examine nursing home per diem payments with dates of service that overlap a covered Medicare Part A service.
- Transparency within Nursing Facility Ownership - OIG will review ownership structures at investor-owned nursing homes. Nursing facilities are increasingly being purchased by private equity or other for-profit investor firms. Prior OIG work showed that, after the facility purchase, in some cases, new owners created a complex web of ownership that essentially left the operators of the nursing facility with no assets. Determination of which entity is legally liable for patient care can be made difficult because of the ownership structure. In addition, after the facility purchase, in some cases new owners have reduced staffing levels and taken other cost-cutting measures that increase profit at the expense of quality of care. OIG will determine which entities are benefiting from the Medicaid reimbursement and study the effects of these types of ownership changes on the care received by beneficiaries in nursing homes.
- State and Federal Oversight of Home- and Community-Based Services Provided in Assisted Living Facilities (ALF) – OIG will review State and Federal oversight of Medicaid Home- and Community-Based Services provided in ALF. These facilities may receive Medicaid funding through the HCBS waiver program under the federal law. Under current regulations, States are required to set their own assurances that necessary safeguards have been taken to protect the health and welfare of home- and community-based services beneficiaries. OIG will determine the extent to which States are complying with Federal requirements for home- and community-based services provided in ALFs.
- State and Federal Oversight of Home- and Community-Based Services - OIG will review States’ and CMS’s oversight of home- and community-based services waiver programs. Medicaid home- and community-based services waiver programs allow States to provide alternative services for individuals who would otherwise require care in nursing homes. Pursuant to regulations, States must provide assurances that necessary safeguards have been taken to protect the health and welfare of the recipients. However, a 2003 General Accounting Office (GAO) review found that CMS and the States did not provide adequate oversight of home- and community-based services waivers. OIG will determine the extent to which States are complying with Federal regulations. OIG also will review CMS’s processes for monitoring States’ compliance with these requirements.
- Plans of Care: Addressing MDS and Resident Assessment Protocols Through Provided Services - OIG will review nursing homes’ use of the federally required MDS and Resident Assessment Protocols (RAPs) to develop nursing home residents’ plans of care and guide the provision of appropriate and necessary care. The law requires nursing homes participating in the Medicare or Medicaid program to use a standardized Resident Assessment Instrument (RAI) to assess each nursing home resident’s strengths and needs. Prior OIG reports revealed that approximately one-quarter of residents’ needs for care, as identified through the RAI, were not reflected in their care plans and that nursing home residents did not receive all psychosocial services identified on care plans.
- States’ Use of Civil Monetary Penalty (CMP) Funds – OIG will review whether States are correctly applying CMP funds to programs that protect the health or property of nursing facility residents pursuant to the law. CMPs are remedies that CMS and States may use to address a nursing facility’s failure to meet Medicare and Medicaid health and safety requirements. OIG will examine the amounts that States have received from CMPs, States’ use of CMP funds, and States’ and CMS’s oversight of the use of CMP funds.
- Payments for “Bed Holds” - OIG will review the appropriateness of Medicaid payments for “bed holds.” States have implemented bed hold policies to encourage nursing homes to provide continuity of residence and care for Medicaid beneficiaries. Under regulations, State Medicaid agencies are authorized to make payments to nursing homes for reserving beds while residents are on temporary leaves of absence. Failure of nursing homes to report bed hold days accurately could result in increased cost to State Medicaid programs and the Federal Government. OIG will determine whether CMS has effectively provided oversight of States’ compliance with their bed hold policies and assess the adequacy of States’ oversight of facilities’ compliance with temporary-absence-reporting requirements.
Other Medicaid Services:
- Medicaid Payments for Transportation Services - OIG will review payments made to providers for transportation services. Federal regulations require States to ensure necessary transportation for Medicaid beneficiaries to and from providers. Each State may have different Medicaid coverage criteria, reimbursement rates, rules governing covered services, and beneficiary eligibility for services. OIG will determine the appropriateness of State Medicaid agencies’ payments for transportation services.
- State Policies To Safeguard Medicaid Nonemergency Transportation Services - OIG will review current State policies, procedures, and oversight activities to safeguard Medicaid nonemergency transportation services against fraud and abuse. Pursuant to regulations, Medicaid must ensure necessary transportation for recipients to and from providers. Prior OIG reviews found that State Medicaid program internal controls were lacking or not fully enforced and that Medicaid nonemergency transportation services were at high risk for fraud. OIG will determine the extent of safeguards used by States to prevent and detect fraud and abuse of Medicaid nonemergency transportation services.
- Rehabilitative Services – OIG will review claims for rehabilitative services to determine whether the services met Federal reimbursement requirements. The law defines rehabilitative services as any medical or remedial services provided in a facility, a home, or other setting. The services must be recommended by a physician or other licensed practitioner of the healing arts for the maximum reduction of physical or mental disability and restoration of an individual to the best possible functional level. Previous OIG reviews found a significant number of services claimed that were not eligible for reimbursement.
- Medicaid Payments for Services Provided Under Section 1115 Demonstration Projects - OIG will review selected States’ demonstration projects pursuant to the law to determine whether services are being provided in accordance with the conditions of the projects’ approval. The law authorizes the HHS Secretary to approve demonstration projects that are likely to assist in promoting the objectives of the Medicaid program. Under this authority, some States have expanded Medicaid eligibility to individuals not otherwise eligible for Medicaid, provided services not typically covered by Medicaid, or used innovative systems to deliver services.
- Medicaid Waiver Safety Net Care Pools (SNCPs) – OIG will review section 1115 demonstration projects that contain SNCPs to determine whether States are abiding by the Medicaid demonstration terms and conditions as they relate to the SNCP. The law provides broad authority to authorize experimental, pilot, or demonstration projects likely to assist in promoting the objectives of the Medicaid statute. SNCPs permit the reimbursement of a broad array of uncompensated costs. For example, the pools may be used to reimburse the cost of providing to the uninsured physician services, clinic services, and any other services that CMS does not consider to be inpatient or outpatient hospital services.
- Medicaid Payments for Services Provided Under Section 1915(b) Managed Care/Freedom of Choice Waivers - OIG will review the cost effectiveness of selected States’ section 1915(b) waivers. Under the waiver authority in the law, CMS may authorize States to provide medical assistance through managed care organizations. These waivers affect service delivery to some or all of the individuals eligible for Medicaid in the State. States may elect to enroll on a mandatory basis beneficiaries in managed care programs or may carve out specialty care. Both the law and regulations provide that these waivers are not to negatively affect beneficiary access or quality of care or service and must be cost effective. OIG also will review the effectiveness of CMS’s national review protocol for the oversight process.
- Sections 1915(b) and (c) Concurrent Waivers - OIG will review each portion of sections 1915(b) and (c) concurrent waivers to determine whether the waivers are cost effective and whether the services provided through the waivers were provided in accordance with the approved waiver terms and conditions. The section 1915(b) waivers also are known as managed care/freedom of choice waivers, and section 1915(c) waivers are also known as home- and community-based waivers. Concurrent waivers allow States to simultaneously utilize sections 1915(b) and (c) program authorities to provide services to a specific group with specific providers. States must meet the Federal requirements for each of the waivers and comply with the separate reporting requirements for each waiver.
- Medicaid Payments for Services Provided Under Section 1915(c) Home- and Community-Based Service Waivers - OIG will review Medicaid payments to providers and selected States to determine whether services provided under section 1915(c) waivers are rendered in accordance with approved waiver agreements. Under the law, § 1915(c) waiver authority, CMS may authorize States to expand the term medical assistance to include home- and community-based services pursuant to written plans of care. Such services can include both traditional medical services and support services, e.g., respite care and case management. In addition, the waivers allow family members to provide services if they meet certain requirements.
- Enrollment of Excluded Medicaid Providers - OIG will review States’ processes for enrolling Medicaid providers. Specifically, we will focus on a subset of Medicaid providers who were subsequently excluded from participating in federally funded health care programs. Pursuant to regulations, States are required to collect information from providers regarding the ownership of health care entities and criminal convictions as part of the enrollment process for participating in Federal health care programs. However, there is no corresponding requirement that States verify the information. Previous GAO and OIG reports found that most States had not verified information that providers submitted in their applications nor required periodic reenrollment. OIG will assess the prevalence of judgments, tax liens, and criminal convictions among a population of excluded Medicaid providers and the extent to which States had checked providers’ backgrounds both before and after enrollment. OIG also will determine how much States reimbursed these providers when they were active.
- Medicaid Transformation Grants (MTGs) - OIG will review MTGs to determine whether costs claimed by State agencies were adequately supported and allowable. MTGs were permitted, under the law, to be used for health information technology (HIT) and health information exchange (HIE) initiatives in FY 2007 and FY 2008. Methods for reducing patient error rates through the implementation and use of electronic health records, electronic clinical decision support tools, or e-prescribing programs were cited as permissible use of funds. In January 2007, CMS awarded 33 grants, totaling $103 million. Eighteen of these grants were for HIT and HIE initiatives, totaling $64 million.
- Medicaid Provider Tax Issues – OIG will review State and health-care-related taxes imposed on various Medicaid providers to determine whether such taxes comply with applicable Federal laws and regulations and are being used for the stated purposes. The law requires a reduction in a State’s medical assistance expenditures equal to the amount of any impermissible health-care-related taxes. Federal regulations set forth the standard for permissible health-care-related taxes. Prior OIG work has raised concerns regarding States’ use of health-care-related taxes, including whether taxes received by States adversely affect the providers required to pay the taxes.
- Medicaid Eligibility in Multiple States - OIG will review the appropriateness of Medicaid payments for beneficiaries with Medicaid eligibility in multiple States. Federal regulations require States to provide Medicaid to eligible residents, including residents who are absent from the State. OIG has determined that individual beneficiaries have been eligible in more than one State during a specific period. Initial survey work has confirmed that duplicate payments are made to providers in different States, for a specific beneficiary, for identical or overlapping dates of service.
- Duplicate Medicaid Payments to Providers on Behalf of Hurricane Evacuees - OIG will review Medicaid payments to determine whether two providers were paid for the same service. As a result of the 2005 hurricanes, thousands of beneficiaries were evacuated from their home States and relocated to other (host) States. Beneficiaries were eligible for Medicaid in their new host States and may have received services from providers in their host States. OIG will determine whether providers in the host States billed and received payment from both the beneficiaries’ home States and host States.
- State Agencies’ Redeterminations of Medicaid Eligibility - OIG will review the State agencies’ procedures for redetermining the eligibility status of Medicaid beneficiaries. During recent audits of Medicaid payments for services provided to beneficiaries with concurrent eligibility in two States, we found that eligibility status reviews were not always performed in a timely manner. Federal regulations provide that State agencies must redetermine the eligibility of Medicaid beneficiaries, with respect to circumstances that may change, at least every 12 months. OIG will determine the amount of unallowable payments associated with beneficiaries who did not receive the required Medicaid eligibility redeterminations.
- Medicaid Statistical Information System (MSIS) Data Reporting - OIG will review MSIS data to determine whether the data are current, accurate, and sufficiently comprehensive for use in detecting Medicaid fraud, waste, and abuse . The law requires States to submit MSIS claims and eligibility information electronically to CMS. The MSIS is the only comprehensive national database of Medicaid beneficiary-level claims and eligibility information and is the
- Early Implementation of the Medicaid Transfer of Asset Rules - OIG will review the extent to which States have implemented the Medicaid transfer of asset rules required by the DRA. To be eligible for Medicaid, applicants must meet specific income and asset standards. Those with assets must spend down many of these assets before they become eligible. Recent law changed the transfer of asset rules related to Medicaid eligibility for long-term care by extending the look-back period for asset transfers from 3 years to 5 years. OIG also will review the extent to which States’ Medicaid enrollment processes address these asset transfer requirements.
Medicare and Medicaid Information Systems and Data Security:
- Medicare: Annual Reports to Congress on Contractor Information Systems Security Programs - OIG will review independent evaluations of information systems security programs of Medicare FIs, carriers, and MACs. The law requires annual independent evaluations of FIs, carriers, and MACs’ security programs and subsequent OIG assessment of these evaluations. OIG is required to annually report the results of its assessments to Congress. OIG’s report to Congress will include an assessment of the scope and sufficiency of the evaluations performed and summarizes the results of independent evaluations.
- Medicare: Assessment of Claims Bypassing the Common Working File and the Impact on the National Claims History File – OIG will review Medicare claims to determine the extent to which claims are processed and paid without the CWF’s editing and the impact on the completeness of the NCH. The CWF is a system that uses localized databases, which are maintained by host contractors, to validate and approve prepayment of Medicare claims and to coordinate Medicare Part A and B benefits. The system also provides contractors with beneficiary entitlement and utilization information. In addition, the CWF is used by CMS to populate its NCH File, which is used to support regulatory, reimbursement, and policy functions performed within the agency or by a contractor, consultant, or grantee. The independent auditors of HHS’s financial statements disclosed that some Medicare fee-for-service claims are processed and paid without being adjudicated through the CWF.
- Medicare and Medicaid Health Information Data Security and Privacy - OIG will review CMS’s oversight, implementation, and enforcement of the HIPAA Security Rule. The data security standards required under HIPAA are known as the HIPAA Security Rule. The HIPAA Security Rule applies to HIPAA-covered entities, including Medicare and Medicaid providers. CMS is responsible for overseeing compliance with this regulation. OIG also will review various HIPAA-covered Medicare program providers’ compliance with the HIPAA Privacy Rule requirements defined in the regulations and will determine the adequacy of oversight provided by the Office for Civil Rights for the HIPAA Privacy Rule.
- Medicaid Management Information Systems (MMISs)—Business Associate Agreements - OIG will review CMS’s oversight activities related to data security requirements of States’ MMISs, which process and pay claims for Medicaid health benefits. Business associates of States’ MMISs typically include support organizations, such as data processing services and medical review services. State Medicaid agencies are among the covered entities that must comply with HIPAA Security Final Rules, which stipulate minimum requirements that contracts with business associates must include to protect the privacy and security of certain electronic personally identifiable health information. OIG will determine whether business associate agreements have been properly executed to protect beneficiary information, including safeguards implemented pursuant to the HIPAA standards.
For a copy of the entire OIG 2009 Work Plan go to http://oig.hhs.gov/publications/workplan.asp and double click on Entire Office of Inspector General Work Plan.