Other OIG Developments

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The HHS Office of Inspector General (OIG) estimates that CMS made $729.4 million in Electronic Health Incentive (EHR) payments to providers who did not meet meaningful use requirements from May 2011 to June 2014 – representing about 12% of the $6 billion in total EHR payments made during this period. This dramatic finding is based…

The Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) has released the 2017 edition of its Compendium of Unimplemented Recommendations  (“Compendium”). In the Compendium, OIG identifies the top 25 unimplemented recommendations that HHS would need to prioritize in order to facilitate OIG’s recommendations on cost savings, program effectiveness, efficiency, and quality improvements in HHS programs. More than half of these top 25 recommendations focus on programs regulated by the Centers for Medicare & Medicaid Services (CMS), while others focus on programs regulated by other HHS agencies and states. The top priorities identified by the OIG in the Compendium include recommendations broadly aimed at:

  • Protecting beneficiaries from drug abuse, including opioid abuse
  • Ensuring program integrity, quality of care, and safety in programs that serve children
  • Reducing Medicaid fraud and patient harm, including in the delivery of personal care services
  • Reducing home health fraud
  • Promoting economy and efficiency in drug pricing and reimbursement

Continue Reading OIG Issues Top 25 Unimplemented Cost-Savings and Quality-Improvement Recommendations for HHS Programs

The OIG and the Health Care Compliance Association (HCCA) recently held a roundtable where the discussion focused on a broad range of ideas regarding how health care organizations can measure their compliance program effectiveness – while stressing that each organization must tailor its compliance program to reflect the organization’s specific circumstances. These ideas are contained in a document, “Measuring Compliance Program Effectiveness – A Resource Guide,” which addresses both what and how to measure compliance with the standard seven elements of a compliance program:
Continue Reading OIG and HCCA Offer Suggestions for Measuring Health Organization Compliance Program Effectiveness

The OIG has released national and state-by-state data quantifying State Medicaid Fraud Control Unit (MFCUs) accomplishments in fiscal year 2016. During this period MFCUs were credited with a total of:

  • 1,721 indictments (1,249 involving fraud and 472 involving abuse or neglect);
  • 1,564 convictions (1,160 involving fraud and 404 involving abuse or neglect);
  • 998 civil

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The HHS Office of Inspector General (OIG) has released another in series of Congressionally-mandated reports on Medicare market shares of mail order diabetes test strips, this one covering the three-month period after implementation of the National Mail-Order recompete on July 1, 2016. This market share data is intended to help CMS determine if competitive bidding…

The Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) has issued a report, “Vulnerabilities Remain Under Medicare’s 2-Midnight Hospital Policy,” which assessed changes in hospital inpatient and outpatient stays since implementation of the “2-midnight” policy. This policy generally provides that an inpatient stay generally requires at least…

The HHS Office of Inspector General’s (OIG) latest Semiannual Report to Congress highlights top audits, investigations, and enforcement activities for the period of April 1 to September 30, 2016 and summarizes overall accomplishments for fiscal year (FY) 2016. Notably, the OIG reports:

  • Expected FY 2016 recoveries will exceed $5.66 billion, including nearly $1.2 billion in

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The Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) has published a final rule to codify the OIG’s expanded authority under the Affordable Care Act (ACA) to impose civil monetary penalties (CMPs) on providers and suppliers under a variety of additional scenarios. For example, for failure to timely report and return an identified overpayment, the final rule permits the OIG to impose a penalty of up to $10,000 for each item or service (rather than $10,000 per day as proposed).  Furthermore, the rule establishes up to $10,000 per day penalties—at the National Drug Code (NDC) product Identifier level—for drug manufacturers who fail to timely report and certify drug-pricing data.

Likewise, the final rule codifies the OIG’s expanded authority under the ACA to permit CMPs for conduct including:
Continue Reading OIG Finalizes Expanded CMP Authorities under the ACA

The number of Medicare beneficiaries who received durable medical equipment (DME) items generally fell after Round 2 of competitive bidding program (CBP) and the national mail-order program for diabetes testing supplies were implemented July 1, 2013, according to a Government Accountability Office (GAO) report issued this fall. Specifically, from 2012 to 2014, the number of…

The Office of Inspector General (OIG) has increased the value of permissible gifts that may be made to Medicare beneficiaries without running afoul of the civil monetary penalty (CMP) provision prohibiting beneficiary inducements (Social Security Act § 1128A(a)(5)).  The statute provides for CMPs of up to $10,000 for offers or transfers to a Medicare or…

The HHS Office of Inspector General (OIG) has issued its FY 2017 Work Plan, which lays out the OIG’s current audit, evaluation, and other legal and investigative priorities. The largest number of new initiatives by far target Medicare Parts A and B, including reviews focusing on the following:
Continue Reading New OIG Investigations to Look at Wide Range of Medicare, Medicaid Services in FY 2017

The OIG has issued an “Investigative Advisory on Medicaid Fraud and Patient Harm Involving Personal Care Services” that identifies various “fraud schemes” it has encountered involving personal care services (PCS) — nonmedical assistance typically provided by an attendant working for a personal care agency.  PCS is an optional Medicaid benefit offered in certain…

The OIG estimates that CMS made $358.8 million in improper Medicare payments for chiropractic services in 2013 – totaling 82 percent of Medicare chiropractic services in that period (note, however, that these findings were based on a small pool of 105 services for which Medicare paid $2,712). According to the OIG, the documentation provided by…

A recent OIG report examined whether hospices are meeting all requirements associated with the election statement that Medicare beneficiaries sign when they choose hospice care, and whether physicians are meeting all requirements for certifying Medicare beneficiaries for hospice care.  According to the OIG, more than one third of hospice general inpatient (GIP) stays in 2012…

The HHS Office of Inspector General (OIG) and the Government Accountability Office (GAO) recently issued several reports on various Medicare Part B drug reimbursement issues. In a report entitled “Medicare Part B: Data on Coupon Discounts Needed to Evaluate Methodology for Setting Drug Payment Rates,” the GAO assessed the impact of manufacturer coupon programs on Medicare payment rates for high-expenditure Medicare Part B drugs. The GAO observed that while coupon programs are prohibited in the Medicare program, they are generally available to privately insured patients, and the Part B drug payment methodology, which is based on reported average sales price (ASP), does not take into account coupon discounts that reduce the effective market price. The GAO estimated that for 18 high-expenditure drugs for which it obtained coupon discount data, the ASP exceeded the effective market price by an estimated 0.7% in 2013. According to the GAO, Part B spending for these drugs could have been reduced by an estimated $69 million “if ASP equaled the effective market price.” The GAO suggested that “[u]pward trends in coupon program use and drug prices suggest that these programs could cause the methodology for setting Part B drug payment rates to become less suitable over time for drugs with coupon programs.” The GAO therefore recommended that Congress consider (1) giving CMS authority to collect data from drug manufacturers on coupon discounts for Part B drugs paid based on ASP; and (2) requiring CMS to periodically collect these data and report on the implications of coupon programs for this methodology.
Continue Reading GAO, OIG Issue Reports on Medicare Part B Drug Payment Issues

The OIG has updated its guidance for providers under Corporate Integrity Agreements regarding the circumstances that might affect the independence and objectivity of independent review organizations (IROs). The updated guidance reflects 2011 revisions to Government Accountability Office (GAO) auditing standards (known as the “Yellow Book”).

The OIG has issued a report entitled “MACs Continue to Use Different Methods to Determine Drug Coverage,” which reviews how Medicare Administrative Contractors (MACs) make Medicare Part B drug coverage determinations and ensure that claims are paid according to these determinations. Based on the results of a survey of MACs regarding 2012 Part…