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 states. According … Continue Reading
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 … Continue Reading
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 … Continue Reading
The OIG has released its Medicaid Fraud Control Units Fiscal Year 2015 Annual Report, which compiles data on investigations and prosecutions by the 50 MFCUs. According to the OIG, MFCUs attained 1,553 convictions in FY 2015, the highest in the last five years. Almost one-third of these convictions involved personal care services attendants, and 71% … Continue Reading
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 … Continue Reading
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”).… Continue Reading
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 B drug … Continue Reading
According to a recent HHS Office of Inspector General (OIG) report, about 29% of Medicare beneficiaries experienced adverse or temporary harm events during their rehabilitation hospital stay, based on sample of 417 beneficiaries in March 2012. This rate is similar to the incidence of adverse events in acute-care hospitals and skilled nursing facilities. The OIG … Continue Reading
The OIG has issued a memo to CMS suggesting that some states may be claiming matching funds for government-owned but privately-operated hospitals, where no state or local government funds are used to operate the hospital. The OIG suggests that CMS consider requiring that an entity be operated by a unit of government in order to … Continue Reading
On June 22, 2016, the Department of Health and Human Services Office of Inspector General (“OIG”) issued a comprehensive report detailing its nationwide analysis of common characteristics in home health fraud cases. In tandem with this report, the OIG issued an Alert on improper arrangements and conduct by and among home health agencies (“HHAs”) and physicians. … Continue Reading
A new OIG report examines CMS’s oversight of Medicare billing by provider-based facilities – that is, facilities that operate under the ownership, administrative, and financial control of a hospital and meet other requirements, and that bill as an outpatient department of the hospital rather than a freestanding facility. The OIG observes that Medicare payments under … Continue Reading
The HHS OIG has updated its FY 2016 Work Plan to reflect new and/or completed items since initial release of the FY 2016 Work Plan in November 2015. For instance, the mid-year update indicates that the OIG plans to conduct several new Medicare reviews, including reviews regarding:… Continue Reading
The OIG recently examined how states that pay for drugs through Medicaid managed care organizations (MCOs) identify and exclude 340B drug claims when collecting Medicaid rebates, since states are prohibited from collecting “duplicate discounts” (i.e., when manufacturers pay Medicaid rebates on drugs sold at the discounted 340B price). The OIG also reviewed potential vulnerabilities that … Continue Reading
The HHS Office of Inspector General (OIG) and the Government Accountability Office (GAO) have recently examined a number of Medicare and Medicaid provider screening and related program integrity issues. The OIG reports include the following:… Continue Reading
CMS recently released the names of the new contract suppliers under the Round 2 Recompete of the Medicare durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) competitive bidding program and the national mail-order competition for diabetes supplies. The CMS announcement was followed shortly by release of an HHS Office of Inspector General (OIG) report that … Continue Reading
The OIG has issued its Spring 2016 Semiannual Report to Congress, which describes significant enforcement and investigative activities relating to HHS programs during the first half of FY 2016 (October 1, 2015 – March 31, 2016). The OIG reports expected recoveries of more than $2.77 billion ($554.7 million in audit receivables and about $2.22 billion … Continue Reading
The Office of Inspector General (OIG) of the Department of Health and Human Services has issued new, non-binding “Criteria for Implementing Section 1128(b)(7) Exclusion Authority” updating the factors OIG will consider in deciding whether to exclude persons “whose continued participation in the [federal health care programs] constitutes a risk to the programs and their beneficiaries.” … Continue Reading
The HHS Office of Inspector General (OIG) recently issued a report examining implementation of Medicaid National Correct Coding Initiative (NCCI) edits, as required by the Affordable Care Act since October, 2010. The report finds that several problems have limited the success of these edits (medically unlikely edits and procedure-to-procedure edits), which are designed to encourage … Continue Reading
The OIG has released the 2016 edition of its “Compendium of Unimplemented Recommendations,” which identifies what the OIG considers to be its top 25 unimplemented recommendations in terms of HHS program savings and/or quality improvements. About one-third of the priority recommendations involve Medicare Parts A and B policies, including recommendations to adjust payment policies for … Continue Reading
According to a recent OIG report, hospices billed inappropriately almost one-third of Medicare general inpatient care (GIP) stays in 2012, resulting in $268 million in inappropriate Medicare payments. The GIP level of care includes hospice inpatient unit, hospital, or SNF services for pain control or acute or chronic symptom management that cannot be managed in other settings, … Continue Reading
The federal government won or negotiated more than $1.9 billion in judgments and settlements, and attained additional administrative impositions in health care fraud cases and proceedings in FY 2015, according to the latest HCFAC program annual report. These new efforts, together with prior year actions, resulted in a total of $2.4 billion in health fraud … Continue Reading
The HHS Office of Inspector General (OIG) has issued an interim evaluation report on an Affordable Care Act (ACA) program that provides grants to states to implement background check programs for prospective long-term care employees. According to OIG, 25 states currently are participating in the program at different stages (for instance, some have not yet … Continue Reading
The Government Accountability Office (GAO) has issued a report on trends in Medicaid managed care spending, enrollment, and oversight. Notably, the GAO reports that over 10 years (FY 2004 through 2014), federal Medicaid managed care spending grew from $27 billion to $107 billion, representing 38% of total federal Medicaid spending in 2014. The report also … Continue Reading
On December 23, 2015, the Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) published its annual notice soliciting recommendations for new or modified, safe harbor provisions under the federal anti-kickback statute. The notice also invites suggestions for new OIG Special Fraud Alerts. The OIG will accept proposals until February … Continue Reading
