Archives: Office of Inspector General Regulations

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Improper Medicare Payments for Unlawfully Present, Incarcerated Beneficiaries

The OIG has discovered that Medicare has paid millions of dollars in benefits for aliens who are not lawfully present in the country and for incarcerated beneficiaries, contrary to program rules. Specifically Medicare made $91.6 million in payments to health care providers for services to approximately 2,600 unlawfully present beneficiaries during calendar years 2009 through … Continue Reading

OIG Calls for Cuts in Medicare Rates for Back Orthoses

The OIG is calling on CMS to lower Medicare payment for certain back orthosis products, either by subjecting these products to the Medicare durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) competitive bidding program or by making an inherent reasonableness adjustment. This recommendation stems from the OIG’s findings that Medicare payment amounts far exceeded supplier … Continue Reading

OIG Finds DMEPOS Competitive Bidding Not Spurring Suppliers to Solicit Specific Brands/Modes of Delivery

The OIG has released a statutorily-mandated report on the extent of supplier solicitation of physicians under the Round 1 rebid of the Medicare DMEPOS competitive bidding program, which began in nine competitive bidding areas on January 1, 2011.  Under competitive bidding rules, a physician can prescribe a specific brand or mode of delivery (e.g., gaseous … Continue Reading

OIG Assesses Medicare Oversight of Home Health Agencies

The OIG has examined CMS and Medicare contractor oversight of home health agencies (HHAs) in light of persistent concerns about Medicare fraud, waste, and abuse involving HHAs. In the report, “CMS and Contractor Oversight of Home Health Agencies,” the OIG concludes that the effectiveness of such oversight efforts is mixed. While two Medicare Administrative Contractors … Continue Reading

OIG Issues Medicare Part B Drug Pricing Report, Calls Out CMS Inaction on Reforms

The OIG has released the most recent in a series of reports comparing Part B drug average sales prices (ASP) and average manufacturer prices (AMP). The latest report (the 28th in the series) compares second quarter 2012 ASPs and AMPs and their impact on Medicare reimbursement for the fourth quarter of 2012. By way of … Continue Reading

OIG Releases 2012 Compendium of Unimplemented Recommendations

The OIG’s December 2012 Compendium of Unimplemented Recommendations highlights unimplemented OIG recommendations that the OIG believes represent significant opportunities for action in FY 2013. The report includes recommendations made through FY 2011 that were not fully implemented as of December 2012. The OIG’s priority open recommendations, which in the OIG’s view represent the most significant … Continue Reading

OIG Recommends Enforcement of Federal Standards for HCBS in Assisted Living Facilities

A recent OIG report examined the extent to which home and community-based services (HCBS) for beneficiaries residing in assisted living facilities (ALF) furnished under a section 1915(c) waiver comply with federal and state requirements. Based on sample of 150 beneficiaries in the seven states with the highest numbers of beneficiaries receiving HCBS in ALFs (Georgia, … Continue Reading

OIG Outlines Top HHS Management Challenges

The OIG has released its annual summary of “Top Management Challenges” facing HHS, which reflects “continuing vulnerabilities that OIG has identified for HHS over recent years as well as new and emerging issues that HHS will face in the coming year.” The OIG again highlights challenges associated with implementation of the ACA, along with management … Continue Reading

OIG Recommends Resurrection of Least Costly Alternative (LCA) Drug Policy

In a recent report, “Least Costly Alternative Policies: Impact on Prostate Cancer Drugs Covered Under Medicare Part B,” the OIG suggests that CMS consider seeking legislative authority to implement LCA policies for Part B drugs under certain circumstances. By way of background, between 1995 and 2010, Medicare subjected certain Part B prostate cancer drugs to … Continue Reading

OIG “Portfolio Report” on Personal Care Services

The OIG has released what it dubs a “Portfolio Report” entitled “Personal Care Services: Trends, Vulnerabilities, and Recommendations for Improvement.” The report synthesizes the OIG’s previous work on this topic and offers new recommendations to address vulnerabilities associated with personal care services. A related podcast and OIG web site “spotlight” page on Medicaid personal care … Continue Reading

OIG Calls for Improvements in Medicare Appeals Process

The OIG has issued a report entitled “Improvements Are Needed at the Administrative Law Judge Level of Medicare Appeals.” The report discusses the impact of regulatory and organizational changes that went into effect in 2005 that required Medicare administrative law judges (ALJ) to follow new regulations addressing how to apply Medicare policy, when to accept new … Continue Reading

OIG Finds Overwhelming Hospital Compliance with Present on Admission (POA) Indicator Reporting

Hospital coding staff correctly reported indicators that identified conditions as present on admission (POA) in 97% of sampled claims from 2008, according to an OIG report entitled “Assessment of Hospital Reporting of Present on Admission Indicators on Medicare Claims.” The reported coding errors involved the assessment of developing or chronic conditions (21%), errors in assigning … Continue Reading

OIG Report Reviews Updated Medicare Part B Drug Pricing Data

The Social Security Act requires the OIG to notify the HHS Secretary if the average sales price (ASP) for a particular drug exceeds the drug’s average manufacturer price (AMP) or widely available market price (WAMP) by a threshold, currently set at 5%. If that threshold is met, the Secretary is authorized to disregard the drug’s … Continue Reading

OIG Reports on Questionable Medicare HHA Billing

A recent HHS Office of Inspector General (OIG) report asserts that Medicare inappropriately paid $5 million for home health claims in 2010 with the following three errors: overlapping with claims for inpatient hospital stay; overlapping with claims for skilled nursing facility (SNF) stays; or billing for services on dates after the beneficiary’s death. The OIG … Continue Reading

OIG Highlights Adverse Events in Hospitals

The OIG has issued a report entitled “Few Adverse Events in Hospitals Were Reported to State Adverse Event Reporting Systems.”  Based on a sample of 780 hospitalized Medicare beneficiaries in October 2008, the OIG estimates that 60% of “adverse and temporary harm events” nationally occurred at hospitals in states with reporting systems, but only about … Continue Reading

OIG Examines CMS Reconciliation of Medicare Hospital Outlier Payments

A new OIG report found CMS did not reconcile hospital outlier payments associated with 292 of the 305 cost reports that were referred to it by nine selected Medicare contractors, which prevented the Medicare contractors from reaching final settlement of the 292 cost reports.  Payments were due from hospitals to Medicare for 236 of the … Continue Reading

OIG Considering Revisions to Provider Self-Disclosure Protocol

On June 18, 2012, the OIG announced that it intends to update its 1998 Provider Self-Disclosure Protocol, which established a process for health care providers to disclose potential fraud involving the federal health care programs. According to the OIG, it has resolved more than 800 disclosures, resulting in over $280 million in recoveries, during the … Continue Reading

Medicare Payment for Vision-Loss Drugs Reviewed by OIG

The OIG has issued a report entitled “Medicare Payments for Drugs Used To Treat Wet Age Related Macular Degeneration,” which discusses the cost of Lucentis and off-label use of Avastin to treat wet AMD and the potential impact of cost differences on prescribing decisions. The OIG recommends that CMS: (1) establish a national payment code … Continue Reading

OIG Highlights Lack of Data Regarding Physicians Opting Out of Medicare

The OIG has begun to analyze the extent to which and reasons why physicians opt out of the Medicare program, along with the effects on Medicare beneficiaries. The OIG was not able to complete its assessment because no centralized data exist. Limited data reviewed by the OIG indicate that the number of opted-out physicians appears … Continue Reading

Annual OIG Solicitation of New Safe Harbors, Special Fraud Alerts

On December 28, 2011, the HHS Office of Inspector General (OIG) published its annual notice soliciting recommendations for developing new and modifying existing safe harbor provisions under the federal anti-kickback statute, as well as developing new OIG Special Fraud Alerts.  Comments will be accepted until February 27, 2012.  A status report on recommendations received in … Continue Reading

OIG Highlights Medicaid Rebate Program, Indian Health Services (IHS) Issues

The OIG has created a “spotlight page” on its website to highlight its reports and findings involving the Medicaid drug rebate program. The page features comparisons of drug spending under Medicaid and Medicare Part D, manufacturer compliance with Average Manufacturer Price reporting requirements, manufacturer development of new versions of existing brand-name drugs to minimize rebate obligations, … Continue Reading

OIG Examines Medicare’s Response to Hospital Adverse Events

The OIG has issued a report entitled “Adverse Events in Hospitals: Medicare’s Responses to Alleged Serious Events.” The report assesses the responses of CMS, state survey and certification agencies, and hospitals to complaints alleging serious adverse events. The OIG concludes that Medicare’s hospital oversight system missed opportunities to address patient safety in response to alleged serious adverse … Continue Reading