OIG Adds Thirteen New Work Plan Projects in June 2018

The Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently issued thirteen updates to its OIG Active Work Plan (Work Plan). The Work Plan outlines ongoing and planned audits and evaluations for the fiscal year and beyond. In 2017, the OIG began releasing its Work Plan projects on an ongoing basis, as opposed to providing biannual updates. The monthly updates add new items and remove completed tasks from the Work Plan. A monthly update schedule ensures that the Work Plan closely aligns with the OIG’s work planning process.

The OIG assesses relative risks in HHS programs and operations to identify those areas most in need of attention. The OIG considers several factors when creating Work Plan items, including legal mandates, congressional requests, budgetary concerns, potential for positive impact, and others. In addition to working on projects that often lead to audits, reviews, and reports, the OIG also engages in a number of legal and investigative activities that are separately reported.

June 2018 Additions to the OIG Work Plan

1. Specialty Drug Pricing and Reimbursement in Medicaid.
   • States use CMS’s national average drug acquisition cost to set Medicaid pharmacy reimbursement amounts. However, this average does not include the cost of drugs sold at specialty pharmacies. The OIG Office of Evaluation and Inspections will determine how state Medicaid agencies define specialty drugs, how much states paid for specialty drugs, how states determine payment methodologies for specialty drugs, and the differences in reimbursement amounts for these drugs among the states.

2. Prescription Opioid Drug Abuse and Misuse Prevention- Prescription Drug Monitoring Programs
   • The Substance Abuse and Mental Health Services Administration (SAMHSA) seeks to identify actions state agencies have taken using federal funds for enhancing prescription drug monitoring programs (PDMPs) to achieve program goals. Those goals include improving safe prescribing practices and preventing prescription drug abuse and misuse. SAMHSA will also determine whether state agencies complied with federal requirements. The audit includes states that have a high number of overdose deaths, a significant increase in the rate of drug overdose deaths, or states that received HHS funding to enhance their PDMPs.

3. Medicare Payments Made Outside of the Hospice Benefit
   • A hospice beneficiary waives all rights to Medicare payments for any services that are related to the treatment of the terminal condition for which hospice care was elected. The hospice agency assumes responsibility for medical care related to the beneficiary’s terminal illness and related conditions. Medicare continues to pay for covered medical services that are not related to the terminal illness. The Office of Audit Services will produce summary data on all Medicare payments made outside the hospice benefit for beneficiaries under hospice care. This will be analyzed without determining the appropriateness of such payments. Separate reviews of selected individual categories of service will also be conducted.

4. Denials and Appeals in Medicare Part C
   • CMS uses a capitated payment model to pay private insurers that provide health care services under Medicare Part C. Capitated payment models are on a payment-per-person rather than a payment-per-service basis. Beneficiaries and providers can appeal denied services and payments to multiple levels of review within the administrative appeals process. The Office of Evaluation and Inspections will determine the extent to which denials that have been appealed to each level of review were overturned.

5. Accountable Care Organizations’ Strategies Aimed at Reducing Spending and Improving Quality
   • The Office of Evaluation and Inspections will identify accountable care organizations’ (ACOs) strategies aimed at reducing spending and improving quality. Specifically, the agency will describe ACOs’ strategies intended to reduce spending and improve care in different service areas, such as hospitals and nursing homes. ACOs were introduced into the Medicare Program by the Medicare Shared Savings Program. This was done to promote accountability of hospitals, physicians, and other providers, coordinate items and services, encourage investment in infrastructure, and redesign care processes for high-quality and efficient service delivery.

6. State and Territory Response and Recovery Activities for the 2017 Hurricanes
   • The Office of Audit Services will conduct reviews of selected state and one territory’s hurricane preparedness and response activities. The agency seeks to determine if the states and territory have the necessary resources to ensure the safety of HHS beneficiaries affected by Hurricanes Harvey, Irma, and Maria. The review will determine the extent to which emergency preparedness plans included necessary activities to enhance ongoing response and recovery operations and strengthen public health and medical response capabilities. It will also assess the effectiveness of state and territory implementation of emergency preparedness response and recovery activities related to the 2017 Hurricanes.

7. Medicare Part B Payments for End-Stage Renal Disease Dialysis Services
   • The Office of Audit Services will review claims for Medicare Part B dialysis services provided to beneficiaries with end-stage renal disease (ESRD) to determine whether such services complied with Medicare requirements. Medicare Part B covers outpatient dialysis services for beneficiaries diagnosed with ESRD. Prior OIG work identified inappropriate Medicare payments for ESRD services. Specifically, OIG identified unallowable Medicare payments for treatments not furnished or documented, services for which there was insufficient documentation to support medical necessity, and services that were not ordered by a physician or ordered by a physician that was not treating the patient.

8. National Background Check Program: Assessment of Concluded State Grant Programs in 2017
   • The Patient Protection and Affordable Care Act (ACA) requires the OIG to evaluate grants provided to states to implement background check programs for prospective employees and providers of long-term-care services. The Office of Evaluation and Inspections will review the procedures that states implemented for long-term care facilities and providers to conduct background checks on prospective employees who would have direct access to patients. The agency seeks to determine the outcomes of the states’ programs and whether the checks led to any unintended consequences.

9. Inappropriate Denial of Services and Payment in Medicare Advantage
   • The Office of Evaluation and Inspections will conduct medical record reviews to determine the extent to which beneficiaries and providers were denied preauthorization or payment for medically necessary services covered by Medicare. Capitated payment models are based on payment per person rather than payment per service provided. A central concern about the capitated payment model used in Medicare Advantage is the incentive to inappropriately deny access to, or reimbursement for, health care services in an attempt to increase profits for managed care plans. CMS seeks to determine the reasons for any inappropriate denials and the types of services involved, to the extent possible.

10. Review of Home Health Claims for Services With 5 to 10 Skilled Visits
    • Low Utilization Payment Adjustments (LUPA) occur when a home health agency (HHA) provides four or fewer visits from a skilled service provider that are included under home health coverage in an episode. The HHA is then paid a standardized per-visit payment based on the visit type. The Office of Audit Services will determine whether home health claims with 5 to 10 skilled visits in a payment episode in which the beneficiary was discharged met coverage conditions and were adequately supported.

11. Denials and Appeals in Medicare Part D
    • The Office of Evaluation and Inspections will examine national trends and CMS’s oversight of prescription drug denials in Part D during 2014-2016. CMS uses a capitated payment model to pay private insurers that provide and administer Medicare Part D benefits. Capitated payment models are on a payment-per-person rather than a payment-per-service basis. This can create an incentive to deny access to services or payment in order to increase an insurer’s profits. CMS is seeking to determine the extent to which denials that have been appealed to each level of review were overturned. The Office of Evaluation and Inspections will also examine variations in appeals and overturned denials across Part D contracts and evaluate CMS’s efforts to monitor and address inappropriate denials in Part D.

12. CMS’s Contingency Planning for Information Technology Systems
    • The Office of Audit Services seeks to determine if CMS’s contingency planning for information technology systems meets federal requirements. The review also seeks to ensure the continuity of the essential functions that support the Agency’s mission.

13. ORR and Grantee Facilities’ Steps to Ensure Health and Safety of Unaccompanied Children
    • The Office of Evaluations and Inspections will review the Office of Refugee Resettlement’s (ORR) efforts to ensure the safety and health of children placed at ORR facilities under the Unaccompanied Alien Children (UAC) program. Children in the UAC program are often cared for in facilities operated by grantees that receive funding from ORR. The review will specifically focus on a variety of safety and health-related issues such as employee background screening, employees’ clinical skills and training, identification and response to incidents of harm, and facility security.

The OIG Work Plan is available at:

https://oig.hhs.gov/reports-and-publications/workplan/index.asp.