April OIG Work Plan Focuses on Oversight of State, Federal Funding

Each month, the U.S. Department of Health and Human Services (HHS) Office of the Inspector General (OIG) releases updates to its Work Plan, which outline the various projects it intends to focus on in the coming months.

The April Work Plan addressed a number of items that should be of interest to a variety of those working in the healthcare industry.

Opioid Funding Oversight

In response to the Opioid crisis, in September 2017, the Health Resources and Services Administration (HRSA) awarded $200 million in Access Increases in Mental Health and Substance Abuse Services (AIMS) supplemental funding to 1,178 health centers and 13 rural health organizations nation-wide. The funding covered January through June 2018. The money was to be used to increase mental health and substance abuse services personnel, leverage health information technology, and provide additional training. HHS says it will now review the use of that funding to determine whether it was used in accordance with federal requirements and the terms of the grant.

Medicaid Data Oversight

In an effort to ensure the integrity of the Medicaid system, states are required to submit Transformed Medicaid Statistical Information System (T-MSIS) data. The utilization and claims data is designed to provide the Centers for Medicare & Medicaid (CMS) with the information it needs to properly oversee the Medicaid program. It also can be used to help set managed care payment rates, identify inappropriate billing patterns and ensure access to services.

OIG noted that it has consistently identified deficiencies in the quality of managed care encounter data, including inaccurate and missing information, which can render the data of limited use. As part of its Work Plan, OIG said it will determine whether the data for selected (three to five) states contains the required elements and includes the quality data needed to more effectively oversee the Medicaid program. OIG also will determine what steps these states have taken to ensure that all required data elements are submitted to T-MSIS and identify any factors that contributed to data quality issues.

MCO Oversight

By contracting with various types of managed care organizations to deliver Medicaid program healthcare services to beneficiaries, states can reduce Medicaid program costs and better manage the use of health services. However, because this contractual arrangement shifts financial risk from state agencies and the federal government, it can create an incentive for MCOs to deny patients access to covered services. OIG said it will review whether Medicaid MCOs have complied with federal requirements when denying access to requested medical and dental services and prescription drugs that require prior authorization.

Personal Care Services Monitoring

OIG also says it will determine whether improvements have been made to the oversight and monitoring of personal care services (PSC) benefits through the Medicaid program and whether those improvements have reduced the number of PCS claims that are not in compliance with federal and state requirements. PSC benefits are used to assist the elderly, people with disabilities and those with chronic or temporary conditions with daily living, thus allowing them to remain in their home. Previously, the OIG has found significant problems with states’ compliance with PSC requirements and in some cases those safeguards intended to ensure medical necessity, patient safety and quality and to prevent improper payment were not working.

End-stage Renal Disease Payment Oversight

Practitioners who manage the care of patients who receive outpatient dialysis services for patients with end-stage renal disease are paid a monthly capitation fee. That payment is based on the number of visits provided each month and on the age of the beneficiary. Providers can only bill using one of three procedural terminology (CPT) codes. CMS calculates the Medicare Fee-for-Service improper payment rate through the Comprehensive Error Rate Testing (CERT) program. The fiscal year 2018 Medicare FFS program improper payment rate was 8.12 percent, representing $31.62 billion in improper payments. These improper payments were due to insufficient documentation, incorrect coding, or no documentation submitted. The OIG said it will review whether physicians or other qualified healthcare professionals billed monthly ESRD-related visits in accordance with federal requirements.

The OIG Work Plan is revised and updated monthly. Healthcare providers should review these monthly updates and use them to update policies and procedures. If you have any questions or concerns, the Health Law Offices of Anthony C. Vitale can assist. Contact us for additional information at 305-358-4500, or send us an email to info@vitalehealthlaw.com and let’s discuss how we might be able to help.