U.S. Department of Health and Human Services Office of the Inspector General  : WORK PLAN Fiscal Year 2015

????????????????????????????????????????????????????????????????????????The office of the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) was created to protect the integrity of HHS programs and operations and the well-being of beneficiaries by detecting and preventing fraud, waste, and abuse; identifying opportunities to improve program economy, efficiency, and effectiveness; and holding accountable those who do not meet program requirements or who violate Federal health care laws.

OIG staff members serve in the Washington DC headquarters but also deployed throughout the Nation in regional and field offices to conduct audits, evaluations, and investigations; provide guidance to industry. The collaborate with HHS and its operating and staff divisions, the Department of Justice (DOJ) and other executive branch agencies, Congress, and States to bring about systemic changes, successful prosecutions, negotiated settlements, and recovery of funds.

Each year, the OIG prepares and issues a “Work Plan”[1] for the fiscal year that summarizes new and ongoing reviews and activities that OIG plans to pursue with respect to HHS programs and operations during the current fiscal year and beyond.

It is important for providers and suppliers to be aware of the current plan since it is developed to assess relative risks in the programs for which they have oversight authority; identify and set priorities for those areas of concern most in need of attention

So who and what’s on this years “list[2].

Chiropractors:      We will review Medicare Part B payments for chiropractic services to determine whether such payments were claimed in accordance with Medicare requirements.

We will determine and describe the extent of questionable billing for chiropractic services. Previous OIG work has demonstrated a history of vulnerabilities relative to inappropriate payments for chiropractic services, including recent work that identified a chiropractor with a 93-percent claim error rate and inappropriate Medicare payments of about $700,000.

—Portfolio report on Medicare Part B payments: We will compile the results of prior OIG audits, evaluations, and investigations of chiropractic services paid by Medicare to identify trends in payment, compliance, and fraud vulnerabilities and offer recommendations to improve detected vulnerabilities. Prior OIG work identified inappropriate payments for chiropractic services that were medically unnecessary, were not documented in accordance with Medicare requirements, or were fraudulent.

Diagnostic radiologyMedical necessity of high-cost tests:   We will review Medicare payments for high-cost diagnostic radiology tests to determine whether the tests were medically necessary and to determine the extent to which use has increased for these tests.

Selected independent clinical laboratory billing requirements (new) :We will review Medicare payments to independent clinical laboratories to determine laboratories’ compliance with selected billing requirements. We will use the results of these reviews to identify clinical laboratories that routinely submit improper claims and recommend recovery of overpayments.

Ophthalmologists—Inappropriate and questionable billing: We will review Medicare claims data to identify potentially inappropriate and questionable billing for ophthalmology services during 2012. We will also determine the locations and specialties of providers with questionable billing.

Physical therapists—High use of outpatient physical therapy services:  We will review outpatient physical therapy services provided by independent therapists to determine whether they were in compliance with Medicare reimbursement regulations. Prior OIG work found that claims for therapy services provided by independent physical therapists were not reasonable or were not properly documented or that the therapy services were not medically necessary.

Sleep disorder clinicsHigh use of sleep-testing procedures:  We will examine Medicare payments to physicians, hospital outpatient departments, and independent diagnostic testing facilities for sleep-testing procedures to assess the appropriateness of Medicare payments for high-use sleep-testing procedures and determine whether they were in accordance with Medicare requirements.

Adoption of Electronic Health RecordsThe government has been pushing adopting electronic this and that for years.  In an effort to “coax” you into spending the money needed to do this, they dangled the preverbal “carrot” that lead to more widespread adoption of the EMR systems.  As with most things with the carrot was the focus and most providers ignored the strings that it was suspended from, like meeting “meaningful use” in order to “keep” the money they provided.   Judgment day has now arrived.

Medicare incentive payments for adopting electronic health records: We will review Medicare incentive payments to eligible health care professionals and hospitals for adopting EHRs and the Centers for Medicare & Medicaid Services (CMS) safeguards to prevent erroneous incentive payments. We will review Medicare incentive payment data from 2011 to identify payments to providers that should not have received incentive payments (e.g., those not meeting selected meaningful use criteria). We will also assess CMS’s plans to oversee incentive payments for the duration of the program and corrective actions taken regarding erroneous incentive payments.

Medicare Fraud Strike Force Teams and Other Collaboration

The OIG devotes significant resources to investigating Medicare and Medicaid fraud and abuse including the  Health Care Fraud Prevention and Enforcement Action Team (HEAT). These collaborative effort teams were started in 2009 by HHS and DOJ to strengthen programs and invest in new resources and technologies to prevent and combat health care fraud, waste, and abuse. Using this model, Medicare Fraud Strike Force teams coordinate law enforcement operations among Federal, State, and local law enforcement entities and have built a reputation for analyzing data to quickly identify and prosecute fraud.

Strike Force teams were formed in March 2007 and, according to HHS, are now operating in nine major cities. HHS claims “The effectiveness of the Strike Force model is enhanced by inter-agency collaboration within HHS. For example, we refer credible allegations of fraud to the Centers for Medicare & Medicaid Services (CMS) so it can suspend payments as appropriate. During Strike Force operations, OIG and CMS work to impose payment suspensions that immediately prevent losses from claims submitted by Strike Force targets.”

According to DHHS reports[3], In FY 2013, the strike force secured records in the number of cases filed (137), individuals charged (345), guilty pleas secured (234) and jury trial convictions (48). Beyond these remarkable results, the defendants who were charged and sentenced are facing significant time in prison – an average of 52 months in prison for those sentenced in FY 2013, and an average of 47 months in prison for those sentenced since 2007.

In March 2011, CMS began an ambitious project to revalidate all 1.5 million Medicare enrolled providers and suppliers under the Affordable Care Act screening requirements. As of September 2013, more than 535,000 providers were subject to the new screening requirements and over 225,000 lost the ability to bill Medicare due to the Affordable Care Act requirements and other proactive initiatives.  Since the Affordable Care Act, CMS has also revoked 14,663 providers and suppliers’ ability to bill the Medicare program. These providers were removed from the program because they had felony convictions, were not operational at the address CMS had on file, or were not in compliance with CMS rules.

Pretty impressive statistics !  Are you next?   Maybe we should talk.  

Dr. Ron Ramsdell, PhD, FACFEI, DABFE, CFC, LFMAAMA.   (702-838-0054)  


[1] http://oig.hhs.gov/reports-and-publications/archives/budget/files/FY2015_HHSOIG_Congressional_Justification.pdf

[2] https://oig.hhs.gov/reports-and-publications/workplan/#current

[3] http://www.hhs.gov/news/press/2014pres/02/20140226a.html