The OIG released the 2015 Work Plan on its site. We have read through it and can summarize the new initiatives that the OIG will focus on with regard to exclusion and fraud and abuse enforcement, by industry sector:

2015 Work Plan Summary by Health Care Vertical

In particular, there are a few items that relate to studies and focus on eligibility and screening that this blog will address in more detail.

1. State Terminations of providers terminated by Medicare or by other States:

This is actually similar to a study that the Office of Inspector General planned for in its 2014 Work Plan. In the 2015 OIG Work Plan study, the OIG will review States’ compliance with a new requirement that the State terminate their Medicaid program providers that have been terminated under Medicare or by another State Medicaid program.

The OIG will determine whether such providers are terminated by all State Medicaid programs in which they are enrolled, assess the status of the supporting information-sharing system, determine how CMS is ensuring that States share complete and accurate information, and identify obstacles States face in complying with the termination requirement.

The new requirement became effective January 1, 2011, Social Security Act, e 1902(a)(39), as amended by the ACA Section 6501. (OEI 06-12-0030). This Report is expected to be issued in FY 2015

2. State and CMS collection and verification of provider ownership information:

The OIG will determine the extent to which States and CMS collect and verify required ownership information for provider entities enrolled in Medicare and Medicaid. The OIG will also review States’ and CMS’s practices for collecting and verifying provider ownership information and determine whether State and CMS had comparable provider ownership information for providers enrolled in Medicaid and/or Medicare.

Federal regulations require Medicaid and Medicare providers to disclose ownership information, such as the name, address, and date of birth of each person with an ownership or controlling intterest in the provider entity.  42 CFR Section 455.104. (OEI 04-11-00590, 04-11-00591, 04-11-00592). Expected issue date is FYI 2015.

3. Provider Payment suspensions during pending investigations of credible fraud allegations:

The OIG will review payments to providers with allegations of fraud deemed credible by States. The OIG will also review States’ processes for suspending payments if Medicaid is not available for items or services furnished by an individual or entity when the State has failed to suspend payments during a period when there is a credible allegation of fraud.

Upon determinations that allegations of fraud are credible, States must suspend all Medicaid payments to the providers, unless the States have good cause to not suspend payments or to suspend payment only in part. States are required to make fraud referrals to Medicaid Fraud Control Units or to appropriate law enforcement agencies in States without certified Medicaid Fraud Control Unit. The OIG will determine whether select Medicaid State agencies are in compliance with these provisions. (OEI 09-14-00020).  Expected issue date FY 2015.

4. Home Health Companies: Employment of individuals with criminal convictions:

The OIG will determine the extend to which HHA’s employed individuals with criminal convictions and examine the criminal convictions of selected employees with potentially disqualifying convictions. Federal law requires that HHA’s comply with all applicable State and local laws and regulations.

Nearly all states have laws prohibiting certain health-care related entities from employing individuals with certain types of criminal convictions. (OEI 07-14-00130). Expected issue date FY 2015.

Finally, the OIG continues to exclude individuals and entities. OIG exclusions are generally based upon referrals from Federal and state agencies.  In fiscal year 2014, the OIG excluded 4017 individuals and entities from participation in Federal health care programs. This is an increase of 70%+ over 2013.  

You may also like:
Key Takeaways From the OIg’s 2015 Work Plan by National Law Review
Differences in OIG, LEIE, and GSA Exclusion Lists
How to Get Off the OIG Exclusion List

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