Each month, we are pleased to share the most recent additions to the HHS Office of Inspector General (OIG) Work Plan items. Starting in June 2017 – OIG has been updating their Work Plan monthly with any new changes to the active list. Let’s take a look at the new updates from this month.  

What is the OIG Work Plan?

The HHS OIG Work Plan sets forth various projects that OIG plans to undertake during the fiscal year (FY) and beyond.

Projects listed in the Work Plan span HHS’s operating divisions, including the following: 

  • Centers for Medicare & Medicaid Services (CMS)
  • Public health agencies such as the Centers for Disease Control and Prevention (CDC)
  • National Institutes of Health (NIH)
  • Administration for Children and Families (ACF)
  • Administration for Community Living (ACL)
  • Various state and local governments – evaluating the use of federal funds as well as the administration of HHS

*Some of the projects described in the Work Plan are statutorily required.

The November agenda includes 16 new items from HHS Office of Inspector General (OIG). Let’s walk through this latest release so you can address it within your compliance program, if applicable. 

  1. Medicaid Concurrent Eligibility

  2. Additional Programming Code for Toolkit: Using Data Analysis To Calculate Opioid Levels and Identify Patients at Risk of Misuse or Overdose

  3. Audit of HHS Information Technology Recovery Readiness

  4. Medicare Advantage Organizations’ Collection of Ordering Provider Identifiers

  5. Fiscal Year 2020 OIG Oversight of Medicaid Fraud Control Units

  6. Medicaid Fraud Control Units Fiscal Year 2020 Annual Report

  7. Medicare Advantage Risk-Adjustment Data – Targeted Review of Documentation Supporting Specific Diagnosis Codes


Medicaid Concurrent Eligibility

Managed Care Organizations (MCOs) contract with state Medicaid agencies to provide services for enrolled beneficiaries, and are paid on a per-beneficiary per-month basis. If the costs of care provided exceed monthly payments from state Medicaid agencies, MCOs are exposed to financial risk. 

If a Medicaid beneficiary changes their residency to a new state, they cannot maintain concurrent Medicaid eligibility in another state, and MCOs would not receive payment for each beneficiary from the previous state. HHS OIG will be reviewing if states made capitation payments on behalf of beneficiaries who established residency in another state.


Additional Programming Code for Toolkit: Using Data Analysis To Calculate Opioid Levels and Identify Patients at Risk of Misuse or Overdose

Last year, HHS OIG released a valuable resource in addressing the opioid crisis. The toolkit assists users in analyzing large amounts of prescription drug data to identify patients who are at risk of opioid misuse or overdose

HHS OIG will issue the programming code in two commonly used coding languages, R and SQL, for our public and private partners to use to further combat the opioid crisis.


Audit of HHS Information Technology Recovery Readiness

The reach of the U.S. Health and Human Services is vast and accounts for the health and welfare of 1 in 4 Americans. The responsibility associated with this large of a scope of work requires elaborate utilization of information technology. 

HHS must have effective contingency plans in place to ensure that it continues to meet its mission in the event of a disaster or major disruption. OIG will be evaluating how effective backup plans are for HHS information technology systems.


Medicare Advantage Organizations’ Collection of Ordering Provider Identifiers

In 2012, HHS OIG conducted a study to help determine the extent to which Medicare Advantage organizations identified potential fraud and abuse. According to the report, the Centers for Medicare and Medicaid Services (CMS) requires MA organizations to have compliance plans that include measures to detect, correct, and prevent fraud, waste, and abuse (FWA). However, CMS does not require MA organizations to report the results of their efforts to identify and address potential fraud and abuse incidents. 

One element of identifying and addressing the potential for fraud, waste, and abuse is having available NPIs for ordering providers. CMS does not require MA organizations (MAOs) to submit National Provider Identifiers (NPIs) for ordering providers.

In past work, OIG found that nearly two-thirds of records for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS), clinical laboratory, imaging, and home health services reviewed did not include the NPI for the ordering provider. 

OIG recommends that the Center for Medicare and Medicaid Services (CMS) require Medicare Advantage Organizations to submit ordering provider identifiers. In this new study, HHS OIG will be evaluating the following factors: 

  • Amount of MAOs who obtain the NPIs of providers who order DMEPOS, clinical laboratory services, imaging services, and home health services for MA enrollees
  • How MAOs that do not obtain ordering provider NPIs are conducting routine monitoring, auditing, and oversight 
  • Amount of MAOs who voluntarily submit NPIs of providers who order DMEPOS, clinical laboratory services, imaging services, and home health services to CMS

Fiscal Year 2020 OIG Oversight of Medicaid Fraud Control Units and Annual Report

Medicaid Fraud Control Units (MFCUs) investigate and prosecute Medicaid provider fraud as well as patient abuse or neglect in healthcare facilities. OIG manages oversight of each MFCU by annual recertification, assessing each MFCU’s performance and compliance with Federal requirements, and administering a Federal grant award to fund a portion of each MFCU’s operational costs. 

HHS OIG will be performing on-site MFCU reviews, provide technical assistance and training, and identify effective practices in MFCU management and operations. HHS OIG will release the MFCU Fiscal Year 2020 Annual Report, which will analyze the statistical information that was reported by the MFCUs, describing in the aggregate the outcomes of MFCU criminal and civil cases. This report will also identify trends in MFCU case results.

Find the full list of Recently Added Items on OIG’s site. Take a look at our recaps of all the archived releases by visiting the ProviderTrust Work Plan page.


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ProviderTrust Mike Rosen Cofounder

Written by Michael Rosen, Esq.

ProviderTrust Co-Founder, mrosen@providertrust.com

Michael brings over 20 years of experience founding and leading risk mitigation businesses, receiving numerous accolades such as Inc. Magazine’s Inc. 500 Award and Nashville Chamber of Commerce Small Business of the Year.

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