The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) 2016 Work Plan comes with a warning: the OIG continues to be relentless in detecting and pursuing waste, fraud, and abuse. 

In the 75-page plan, posted to the OIG’s website on Monday, the agency reported that in the most recent fiscal year it had recoveries of more than $3 billion. The OIG indicated that it also had excluded 4,112 individuals and entities from participating in HHS programs during that time. Moreover, the OIG noted that it had brought 925 criminal actions against individuals or entities that engaged in crimes against HHS programs, as well as 682 civil actions, which the OIG includes as false claims and “unjust-enrichment lawsuits filed in federal district court, CMP settlements, and administrative recoveries related to provider self-disclosure matters.”

Officials further said that the agency anticipates expanding its focus on “delivery system reform and the effectiveness of alternate payment models, coordinated care programs, and value-based purchasing.”

Other new work that the OIG plans to pursue in 2016 includes what it describes as “a holistic examination of HHS efforts to reduce opioid abuse, adherence to safety standards in Administration for Children and Families’ Unaccompanied Children Program, and evaluation of CMS’s Fraud Prevention System.” 

Officials also noted that most of the OIG’s work involves investigating Medicare and Medicaid issues, including billing for services not rendered, medically unnecessary or misrepresented services, patient harm, off-label marketing of prescription drugs, and the solicitation and receipt of kickbacks, including illegal payments to patients for involvement in fraud schemes and illegal referral arrangements between physicians and medical companies.

The OIG also described as a “groundbreaking partnership” its private and public sector information and data-sharing alliance, which was formed in the pursuit of detecting and combating waste, fraud, and abuse. The partnership is known as the Healthcare Fraud Prevention Partnership (HFPP). 

Several of the 40 new inquiries described in the OIG Work Plan include the following:

Medicare Parts A and B Payments

The OIG indicated that it would review Medicare payments to acute-care hospitals to determine whether certain outpatient claims billed to Medicare Part B for services provided during inpatient stays were allowable and conducted in accordance with the Inpatient Prospective Payment System (IPPS), noting that supplies and services furnished to inpatients are covered under Part A and should not be billed separately to Part B.

Medical Device Payments

Officials said they would determine whether Medicare payments for replaced medical devices were made in accordance with Medicare requirements. Federal regulations require reductions in Medicare payments for the replacement of implanted devices.

CMS Validation of Quality Data Reporting

Quality data for the hospital value-based purchasing program and the hospital acquired condition reduction program that has been validated by CMS will be reviewed by the OIG, which will undertake a study that will describe the actions that CMS has taken as a result of its validation.

Skilled Nursing Facility Prospective Payment System

The OIG will review compliance with various aspects of the skilled nursing facility (SNF) prospective payment system, including the documentation requirement in support of the claims paid by Medicare. Officials said that they had found that SNFs had “increasingly billed for the highest level of therapy even though key beneficiary characteristics remained largely the same.”

Ambulatory Surgical Centers

Having found problems with Medicare’s quality oversight of Ambulatory Surgical Centers, the OIG noted that it would review Medicare’s quality oversight of ASCs.

Medicare Payments for Undocumented U.S. Residents Officials also said they would review procedures established by CMS to prevent and recoup Medicare payments for items and services furnished to undocumented beneficiaries living in the United States. The OIG indicated that prior reviews identified $91.6 million in improper payments made to providers for services rendered to such beneficiaries.

Looking to the Future

During 2016 and beyond, OIG officials said the agency would continue oversight of hospice care, including oversight of certification surveys and hospice worker licensure requirements. SNF compliance with patient admission requirements also will be reviewed.

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