The U.S. Department of Health and Human Services (“HHS”) Office of Inspector General (“OIG”) just released its “Work Plan” for the 2014 fiscal year. The Work Plan identifies OIG’s new and continuing focus areas for enforcement to protect programs administered by HHS agencies, such as the Centers for Medicare & Medicaid (“CMS”), the National Institutes of Health (“NIH”), and the Food and Drug Administration (“FDA”).

NEW FOCUS AREAS FOR 2014:

As expected, OIG’s primary objectives impact the Medicare and Medicaid programs, and target participating providers, suppliers, and their contractors. The 2014 Work Plan includes reviews to assess the implementation of the Affordable Care Act. Notable Work Plan initiatives include:

Hospitals

  • Analysis of Salaries Included in Hospital Cost Reports. OIG will review data from hospital cost reports to examine whether salaries represent reasonable compensation and are furnished in connection with patient care.
  • Oversight of Hospital Privileges. In emphasizing patient safety, OIG will assess how hospitals grant initial staff privileges to candidates,  including verification of their credentials and a review of the National Practitioner Databank.

Nursing Homes

  • Medicare Part A Billing by Skilled Nursing Facilities. OIG wants to ensure that SNFs do not bill claims in error, resulting in inappropriate Medicare reimbursement. OIG will describe variations in billing among these facilities during selected years.

Drugs & Medical Devices

  • Medicare Costs Associated with Defective Medical Devices. OIG will conduct a review of costs for medical services associated with defective medical devices.
  • FDA—Inspection of Generic Drug Manufacturers. OIG will explain the scope and results of FDA inspections of generic drug manufacturers, including enforcement actions taken in response to discovered deficiencies.
  • Manufacturer Reporting of Average Sales Prices (ASPs) for Part B Drugs. OIG will assess the potential financial impact of requiring all manufacturers of Part B-covered drugs to submit ASPs to CMS. OIG has already recommended a change in legislation to implement this requirement.

Medical Equipment and Supplies

  • Comparing Medicare’s Fee Schedule with Amounts Paid by Other Payers. OIG will compare the fee schedules of Medicare, private insurance companies, and the Department of Veterans Affairs for particular equipment, including commode chairs, folding walkers, and transcutaneous electrical nerve stimulation (TENS) units. If wasteful spending is identified, expect to see new limitations in the Medicare fee schedule.
  • Portable X-Ray Equipment—Supplier Compliance with Transportation and Setup Fee Requirements. OIG will assess whether portable x-ray services were ordered and performed according to Medicare coverage requirements. This includes the transportation and setup of portable x-ray equipment, substantiated by appropriate documentation.

Dialysis and Chiropractic Providers/ Ambulance Suppliers

  • End-Stage Renal Disease—Dialysis Facility Survey Cycle. To ensure that poorly performing facilities are identified, OIG will assess the adequacy of the state-based survey and certification processes for dialysis facilities.
  • Ambulance and Chiropractic Services. Emphasizing its effort to combat fraud, OIG will compile portfolio reports to address vulnerabilities related to ambulance and chiropractic services, identify the extent of inappropriate billing of chiropractic and maintenance therapy services, and recommend ways to improve efficiency and minimize inappropriate payments.

Information Technology Security, Protected Health Information, and Data Security

  • Controls Over Networked Medical Devices at Hospitals. In an effort to protect electronic Protected Health Information, OIG will assess hospitals’ security controls over networked medical devices for compliance with federal law.

Other Provider Issues

  • Idle Medicare Provider Records. CMS can deactivate any Medicare provider who has not submitted any claims for 12 consecutive months. OIG will conduct a review of providers that fall into this category in an effort to combat fraudulent activity.
  • Provider Payment Suspensions during Pending Investigations of Credible Fraud Allegations (Medicaid). OIG will assess state Medicaid agencies’ compliance with provisions governing suspension of payments to providers where a credible allegation of fraud exists.

Affordable Care Act Reviews

With the Affordable Care Act (ACA) now underway, OIG will begin monitoring health insurance marketplaces and expansion of the Medicaid program:

  • Health Insurance Marketplaces
    • OIG   will   examine   payment   accuracy,   eligibility   systems, contracts, and security of data and consumer information.
  • Medicaid Expansion and Other Medicaid Issues
    • Enhanced  Federal  Medicaid  Assistance  Percentage  (FMAP). States are now authorized to use an enhanced FMAP of 100% for individuals newly eligible for benefits due to the expansion of Medicaid. OIG will review state Medicaid claims to assess whether the FMAP was correctly applied.
    • Medicaid Eligibility Determinations in Selected States. Under the ACA, the Medicaid minimum eligibility level was increased to 133% of the federal poverty level. In selected states, OIG will assess the accuracy of Medicaid eligibility determinations.
  • Other Affordable Care Act Requirements and Programs
    • Hospice    in    Assisted    Living    Facilities  OIG    will    gather information related to Medicare beneficiaries staying in assisted living facilities, such as length of stay, level of care received, and common terminal illnesses. This data will help CMS reform the payment system and quality of hospice care pursuant to the ACA.
    • Accuracy of the Physician Compare Web Site. Individuals now have access to the “Physician Compare Web Site” to assist in making informed health care decisions. OIG will review CMS’s maintenance of this web site to ensure accurate and complete information about physicians.