5 New OIG Work Plan Items Added in July 2023

The U.S. Department of Health and Human Services Office of Inspector General (OIG) added a large number of new items to its Work Plan in July – more than previous months. Let's take a closer look at some key highlights.

Medicare Advantage

In April 2023, Inspector General (IG) Christi Grimm informed the compliance community that the organization is strengthening its focus on compliance risks associated with Medicare Advantage (MA) plans. The OIG seems to be backing up the IG’s statement by adding three different Work Plan items related to MA.

High-Risk Diagnosis Codes Toolkit

The OIG has been creating toolkits associated with many different compliance areas. They are going to add another toolkit focused on identifying high-risk diagnosis codes. Recall that payments to MA organizations are risk adjusted on the basis of each enrollee's health status. MA organizations are required to submit risk adjustment data to the Centers for Medicare and Medicaid Services (CMS) and miscoded diagnoses may cause CMS to pay MA organizations improper amounts.

For this toolkit, OIG will develop a resource that will provide highly technical information to assist MA organizations with analyzing the accuracy of the risk adjustment data they receive from their providers and submit to CMS. OIG will provide this information as a starting point to allow MA organizations to research enrollees who receive diagnoses that are at high risk of being miscoded and to take appropriate action if needed.

Physician Claims Compared with Inpatient Stays

Beyond arming MA organizations with the toolkit mentioned above, OIG also plans to perform some focused audits and reviews themselves. For example, one review added to their Work Plan will compare diagnosis codes and physician claims with inpatient stays.

For this review, OIG will focus on enrollees who had a diagnosis on a physician or outpatient claim that did not appear on a concurrent inpatient claim. In these instances, the diagnosis codes from the physician or outpatient claim – potentially unconfirmed diagnosis codes that misrepresented the enrollee’s health status – were submitted to CMS and resulted in increased payments to MA organizations.

If these occurrences were reviewed as part of a Risk Adjustment Data Validation (RADV) audit (or during a subsequent RADV appeals process), CMS could potentially review the claims collectively, instead of separately, to ensure the accuracy of the enrollee's health status. OIG wants to identify the increased payments to MA organizations that were based on any unconfirmed and inaccurate diagnoses.

MA Payments and Health Risk Assessments (HRA)

Health risk assessments (HRAs) are conducted by physicians or other health care professionals to collect information about patients' health status, health risks, and daily activities. Past work performed by the OIG identified concerns about the extent to which Medicare Advantage Organizations (MAOs) use HRAs to improve care, as intended, and the sufficiency of oversight by CMS.

OIG’s prior work found that in 2017, diagnoses reported by MAOs based only on HRAs (and no other service records that year) resulted in an estimated $2.6 billion in risk-adjusted payments. OIG's findings raised concerns about the quality and coordination of care for enrollees, the validity of diagnoses reported on HRAs, and the appropriateness of payments generated by HRAs for 2017.

In this newly added Work Plan item for July 2023, the OIG will create a data snapshot and determine the extent to which diagnoses reported only on HRAs (or added to HRAs by chart reviews) generated estimated risk adjusted payments for 2022.

They also plan to determine whether enrollees with certain demographic characteristics were overrepresented among the enrollees who had diagnoses reported only on HRAs (or added to HRAs by chart reviews) that generated payments. Lastly, the OIG explained they will interview CMS to identify the actions it has taken to address the impact of HRAs on MA payment integrity and quality of care.

Emergency Power Preparedness in Nursing Homes

The OIG referenced some recent severe weather events they believe highlighted the need for and importance of emergency power systems for nursing homes. According to the OIG, nursing homes are required to provide an alternate source of energy (usually a generator) to maintain temperatures to protect residents' health and safety, as well as for food storage, emergency lighting, fire protection, and sewage disposal (if applicable), or to evacuate the residents.

If nursing homes have generators, they must have alternate energy sources installed in a safe location and are required to perform weekly maintenance checks. During the OIG’s onsite inspections of nursing homes as part of their recent life safety and emergency preparedness audits, they found numerous facilities with generators that were more than 30 years old.

With that in mind, the OIG plans to conduct an audit specific to the age of emergency power systems in use by nursing homes and whether those systems can deliver reliable and adequate emergency power, including power to HVAC systems, and whether they have been maintained in accordance with Federal requirements.

Fairness in Kidney Transplant Access

There have been some recent news stories related to equitable access to organ transplants.  In one story posted by WebMD, a young woman learned that the formulas and metrics used to place her in a certain priority on the organ waitlist were flawed, and the article continues to claim areas of bias and unfairness.

A transplant program at a hospital with a Medicare provider agreement must meet Medicare Conditions of Participation (CoPs) in order to receive CMS approval for providing transplant services. CoPs for transplant programs include a requirement that programs use written patient selection criteria to determine a patient's suitability for placement on the waiting list for a transplant and that patient selection criteria ensure the fair and nondiscriminatory distribution of organs.

But CMS stops short of defining patient selection criteria, and inequities in access to organ transplants persist. This new Work Plan item is designed to evaluate how kidney transplant programs' patient selection criteria and related processes may affect the fair and nondiscriminatory distribution of organs. Additionally, the OIG will assess how CMS monitors programs' compliance with, and takes corrective action regarding, its requirement that each program's patient selection criteria ensure the fair and nondiscriminatory distribution of organs.


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