Crucial Insights into the OIG’s February 2023 Work Plan Updates

While February 2023 saw a small number of new items added to the U.S. Department of Health and Human Services Office of Inspector General’s (OIG) work plan, the added items are important for compliance professionals.

Medicare Enrollment Data

In the summer of 2022, the OIG published a data brief about the inaccuracies in Medicare's race and ethnicity data. According to the OIG, these inaccuracies hinder the ability to assess health disparities among Medicare beneficiaries.

With a total of 66 million beneficiaries enrolled in Medicare, disparities based on race or ethnicity can affect a large amount of people. Last summer’s data brief explained that inaccuracies and other limitations were particularly true for those identified as American Indian/Alaska Native, Asian/Pacific Islander, or Hispanic. The OIG concluded the data inaccuracies stem from deficiencies in the source data and recommended that Medicare develop its own source of race and ethnicity data.

The OIG added a work plan item in February 2023 that describes their intention to create a resource guide bridging data and practice relating to race and ethnicity data. The resource guide is intended to “provide detailed information about the data analyzed in the recent data brief, including the origins of race and ethnicity variables in the enrollment database, the accuracy of the variables when compared to self-reported race and ethnicity data, and considerations for alternative data sources for race and ethnicity analysis.”

Nursing Homes’ Use of Antipsychotic Medications

Nursing homes frequently utilize antipsychotic drugs among residents, but the potential for inappropriate use of these drugs in this population is a real risk.

Historically speaking, antipsychotic drugs were developed to treat schizophrenia, a serious mental disorder generally diagnosed in much younger populations. Some of the concerns with commonly using these powerful drugs among nursing homes residents stems from the severe side effects associated with some of these medications. This is particularly true among elderly individuals with dementia.

According to the OIG, the Food and Drug Administration issued a boxed warning in 2008 against the use of all antipsychotic drugs among elderly individuals with dementia because of the increased risk of death. Over the years, the OIG has raised concerns about the high use of antipsychotic drugs among nursing home residents.

In an attempt to discourage the use of these drugs in inappropriate circumstances, the Centers for Medicare and Medicaid Services (CMS) developed quality measures related to the use of antipsychotic drugs among nursing home residents. These measures are reported publicly.

OIG added a work plan item due to more recent concerns about the potential falsification of schizophrenia diagnoses to make the use of antipsychotic drugs appear appropriate and avoid Federal attention.

The OIG will conduct an in-depth review of survey reports to:

1. Examine the nature of nursing home citations related to the use of antipsychotic drugs, and
2. Identify vulnerabilities that contribute to the inappropriate use of these drugs.

Payments to Providers

In November 2022, the U.S. Department of Justice (DOJ) announced charges against individuals who diverted payments from Medicare or Medicaid that were meant for hospitals. Instead, those payments were sent to individuals who allegedly siphoned these funds for their own use.

Most people and businesses, including healthcare providers like hospitals, receive payment for their jobs or services through electronic funds transfers (EFT). Very few entities receive paper checks any longer.

By way of example, it’s been alleged the defendants sent fraudulent emails from accounts resembling those associated with actual hospitals to public and private health insurance programs requesting that future reimbursements be sent to new bank accounts that did not belong to the hospitals. The defendants allegedly diverted $4.7 million that was supposed to be payment from Medicare and Medicaid to hospitals.

The DOJ reported that “five state Medicaid programs, two Medicare Administrative Contractors, and two private health insurers allegedly were deceived into making payments to the defendants and their co-conspirators instead of depositing the reimbursement payments into bank accounts belonging to the hospitals.”

Given this, and similar schemes which the OIG has learned about since 2020, the OIG plans to collect information from states and Medicare Administrative Contractors about vulnerabilities that might exist regarding EFTs. They hope to provide possible solutions to strengthen prevention of EFT fraudulent activities. Lastly, OIG states they will “collect information about any actions taken by CMS to address EFT fraud and assess the feasibility of CMS systems playing a role in fraud prevention efforts.”

Conclusion

It is interesting to learn about the various ways health care organizations are subject to risks from different directions. In this summary, the OIG is concerned with inaccurate data, antipsychotic drugs, and electronic bank transfers. If your organization has any exposure in these areas, your compliance department can likely be part of the solution.

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