Deeper Than the Headlines: OIG April 2019 Work Plan Items

[Drumroll] It’s that time again! Time to review what the OIG has added to their work plan in the month of April 2019. Let’s take a look at a few of them but don’t forget to review the entire list yourself in case you need to plan for any additional items.

Review of Monthly ESRD-Related Visits Billed by Physicians or Other Qualified Healthcare Professionals

Most physicians and other practitioners (e.g., clinical nurse specialists, nurse practitioners or physician's assistants) who manage the care of patients who receive outpatient dialysis services at end-stage renal disease (ESRD) facilities are paid a monthly capitation payment (MCP) for ESRD-related physician services. The MCP amount is based on the number of visits provided within each month and the age of the ESRD beneficiary. The physician or other practitioners can bill only one of three current procedural terminology (CPT) codes for ESRD-related visits of one per month, two to three per month, or four or more per month. The Comprehensive Error Rate Testing program's special study of the HCPCS codes for ESRD-related services found that for some codes, approximately one-third of the payments for ESRD-related services were improper payments due to insufficient documentation, incorrect coding, or no documentation submitted. OIG will review whether physicians or other qualified healthcare professionals billed monthly ESRD-related visits in accordance with Federal requirements.

Medicaid Personal Care Services

Personal care services (PCS) is a Medicaid benefit for the elderly, people with disabilities, and people with chronic or temporary conditions. It assists them with activities of daily living and helps them remain in their homes and communities. Examples of PCS include bathing, dressing, light housework, money management, meal preparation, and transportation. Prior OIG reviews identified significant problems with States' compliance with PCS requirements. Some reviews also showed that program safeguards intended to ensure medical necessity, patient safety, and quality, and prevent improper payments were often ineffective. OIG will determine whether improvements have been made to the oversight and monitoring of PCS and whether those improvements have reduced the number of PCS claims not in compliance with Federal and State requirements.

Access Increases in Mental Health and Substance Abuse Services Funding for Health Centers

As part of HHS's efforts to fight the national opioid epidemic, the Health Resources and Services Administration (HRSA) awarded $200 million in Access Increases in Mental Health and Substance Abuse Services (AIMS) supplemental funding to 1,178 health centers nationwide. Health centers use AIMS funding to expand access to critical mental health services and substance abuse services focusing on the treatment, prevention, and awareness of opioid abuse. The AIMS funding was awarded to health centers in September 2017. AIMS funding can be used to increase mental health and substance abuse services personnel, leverage health information technology, and provide additional training. OIG will determine whether health centers used their AIMS funding in accordance with Federal requirements and grant terms.

Sufficiency and Implementation of Indian Health Service Patient Abuse Policies

Details surrounding the recent conviction of a former Indian Health Service (IHS) physician for patient abuse raised concerns about IHS policies and procedures to prevent and address patient abuse. IHS partners with 573 federally recognized tribes to provide healthcare services to its 2.3 million American Indian and Alaska Native beneficiaries and IHS directly operates 25 acute-care hospitals in 7 areas. IHS has recently adopted new policies regarding this issue, including revising procedures in the Indian Health Manual, which governs IHS hospital practices. This study will evaluate the sufficiency and implementation of these policies. OIG will review and evaluate IHS policies and procedures related to patient abuse, including Drawing a comparison to policies developed by nationally recognized medical professional organizations. OIG will also conduct interviews with IHS officials and staff, and other stakeholders such as State and Federal law enforcement.

Medicaid Managed Care Organization Denials

The State Medicaid agency and the Federal Government are responsible for Financial risk for the costs of Medicaid services. Managed care organizations (MCOs) contract with State Medicaid agencies to ensure that beneficiaries receive covered Medicaid services. The contractual arrangement shifts financial risk for the costs of Medicaid services from the State Medicaid agency and the Federal Government to the MCO, which can create an incentive to deny beneficiaries' access to covered services. Our review will determine whether Medicaid MCOs complied with Federal requirements when denying access to requested medical and dental services and drug prescriptions that required prior authorization.

If your organization is involved in the kinds of products or services mentioned in these newly added OIG Work Plan items, you may want to consider performing pro-active reviews of these areas.