Deeper Than the Headlines: OIG March 2019 Workplan Updates

March 2019 has been a busy month for additions to the OIG’s Work Plan. They’ve added 16 new items. This week, let’s take a look at a few of them.

Potential Duplication of NIH Research Grant Funding

The National Institutes of Health (NIH) has 27 Institutes and Centers that manage research initiatives that include awarding grant funding. The Departments of Defense and Labor, Health and Human Services, and Education Appropriations Act, 2019 and Continuing Appropriations Act, 2019 (Public Law No. 115-245) and its Accompanying Report directed that OIG examine the NIH's oversight of its grantees' compliance with NIH policies, including NIH efforts to ensure the integrity of its grant application and selection processes. OIG plans to review NIH's efforts to ensure the integrity of its grant application and selection process by testing NIH's internal controls for identifying and addressing potentially duplicative grant funding and overlap within its 27 Institutes and Centers. The objective of their review will be to determine whether NIH's internal controls were effective in ensuring that grantees did not receive duplicative NIH grant funding.

Opioid Use in Medicare Part D in States in the Appalachian Region Overdose deaths are at epidemic levels and the opioid crisis is now considered a public health emergency. In 2016, there were more than 42,000 opioid-related overdose deaths in the United States, 115 deaths per day. Nearly 7,000 of these deaths occurred in five States in the Appalachian region-Alabama, Kentucky, Ohio, Tennessee, and West Virginia. Identifying beneficiaries who are at risk of overdose or abuse is key to addressing this national crisis. This data brief will provide data on prescription opioid use in Medicare Part D in these five States in 2017, including the proportion of Medicare beneficiaries who received a prescription opioid and the number of beneficiaries who are at serious risk of opioid misuse or overdose.

Post-Hospital Skilled Nursing Facility Care Provided to Dually Eligible Beneficiaries

Skilled nursing facilities (SNFs) are specially qualified facilities that provide extended care services, such as skilled nursing care, rehabilitation services, and other services to Medicare beneficiaries who meet certain conditions. During previous reviews, OIG noted that some nursing facility residents who were receiving Medicaid-covered nursing home care were admitted to a hospital and returned to the same facility to receive Medicare-covered post-hospital SNF care. In some cases, hospital physicians discharged beneficiaries to "home" rather than "SNF," yet nursing facility physicians certified that skilled care was needed. Because Medicare pays substantially more for SNF care than Medicaid for nursing home care, nursing facilities have financial incentives to increase the level of care to "skilled." OIG plans to determine whether the post-hospital SNF care provided to dually eligible beneficiaries met the level of care requirements. Specifically, they will determine whether:

1. the SNF level of care was certified by a physician (e.g., a hospital or SNF physician) or a physician extender (i.e., a nurse practitioner, clinical nurse specialist, or physician assistant)
2. the condition treated at the SNF was a condition for which the beneficiary received inpatient hospital services or a condition that arose while the beneficiary was receiving care in an SNF for a condition for which the beneficiary received inpatient hospital services
3. daily skilled care was required
4. the services delivered were reasonable and necessary for the treatment of a beneficiary's illness or injury
5. improper Medicare payments were made on the claims OIG reviews. OIG will also determine whether any of the hospital admissions they review were potentially avoidable.

Superfund Financial Activities at the National Institute of Environmental Health Sciences

National Institutes of Health's National Institute of Environmental Health Sciences (NIEHS) provides Superfund Research Program funds for university-based multidisciplinary research on human health and environmental issues related to hazardous substances. Federal law and regulations require that OIG conduct an annual audit of the Institute's Superfund activities (Comprehensive Environmental Response, Compensation, and Liability Act of 1980, 42 U.S.C. § 9611(k)). The OIG will review payments, obligations, reimbursements, and other uses of Superfund money by NIEHS.

These are some of the areas added to the OIG’s WorkPlan in March 2019. If your organization is involved in similar services, it might be wise to perform your own internal audit or review of these same areas.