January Work Plan Updates from the Office of Inspector General

The new year brings fresh updates to the Office of Inspector General’s (OIG) Work Plan, including renewed interest in ongoing items. Here are four key insights for compliance professionals from the OIG's most recent Work Plan update.

Telehealth Compliance Risks

A few months ago, the OIG released a data brief report about Medicare telehealth services during the first year of the pandemic. Some telehealth requirements were loosened during the pandemic, but we knew even then that the audits would shortly follow because not all requirements were completely wiped away.

During that first year of the pandemic, telehealth services increased significantly, and approximately two out of five Medicare beneficiaries used telehealth services. In the data brief, OIG identified about 1,700 providers (out of 742,000) that they felt posed a high risk to the Medicare program relating to telehealth services.

The OIG used seven measures to indicate potential fraud, waste, or abuse of telehealth services. If a provider had at least one of the seven measures, they were considered higher risk and included in the list of 1,700. The measures developed by the OIG include:

• Billing both a telehealth service and a facility fee for most visits
• Billing telehealth services at the highest, most expensive level every time
• Billing telehealth services for a high number of days in a year
• Billing both Medicare fee-for-service and a Medicare Advantage plan for the same service for a high proportion of services
• Billing a high average number of hours of telehealth services per visit
• Billing telehealth services for a high number of beneficiaries
• Billing for a telehealth service and ordering medical equipment for a high proportion of beneficiaries

With this in mind, the OIG added a Work Plan item in January 2023 that will create an OIG Toolkit to analyze telehealth claims and assess the risks these services pose to the Medicare program. The toolkit intends to provide information for the public and private sectors when analyzing claims data for telehealth services. The toolkit's expected delivery date is sometime in 2023.

Opioid Use Disorder

The pandemic did not slow down the previously existing opioid epidemic. According to the OIG, as of April 2021, there had been 100,000 drug overdoses in the preceding 12-month period, representing a 28% increase compared to the same period for the prior year.

Many who have opioid use disorder (OUD) can be treated with certain medications and Medicare and Medicaid coverage for these kinds of medications has recently expanded. However, only 16% of Medicare patients with OUD and only 44% of Medicaid patients with OUD received any treatment with such medications.

With this Work Plan item, the OIG plans to study the percentage of providers treating Medicare or Medicaid beneficiaries with medications for OUD. They also hope to identify which geographic areas are struggling the most in gaining access to medications for those enrolled in Medicare and Medicaid.

Nurses Homes and the Special Focus Facility Program

Nursing home residents are generally considered a vulnerable population, and as a result, all nursing homes are typically reviewed and/or inspected annually. However, the Centers for Medicare & Medicaid Services (CMS) has a program called the Special Focus Facility (SFF) program, which identifies nursing homes with the most severe deficiencies. Approximately 0.5% of all nursing homes in the country participate in the SFF program.

The program requires increased scrutiny, including inspections that are roughly twice as often as all other nursing homes  ̶  no less than once every six months. The nursing homes in the program also face increasingly severe enforcement actions if improvement is not demonstrated. Facilities must pass two consecutive inspections to complete the program. In October 2022, the SFF announced a reduction in the amount of time a nursing home spends as an SFF and an increase in the number of nursing homes that go through the program.

Given this background, the OIG has added this item to its Work Plan to study the implementation of the SFF program with CMS and state survey agencies, including the October changes. They also hope the study will identify factors that have aided graduated SFF nursing homes with sustaining quality improvements and assess how CMS and states incorporate these factors into the SFF program.

Nursing Home Staffing Standards

Nursing homes have many requirements, including quality standards, infection control, and many, many others. One important standard relates to staffing. For example, nursing homes are required to have a registered nurse on duty for a minimum of eight hours per day. Recently, CMS began sharing payroll-based staffing data with the state surveyors to help investigate specific instances of noncompliance with hourly staffing requirements.

The OIG plans to assess how data sharing works in these initial stages. OIG will also review the CMS plan for monitoring the strategy's success and explore state surveyors' experiences using the data in their surveys.

Conclusion

Compliance professionals should be conscientious in their approaches to the issues that apply to their organizations. They should also keep an eye out for the anticipated reports the OIG will publish as a result of these Work Plan items. Reading the details of the reports can aid compliance professionals with the knowledge they need to assess similar risks in their organizations.

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