OIG Work Plan Updates for April 2022: MOUD, EVV, and HIV

April 2022 has brought more items to the OIG Work Plan. Let’s take a closer look at them.

Medicaid Rehabilitation Services Made by Community Residence Providers

Over a decade ago, the OIG performed audits of select states’ Medicaid coverage of rehabilitation services provided to recipients residing in community residences such as group homes and apartments. Examples of rehabilitative services include training in and assistance with daily living skills, medication management, socialization, substance abuse services, and parenting training.

Two of the states audited were New York and Maryland. In New York, for example, the OIG concluded that over $207 million was improperly claimed in Federal Medicaid reimbursement. According to the OIG, the deficiencies occurred because most of the physicians were not familiar with applicable state regulations and program requirements and certain community residence rehabilitation providers did not comply with state regulations. The OIG recommended refunding the $207 million and that the state implement guidance to physicians regarding state regulations on the authorization of community residential rehabilitation services.

Fast forward to April 2022, and the OIG is now adding to its Work Plan a follow-up review of these older audits.

Through this newly proposed work, the OIG will determine whether states claimed Federal Medicaid reimbursement for rehabilitation services provided by community residence providers following Federal and state requirements. In addition, they will evaluate whether previously audited States have made improvements to their Medicaid community residence rehabilitation programs based on the prior recommendations. Even though this is an audit of states’ reimbursement from the Federal Government, rest assured that if states improperly received Federal reimbursement, it is likely the states will be asking providers to return improperly obtained funds.

Electronic Visit Verification System for Medicaid In-Home Services

The 21st Century Cures Act requires states to implement Electronic Visit Verification (EVV) for all Medicaid personal care services (PCS) and home health services (HHCS) that require an in-home visit by a provider. Many resources have been published about this requirement, including an FAQ posted by CMS.

The OIG believes once these requirements are implemented, “EVV could increase the risk that Medicaid beneficiaries’ needs are not being met, potentially compromising their health and safety.”

This OIG work plan item is designed so the OIG can determine whether the State has implemented an EVV system in compliance with Federal and State requirements and determine if the State has created policies and procedures when using EVV to ensure that Medicaid beneficiaries receive their required in-home services.

As Medicaid is a state-run program, each state may be communicating about EVV a little differently. It’s essential to be aware of your state’s requirements and implementation of an EVV system.

For example, Wisconsin publishes updates on its website.

New York also has a website.

Check your state’s Medicaid or department of health website for similar information.

Use of Medications for Opioid Use Disorder (MOUD) in Medicaid

Deaths from opioid overdoses surged to unprecedented levels during the COVID-19 pandemic. According to the OIG, as of April 2021, 75,000 people died from opioid overdoses in the preceding 12 months, a 35-percent increase from the same period the previous year. In addition, hardly a week goes by when there isn’t some sort of announcement of government enforcement against providers crossing the line regarding opioid prescribing. For example, see this recent announcement about a Texas physician who was convicted for unlawfully prescribing more than one million pills of the opioid hydrocodone.

Healthcare providers can assist with treating those abusing opioids through medications for opioid use disorders or MOUD. The Medicaid program covers almost 40 percent of nonelderly adults with opioid use disorder (OUD), underscoring the critical role that the program can play in providing access to MOUD.

Through this work plan item, the OIG plans to study the extent to which beneficiaries diagnosed with OUD receive MOUD in Medicaid.

Gaps in HIV Care

People with HIV can improve their health and prevent HIV transmissions by receiving recommended HIV care. The Federal government, through the Health Resources & Services Administration (HRSA), publishes and maintains performance measures as it relates to HIV care.

For example, some of the measures include:

    • HIV Viral Suppression
    • Prescription of HIV Antiretroviral Therapy
    • HIV Medical Visit Frequency
    • Gap in HIV Medical Visits
    • PCP Prophylaxis
    • Annual Retention in Care

However, certain groups with HIV, such as African Americans, are less likely to receive regular HIV care compared to other groups. Medicaid is the single largest source of insurance for people living with HIV.

OIG plans to study how Medicaid beneficiaries diagnosed with HIV receive care that aligns with the widely used Federal performance measures, both overall and by selected demographic factors that include race/ethnicity, sex, and location.

The hope in identifying gaps and disparities in care is to help CMS, states, and managed care organizations identify areas for improvement to improve health outcomes and reduce HIV transmission.

Compliance programs should proactively assess risks and mitigate them as appropriate. Reviewing the OIG work plan is one area to consider when assessing risks.


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