OIG Updates

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Recent Postings from OIG

September 5, 2017

Medicare Part B Drug Payments: Impact of Price Substitutions Based on 2014 Average Sales Prices

The Social Security Act mandates that OIG compares ASPs with average manufacturer prices (AMPs). If OIG finds that the ASP for a drug exceeds the AMP by a certain percentage (currently 5 percent), the Act directs the Secretary of Health and Human Services to substitute the ASP-based payment amount with a lower calculated rate. Through regulation, CMS outlined that it would make this substitution only if the ASP for a drug exceeds the AMP by 5 percent in the 2 previous quarters or 3 of the previous 4 quarters.

See Report

Calculation of Potential Inflation-Indexed Rebates For Medicare Part B Drugs 2017

In an earlier report, OIG found that a rebate program for Part B drugs could have resulted in at least $2.7 billion in rebates (both basic rebate and inflation-indexed rebate segments) in 2011. OIG conducted this current review after receiving a congressional request asking us to update our earlier rebate calculations using only the inflation-indexed portion of the Medicaid rebate methodology.

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August 28, 2017

The Centers for Medicare & Medicaid Services Has Inadequate Procedures To Ensure That Incidents of Potential Abuse or Neglect at Skilled Nursing Facilities Are Identified and Reported in Accordance With Applicable Requirements

This audit is part of the ongoing efforts of the Office of Inspector General (OIG) to detect and combat elder abuse. We are communicating these preliminary results because of the importance of detecting and combating elder abuse. Also, according to Government Auditing Standards, "early communication to those charged with governance or management may be important because of their relative significance and the urgency for corrective follow-up action."

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July 17, 2017

OIG updates the Work Plan.

Updated Plan

July 6, 2017

Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles: 2017

This report fulfills for 2017 the annual reporting mandate from the Patient Protection and Affordable Care Act (ACA) for 2017. The ACA requires OIG to conduct a study of the extent to which formularies used by Medicare Part D plans include drugs commonly used by full benefit dual eligible individuals (i.e., individuals who are eligible for both Medicare and full Medicaid benefits). These individuals generally get drug coverage through Medicare Part D. Pursuant to the ACA, OIG must annually issue a report with recommendations as appropriate. This is the seventh report the OIG has produced to meet this mandate.

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June 13, 2017

2016 Performance Data for the Senior Medicare Patrol Projects2016 Performance Data for the Senior Medicare Patrol Projects

This memorandum report presents performance data for the Senior Medicare Patrol (SMP) projects, which receive grants from ACL to recruit and train retired professionals and other senior citizens to recognize and report instances or patterns of health care fraud. OIG has collected these performance data since 1997.

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Medicare Paid Hundreds of Millions in Electronic Health Record Incentive Payments That Did Not Comply With Federal Requirements

he Health Information Technology for Economic and Clinical Health Act established the Medicare and Medicaid electronic health record (EHR) incentive programs to promote the adoption of EHRs and to improve health care quality, safety, and efficiency through the promotion of health information technology and electronic health information exchange. As an incentive for using certified EHR technology, the Federal Government is making payments to eligible professionals (EPs) and hospitals that attest to the “meaningful use” of EHRs. To receive an incentive payment, EPs attest that they meet program requirements by self-reporting data through the Centers for Medicare & Medicaid Services’ (CMS) online system. he Health Information Technology for Economic and Clinical Health Act established the Medicare and Medicaid electronic health record (EHR) incentive programs to promote the adoption of EHRs and to improve health care quality, safety, and efficiency through the promotion of health information technology and electronic health information exchange. As an incentive for using certified EHR technology, the Federal Government is making payments to eligible professionals (EPs) and hospitals that attest to the “meaningful use” of EHRs. To receive an incentive payment, EPs attest that they meet program requirements by self-reporting data through the Centers for Medicare & Medicaid Services’ (CMS) online system.

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June 8, 2017

Eye on Oversight Video: Abuse in Nursing Homes Eye on Oversight Video: Abuse in Nursing Homes

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June 1, 2017

Spring 2017 Semiannual Report to Congress

This spring edition of the Semiannual Report to Congress covers OIG activities from October 2016 through March 2017. Historically, about 80 percent of OIG's resources are directed to work related to Medicare and Medicaid. This is mirrored in the organization and content of the report.

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May 19, 2017

Medicaid Fraud Control Units Fiscal Year 2016 Annual Report Medicaid Fraud Control Units Fiscal Year 2016 Annual Report

The Department of Health and Human Services (HHS) OIG is the designated Federal agency that oversees State Medicaid Fraud Control Units (MFCUs or Units). This MFCU Fiscal Year (FY) 2016 Annual Report highlights statistical achievements from the investigations and prosecutions the 50 MFCUs conducted for FYs 2012 through 2016. The report also identifies beneficial practices noted in OIG onsite review reports.

See Report

May 16, 2017

U.S. Department of Health and Human Services Met Many Requirements of the Improper Payments Information Act of 2002 but Did Not Fully Comply for Fiscal Year 2016U.S. Department of Health and Human Services Met Many Requirements of the Improper Payments Information Act of 2002 but Did Not Fully Comply for Fiscal Year 2016

The Office of Inspector General (OIG) must review the Department of Health and Human Services (HHS) compliance with the Improper Payments Information Act of 2002 (IPIA; P.L. No. 107-300) as amended by the Improper Payments Elimination and Recovery Act of 2010 (P.L. No. 111-204) and the Improper Payments Elimination and Recovery Improvement Act of 2012 (IPERIA; P.L. No. 112-248). Ernst & Young (EY), LLP, under its contract with the HHS OIG, audited the fiscal year 2016 HHS improper payment information reported in the Agency Financial Report (AFR) to determine compliance with IPIA and related guidance from the Office of Management and Budget (OMB).The Office of Inspector General (OIG) must review the Department of Health and Human Services (HHS) compliance with the Improper Payments Information Act of 2002 (IPIA; P.L. No. 107-300) as amended by the Improper Payments Elimination and Recovery Act of 2010 (P.L. No. 111-204) and the Improper Payments Elimination and Recovery Improvement Act of 2012 (IPERIA; P.L. No. 112-248). Ernst & Young (EY), LLP, under its contract with the HHS OIG, audited the fiscal year 2016 HHS improper payment information reported in the Agency Financial Report (AFR) to determine compliance with IPIA and related guidance from the Office of Management and Budget (OMB).

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March 16, 2017

Health Information Technology: HHS Should Assess the Effectiveness of Its Efforts to Enhance Patient Access to and Use of Electronic Health Information.

Data from the 2015 Medicare EHR Program show that relatively few patients electronically access their health information when offered the ability to do so. Patients GAO interviewed described primarily accessing health information before or after a health care encounter, such as reviewing the results of a laboratory test or sharing information with another provider.

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2017 Compendium of Unimplemented Recommendations2017 Compendium of Unimplemented Recommendations

The Compendium of Unimplemented Recommendations (Compendium) is a core publication of the Department of Health and Human Services (HHS or Department) Office of Inspector General (OIG). In this edition, we focus on the top 25 unimplemented recommendations that, in OIG͛s view, would most positively affect HHS programs in terms of cost savings, program effectiveness and efficiency, and quality improvements and should, therefore, be prioritized for implementation. The recommendations come from OIG audits and evaluations performed pursuant to the Inspector General Act of 1978 (IG Act), as amended. The Appendix of the Compendium includes a broader list of significant unimplemented recommendations from OIG.

March 6, 2017

OIG posts statistical information for FY2016 Medicaid Fraud Control Units and enforcement actions

In FY 2016, State Medicaid Fraud Control Units (MFCUs) were responsible for 1,721 indictments, 1,564 convictions, and $1.8 billion in criminal and civil recoveries, as reported to OIG.

February 15, 2017

Drug Pricing and Reimbursement Web Portfolio

OIG posts a Drug Pricing and Reimbursement Web portfolio on its website. This portfolio, in development since last summer, pulls together the HHS OIG’s body of work since 2010 as well as other relevant items that relate to drug pricing and reimbursement in HHS programs. The portfolio features planned work, completed reports, industry guidance, and enforcement actions.

January 11, 2017

Final Rule: Health Care Programs: Fraud and Abuse; Revisions to the Office of Inspector General's Exclusion Authorities

See Federal Register

January 5, 2017

High-Price Drugs Are Increasing Federal Payments for Medicare Part D Catastrophic Coverage

Federal payments for catastrophic coverage exceeded $33 billion in 2015, which is more than triple the amount paid in 2010. Spending for high-price drugs contributed significantly to this growth. By 2015, high-price drugs were responsible for almost two-thirds of the total drug spending in catastrophic coverage.

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December 21, 2017

Early Implementation Review: CMS’s Management of the Quality Payment Program

CMS has made significant progress towards implementing the QPP. Although many milestones remain before the QPP payment adjustments in 2019, OIG identified two vulnerabilities that are critical for CMS to address in 2017, because of their potential impact on the program’s success: (1) providing sufficient guidance and technical assistance to ensure that clinicians are ready to participate in the QPP, and (2) developing IT systems to support data reporting, scoring, and payment adjustment.

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December 19, 2017

Vulnerabilities Remain Under Medicare’s 2-Midnight Hospital Policy

We found that the number of inpatient stays decreased and the number of outpatient stays increased since the implementation of the 2-midnight policy. Further, short inpatient stays decreased more than long outpatient stays. Despite these changes, vulnerabilities still exist.

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December 16, 2017

HHS-OIG Year in Review

The 2016 Year in Review highlights significant work in our continuing battle against fraud, waste, and abuse in Department of Health and Human Services programs, including Medicare and Medicaid.

Watch Video

November 10. 2016

FY 2017 Office of Inspector General Work Plan

The Work Plan includes projects planned in each of the Department's major entities: the Centers for Medicare & Medicaid Services; the public health agencies; the Administrations for Children & Families; and Administration on Aging. Information is also provided on projects related to issues that cut across departmental programs, including State and local government use of Federal funds, as well as the functional areas of the Office of the Secretary of Health & Human Services (HHS).

See Work Plan

November 4. 2016

Eye on Oversight Video: Vulnerabilities in Personal Care Services

Investigations have revealed abuse and neglect by PCS attendants. OIG hopes that its recommendations to the Centers for Medicare and Medicaid Services will ensure that people in need of PCS services are not at risk of abuse or neglect.

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October 24. 2016

Arizona Did Not Always Verify Correction of Deficiencies Identified During Surveys of Nursing Homes Participating in Medicare and Medicaid

The Arizona Department of Health Services, Division of Licensing Services, Bureau of Long-Term Care Licensing (State agency), did not always verify nursing homes' correction of deficiencies identified during surveys in calendar year (CY) 2014 in accordance with Federal requirements.

See Report
October 18. 2016

Video Series Eye on Oversight

Vulnerabilities in Personal Care Services

October 7. 2016

Medicare's Policies and Procedures Identified Almost All Improper Claims Submitted for Deceased Individuals and Recouped Almost All Improper Payments Made for These Claims for January 2013 Through October 2015

CMS had policies and procedures to ensure that payments were not made for Medicare services ostensibly rendered to deceased individuals. These policies and procedures generally ensured that CMS did not make improper payments when its data systems indicated at the time a claim was processed that the individual had died before the claimed date of service.

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Medicare Improperly Paid Providers Millions of Dollars for Incarcerated Beneficiaries Who Received Services During 2013 and 2014

CMS's policies and procedures generally prevented improper payments in cases when CMS's data systems identified a beneficiary as incarcerated at the time that a claim was processed. However, CMS's policies and procedures did not allow CMS to detect and recoup improper payments on a postpayment basis when CMS's data systems did not identify a beneficiary as incarcerated at the time that a claim was processed.

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September 30. 2016

Medicare Improperly Paid Millions of Dollars for Unlawfully Present Beneficiaries for 2013 and 2014

The Centers for Medicare & Medicaid Services (CMS) had policies and procedures to ensure that payments were not made for Medicare services rendered to unlawfully present beneficiaries in accordance with Federal requirements, but it did not always follow those policies and procedures.

See Report

Video

Video Series Eye on Oversight: Critical Incidents in Group Homes

OIG Video report on recent findings in Connecticut and Massachusetts where group homes for the disabled did not report critical incidences to state authorities.

See video here

August 10. 2016

MACs Continue to Use Different Methods to Determine Drug Coverage

In keeping with the flexibility MACs have to make coverage decisions, MACs reported using a variety of information sources on drug uses to assist in making coverage determinations.

See Report Here

August 3. 2016

Podcast: July 2016 OIG Monthly Update

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