2015 Report On Unimplemented OIG Recommendations

The Department of Health and Human Services (HHS) Office of Inspector General (OIG) released the March 2015 Edition of the Compendium of Unimplemented Recommendations.  The publication outlines the OIG recommendations from fiscal year 2014 that HHS programs have yet to implement.  Implementing the OIG recommendations generally require one of three actions: legislative, regulatory or administrative. The OIG report focused on the top 25 recommendations that, in their opinion, would positively impact HHS programs in terms of savings and/or quality improvements.

All of the OIG’s recommendations arise from audits and evaluations performed by their office.  The OIG is mandated by law to report to Congress on findings and recommendations.  It accomplishes this through their semi-annual reports to Congress. The Compendium provides highlights from these reports, and serves as a response to requirements associated with the Consolidation Appropriations Act of 2014 that directs the OIG to report on the top 25 recommendations that would best protect the integrity of HHS programs, if implemented.  In their report, the OIG grouped recommendations by HHS operating divisions.  The following list highlights recommendations that relate to Medicare and Medicaid.  The full report details findings that support the recommendations, along with their status.

1. Establish accurate and reasonable Medicare payment rates – CMS should seek legislative authority to expand diagnosis-related group (DRG) window to include additional days prior to inpatient admission, and other ownership arrangements, such as affiliated groups.
2. Establish accurate and reasonable Medicare payment rates for hospital transfers – CMS should revise regulations or seek legislation that would establish a hospital patient transfer payment policy for early discharge to hospice care.
3. Reduce hospital outpatient department payment rates for ambulatory surgical center approved procedures – CMS should seek legislation to exempt the reduced expenditures as result of lower outpatient prospective payment system payment rates from budget neutral adjustments for ASC approved procedures.
4. CMS should develop more oversight through mandated face-to-face encounters to prevent inappropriate home health agency payments.
5. CMS should reduce inappropriate SNF payments by changing the current method for determining how much therapy is needed to ensure appropriate payments.
6. Prevent payments for ineligible Medicare beneficiaries – CMS should implement policies and procedures to detect and recoup improper payments for Medicare services provided to incarcerated beneficiaries.
7. Reconcile Medicare outlier payments in accordance with Federal guidelines and regulations – CMS should implement an automated system that will recalculate outlier claims.
8. Ensure accurate state calculation of costs for Medicaid services provided by local providers by providing definitive guidance for calculating the federal upper payment limits, using facility specific data based upon actual cost report data.
9. Maximize contractor performance and oversight – CMS should better utilize ZPIC workload statistics in evaluations.
10. Ensure the collection of Medicare overpayments – CMS should update the Audit Tracking and Reporting System to accurately reflect the status of audit report recommendations.
11. Improve oversight of management of Medicaid personal care services – CMS should issue new regulations to tighten control over programs and give guidance for claims documentation, beneficiary assessments, plans of care and supervision of attendants.
12. Improve the Medicare appeals process at the Administrative Law level by electronically standardizing the case files.
13. CMS and AHRQ should enhance efforts to identify adverse events to ensure better quality of care and safety.
14. Ensure that Medicaid children receive all required preventive screening services by requiring states to report to CMS on vision and hearing screening for eligible children.
15. Strengthen oversight of state access standards for access to Medicaid Managed Care.
16. CMS should establish effective disaster emergency preparedness and response policies and guidance for hospitals.
17. CMS should establish a cumulative payment threshold, taking into consideration costs and potential program integrity benefits above which a clinician’s claims would be selected for review.
18. CMS should expand oversight and monitoring of drug utilization by restricting certain beneficiaries to a limited number of pharmacies and prescribers.
19. CMS should improve internal controls related to determining applicant’s eligibility for enrollment in qualified health plans and in insurance affordable programs.

About the Author

Richard P. Kusserow established Strategic Management Services, LLC, after retiring from being the DHHS Inspector General, and has assisted over 2,000 health care organizations and entities in developing, implementing and assessing compliance programs.