Blog Post

HHS OIG Cites Ways to Reduce Healthcare Fraud, Waste, And Abuse

Richard P. Kusserow | August 2019

The Department of Health and Human Services (HHS) Office of Inspector General (OIG) annually summarizes unimplemented recommendations that it believes would most positively affect HHS programs in terms of cost savings, effectiveness and efficiency, and public health and safety, if implemented. This year’s July 2019 report is called, “Solutions to Reduce Fraud, Waste, and Abuse in HHS Programs: OIG’s Top Recommendations.” It includes 25 key recommendations, 18 of which relate to the Centers for Medicare & Medicaid Services (CMS). HHS recommends that CMS do the following:

  1. Analyze potential impacts of counting time spent as an outpatient toward the 3-night requirement for Skilled Nursing Facility (SNF) services, so that beneficiaries receiving similar hospital care have similar access to these services;
  2. Implement the statutory mandate that requires surety bonds for home health agencies that enroll in Medicare and consider implementing the requirement for other providers;
  3. Continue to ensure that medical device-specific information is included on claim forms and require hospitals to use certain condition codes for reporting device replacement procedures;
  4. Seek statutory authority to establish additional remedies for hospices with poor performance;
  5. Seek legislative authority to comprehensively reform the hospital wage index system;
  6. Reevaluate the inpatient rehabilitation facility (IRF) payment system, which could include seeking legislative authority to make any changes necessary to more closely align IRF payment rates and costs;
  7. Periodically review claims for replacement positive airway pressure device supplies and take remedial action for suppliers that consistently bill improperly;
  8. Consider seeking legislative authority to implement alternative policies that are less costly for Part B drugs under appropriate circumstances;
  9. Collect comprehensive data from plan sponsors, including data on potential fraud and abuse, to improve its oversight of their efforts to identify and investigate potential fraud and abuse;
  10. Require Medicare Advantage plans to include ordering and referring provider identifiers in their encounter data;
  11. Strengthen oversight of Part D payments for compounded topical drugs to prevent fraud, waste, and abuse while maintaining appropriate access;
  12. Ensure that national Medicaid data are complete, accurate, and timely;
  13. Ensure, along with the Health Resources and Services Administration (HRSA), that states can pay correctly for 340B-purchased drugs billed to Medicaid by requiring claim-level methods to identify 340B drugs and sharing the official 340B ceiling prices;
  14. Require states to either enroll personal care services (PCS) attendants as providers or require PCS attendants to register with their state Medicaid agencies and assign each attendant a unique identifier;
  15. Facilitate state Medicaid agencies’ efforts to screen new and exiting providers by ensuring the accessibility and quality of Medicare’s enrollment data;
  16. Improve managed care organizations’ (MCOs’) identification and referral of cases of suspected fraud or abuse;
  17. Develop policies and procedures to improve the timeliness of recovering Medicaid overpayments and recover uncollected amounts identified by OIG’s audits; and
  18. Re-evaluate effects of the healthcare-related tax safe-harbor threshold and the associated 75/75 requirement to determine whether modifications are needed.

About the Author

Richard P. Kusserow established Strategic Management Services, LLC, after retiring from being the DHHS Inspector General, and has assisted over 3,000 health care organizations and entities in developing, implementing and assessing compliance programs.

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