The Department of Health and Human Services (HHS) Office of Inspector General (OIG) updated its Work Plan with six new items in November. The Work Plan outlines ongoing and planned audits and evaluations for the fiscal year and beyond. In 2017, the OIG began releasing its Work Plan projects on an ongoing basis, in lieu of providing biannual updates. A monthly update schedule ensures that the Work Plan closely aligns with the OIG’s work planning process. The OIG considers several factors when creating Work Plan items, including legal mandates, congressional requests, budgetary concerns and potential for positive impact. In addition to working on projects that often lead to audits, reviews, and reports, the OIG also engages in a number of legal and investigative activities that are separately reported.
The November additions to the OIG Work Plan include the following:
CDC Oversight of the President’s Emergency Plan for AIDS Relief Funds
The Centers for Disease Control and Prevention (CDC) received over $1.7 billion in funds for the President’s Emergency Plan for AIDS Relief (PEPFAR) program in fiscal year 2017. PEPFAR funds allow the U.S. and partnering countries to respond to health challenges and threats posed by the AIDS epidemic. The OIG has conducted a series of PEPFAR audits at the CDC offices in five countries in Africa, North America, and Asia. Prior OIG audits of the CDC identified noncompliance with policies, inadequate monitoring of grantees, and internal control weaknesses in the award of PEPFAR funds both in the U.S. and abroad. The OIG Office of Audit Services (OAS) will conduct a review to assess whether the CDC has improved and implemented internal controls to protect program funds. The OAS will also determine if the CDC has adhered to policies and procedures for awarding and monitoring PEPFAR funds.
Assessing Inpatient Hospital Billing for Medicare Beneficiaries
Inpatient hospital stays accounted for $114 billion, or 17 percent, of what hospitals billed Medicare in 2016. OIG and the Centers for Medicare & Medicaid Services (CMS) have identified upcoding as an issue in hospital billing. Upcoding is the practice of mis-coding or over-coding to increase payment. The Office of Evaluation and Inspections (OEI) will assess inpatient hospital billing through a two-part study. The first part will provide landscape information about hospital billing to determine changes in inpatient hospital billing over time and inpatient billing variances among hospitals. The second part will use the first part’s results to target certain hospitals or codes for a medical review. The OEI will review the second part to determine the extent to which the targeted hospitals billed incorrect codes.
Involuntary Transfer and Discharge in Nursing Homes
Congress passed the Nursing Home Reform Act of 1987 to protect nursing home residents against potentially unsafe and traumatic involuntary transfers and discharges. Still, National Ombudsman Reporting System data from 2011 to 2016 shows that Long-Term Care Ombudsman Program complaints related to “discharge/eviction” are cited more frequently than any other concern. Media sources have also recently reported on the rise in nursing home evictions. As high as one-third of all residents in long-term care facilities are involuntarily discharged according to CMS estimates. As a result, the OEI will conduct a review to determine the extent to which state long-term care ombudsmen address involuntary nursing home transfers and discharges. The review will also determine the extent to which state survey agencies conducted investigations and pursued enforcement actions against nursing homes that inappropriately discharged or involuntarily transferred residents. Finally, the review will assess whether nursing homes meet CMS requirements for involuntary transfers and discharges.
Protecting Medicare Hospice Beneficiaries from Harm
The Medicare hospice program provides vital end of life care to beneficiaries and their families and caregivers. The Medicare hospice program often uses survey reports and complaint investigations as a means of oversight. The OEI will conduct a companion study to the Trends in Hospice Deficiencies and Complaints report (OEI-02-17-00020) to determine the extent and nature of hospice deficiencies and complaints and identify trends. The companion study will use survey reports to provide more detail about poor-quality care that resulted in beneficiary harm. The study will detail specific instances of hospice beneficiary harm and identify vulnerabilities in Medicare processes that otherwise should prevent and address such harm.
Grantees’ Use of President’s Emergency Plan for AIDS Relief Funds
The CDC has grantees in more than 60 countries that work to control the spread of AIDS, including ministries of health and other partners. The CDC awarded more than $1.5 billion in PEPFAR funds in fiscal year 2017 to help partner countries respond to health challenges and threats related to the AIDS epidemic. The OIG has conducted PEPFAR audits in eight countries in Africa and Asia. This OIG oversight has assisted grantees in ongoing and future responses to infectious diseases by helping them to learn grant and program integrity lessons. The OAS will conduct this audit to determine whether selected foreign and domestic grantees managed PEPFAR funds in accordance with reward requirements.
Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries – 10-Year Update
Between 2008 and 2019, the OIG has released or is in the process of releasing 15 reports regarding adverse events (patient harm) in various healthcare settings. One of those reports includes a 2010 study mandated by Congress that found that 27 percent of Medicare beneficiaries experienced adverse events or temporary harm events while hospitalized in 2008. The OEI will use the same methodology as the 2008 study to create a sample of beneficiaries and conduct a study of beneficiaries admitted to acute-care hospitals. The study will measure the incidence of adverse events and temporary harm events, determine the extent to which better care could have prevented the harms. OEI will also analyze the associated costs to Medicare caused by the adverse events or temporary harms. The 2018 study results will then be compared to the prior study’s results to assess any progress in reducing harm at the 10-year mark. Results will be used to identify differences in harm rates, types, contributing factors, preventability, and costs.
The OIG Work Plan is available at: