Industry News

OIG Report Reports On 2015 Unimplemented OIG Recommendation

The HHS OIG released the March 2015 Edition of the Compendium of Unimplemented Recommendations. The publication outlines the OIG’s fiscal year 2014 recommendations that HHS programs have not implemented as of date of publication.  Implementing the OIG recommendations generally require one of three actions: legislative, regulatory, or administrative. The OIG placed focus on the top 25 recommendations that in their opinion would positively impact on HHS programs in terms of savings and/or quality improvements. All recommendations arise from audits and evaluation performed by their office. The OIG is mandated by law to report to Congress on findings and recommendations. This is done with Semi-annual reports to Congress. The Compendium provides highlights from these reports, as well as response to requirements associated with the Consolidation Appropriations Act of 2014 that directs the OIG to report on the top 25 unimplemented recommendations that in the opinion of the OIG would best protect the integrity of HHS programs, if implemented.   In their report, the OIG grouped recommendations by HHS operating divisions. The following highlights recommendations that relate to Medicare and Medicaid. The report details findings that support the recommendations, along with their status.

  1. Establish accurate and reasonable Medicare payment rates by CMS seeking legislative authority to expand 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 by CMS changing regulations or through legislation that would establish and hospital patient transfer payment policy for early discharge to hospice care.
  3. Reduce hospital outpatient department payment rates for ambulatory surgical center approved procedures by CMS seeking 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 prevent inappropriate home health agency payments by developing more oversight through mandated face-to-face encounters.
  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 by CMS implementing 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 by CMS implementing an automated system that will recalculate outlier claims.
  8. Ensure States calculate accurate 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 by CMS better use of ZPIC workload statistics in evaluating them.
  10. Ensure the collection of Medicare overpayments by CMS updating 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 by CMS issuing new regulations to tighten control over programs and giving 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 causing the case files to be standardized and made electronic.
  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.

The OIG Compendium is available at:

Department of Health and Human Services Office of Inspector General.  “Compendium of Unimplemented Recommendations, March 2015 Edition.”