Industry News

OIG Updates Work Plan with New Projects in August.

The Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently issued the August updates to its Active Work Plan (Work Plan).  The updated Work Plan outlines 11 new items, in addition to the ongoing and planned audits and evaluations for the current fiscal year and beyond.  The OIG selects Work Plan items based on relative risks in HHS programs and operations to identify those areas most in need of attention.  The OIG began releasing its Work Plan projects on an ongoing basis in 2017, as opposed to 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, potential for positive impact, and others.  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 August additions to the OIG Work Plan include the following:

  1. Office of Refugee Resettlement (ORR)-Funded Facilities’ Efforts to Ensure Health and Safety of Unaccompanied Children.
  • The Administration for Children and Families’ (ACF) ORR administers the Unaccompanied Alien Children (AUC) program, which provides temporary shelter, care, and other related services to unaccompanied children in its custody. The facilities that care for these children are often operated by grantees that receive funding from ORR.  The OIG Office of Evaluation and Inspections will conduct a review on the care and well-being of all children residing in ORR-funded facilities.  The review will encompass the subset of children who were separated and deemed ineligible for reunification and the efforts made to contact and reunify children with parents and/or identify a suitable sponsor.
  1. Medicare Market Shares of Mail Order Diabetic Test Strips (DTS) from April-June 2018.
  • The Bipartisan Budget Act of 2018 requires the OIG to report on the Medicare market share of both mail order and non-mail order DTS before each round of the Medicare competitive bidding program. The OIG Office of Evaluation and Inspection (OEI) will create two data briefs to help the Centers for Medicare & Medicaid Services (CMS) determine the relative Medicare market share of various DTS in the mail order and non-mail order markets.  The first data brief will determine the mail order DTS Medicare market share for the three-month period from April through June 2018.  The second data brief will determine the non-mail order DTS Medicare market share over the same three-month period.  The data briefs are the first series of reports to include non-mail order DTS data and are the third round of DTS Medicare market share reports since 2010.
  1. Medicare Payments for Clinical Diagnostic Laboratory Tests in 2017: Year 4 of Baseline Data.
  • The Protecting Access to Medicare Act of 2014 requires the OIG to release an annual analysis of the top 25 laboratory tests by expenditures to the public. The OEI will release the 2017 expenditures accordingly.  Medicare beneficiaries do not have to pay copayments or deductibles for lab tests, which are mostly covered by Medicare Part B (Part B).  Part B pays 100 percent of allowable charges, and in 2016 the program paid $6.8 billion for lab tests, accounting for about 2 percent of all Part B payments.
  1. Penetration Test of the Affordable Care Act (ACA) Website and Associated Systems.
  • The ACA established the website and related systems as part of the Federally Facilitated Marketplace (FFM). The FFM provides consumers with access to health care coverage through private, qualified health plans or through federal programs such as Medicaid.  Over nine million people enrolled in coverage through the FFM in 2017.  The OIG Office of Audit Services (OAS) will conduct a penetration test of the ACA systems to determine whether CMS has implemented effective information security controls.
  1. ACF Child Care Development Fund (CCDF): Program Integrity.
  • The CCDF program provides subsidized childcare to low-income families, families receiving temporary public assistance, and families transitioning from public assistance. The program provides family members the opportunity to work, attend training, or receive an education.  States must develop and submit a plan to the ACF that identifies how CCDF funds will be spent for a three-year grant period.  States use the block grants and other federal funds to operate their childcare programs.  The OIG has previously identified a national CCDF payment error rate of 5.74 percent and other vulnerabilities in states’ internal controls.  The OAS will review the CCDF program and determine if state agencies complied with federal and state requirements for payments they made to licensed providers for fiscal years 2016 through 2018.
  1. Blood Lead Screening Tests, Follow-up Services, and Treatment for Medicaid-Enrolled Children.
  • The Early and Periodic Screening, Diagnostic, and Treatment program requires children to receive blood lead screenings. Follow-up services and treatment are also provided to children who have conditions identified through the screening.  Children are vulnerable to cognitive deficiencies associated with lead exposure without this screening and treatment.  The OIG has identified low rates of lead screenings in previous reports, but follow-up services for Medicaid-enrolled children with elevated blood lead levels (EBLLs) has not been conducted.  The OEI will conduct a review of the program to identify the percentage of children under 26 months of age who: (1) received required blood lead screenings; (2) had EBLLs; and (3) received needed follow-up services and treatment.
  1. Physicians Billing for Critical Care Evaluation and Management Services.
  • Critical care is defined as the direct delivery of medical care by a physician for a critically ill or critically injured patient. Critical care service payments may be made for care provided in any location as long as the care provided meets the definition of critical care.  The code for critical care is time-based, and physicians are paid by Medicare based on the number of minutes spent with critical care patients.  The OAS will conduct a review to determine whether Medicare critical care payments are appropriate and paid in accordance with Medicare requirements.
  1. Review of Federal Programs Administered by American Indian and Alaska Native (AI/AN) Tribes.
  • AI/AN tribes receive HHS funds for programs such as the Head Start, Child Care and Development Block Grant, and Indian Self-Determination programs. One of HHS’s top management challenges is ensuring efficient delivery of crucial services to AI/AN tribes, while protecting federal funds from fraud, waste, and abuse.  The OIG has previously found that these federal programs have not always operated in accordance with federal regulations.  Further, grantees did not always properly manage and account for the federal funds they received.  The OAS will therefore conduct an audit to determine if programs serving AI/AN communities operated and managed HHS funds in accordance with federal requirements.
  1. Hospitals’ Compliance with Medicare’s Transfer Policy with the Resumption of Home Health Services and the Use of Condition Codes.
  • Medicare Part A payments for inpatient stays at acute care hospitals are made on the basis of prospectively set rates. These payments are usually made according to the corresponding diagnosis-related group (DRG).  Beneficiary transfers to another facility or to home health services are paid under a graduated per diem rate that should not exceed the full DRG payment.  Hospitals can apply specific condition codes to claims and receive full DRG payments when transferring a patient to home health services.  The OAS will conduct this review to determine whether Medicare appropriately paid hospitals’ inpatient claims subject to the postacute care transfer policy.  Specifically, they will review situations when patients resumed home health services after discharge or hospitals applied condition codes to claims to receive a full DRG payment.
  1. CMS Oversight of Nursing Facility Staffing Levels.
  • Nursing facilities that receive Medicare and Medicaid payments are required to provide sufficient licensed nursing services 24 hours a day. This includes staffing a registered nurse for at least eight consecutive hours each day.  CMS uses the Payroll-Based Journal to analyze staffing patterns and populate the staffing component of the Nursing Home Compare website.  This website allows the public to view results of data that indicate quality of care at nursing facilities.  Results include health and safety inspections information, the quality of care provided at nursing facilities, and staffing.  The OEI will examine nursing staffing levels reported to the Payroll-Based Journal and CMS’s efforts to ensure data accuracy and improve resident quality of care.
  1. Potential Abuse and Neglect of Children Receiving Medicaid Benefits.
  • Medicare beneficiaries may receive treatment at inpatient and outpatient medical facilities for conditions potentially resulting from abuse and neglect. These beneficiaries include children who may have been abused or neglected.  The OIG has conducted previous reviews that highlighted problems with quality of care and the reporting and investigation of potential abuse or neglect of vulnerable beneficiary populations at group homes, nursing homes, and skilled nursing facilities.  This OAS review will determine the prevalence of Medicaid claims indicating potential abuse or neglect of children receiving Medicaid benefits.
  1. Review of States’ Oversight of Opioids.
  • The United States’ opioid crisis led to over 42,000 deaths in 2016. The OAS will analyze Centers for Disease Control and Prevention data from 2013 to 2016 to select states based on opioid overdose trends.  The selected states will be reviewed for their oversight of opioid prescribing and opioid use monitoring.  This will include reviewing policies and procedures, data analytics, programs, outreach, and other efforts.

The OIG Work Plan is available at: