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HHS OIG Chief of Staff Christi Grimm

WASHINGTON, D.C. – The Medicare portion of the newly unveiled 2015 U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) Work Plan, the launch of open enrollment in Patient Protection and Affordable Care Act marketplaces, and oversight of an expanding Medicaid program were three topics on the table when HHS OIG Chief of Staff Christi Grimm spoke on Monitor Mondays earlier this week in a guest appearance that went well beyond the Recovery Auditors (RACs).

In fielding more than a dozen questions, Grimm provided insight into a variety of topics regarding oversight of the nation’s healthcare infrastructure. But of arguably greatest interest were her comments on the work plan, which providers are being encouraged to digest in order to ensure the strength of individual compliance programs.

“(The) OIG uses risk assessments to pinpoint the most important vulnerabilities we should address in our audits and evaluations each year,” Grimm said. “So the issues we focus on are the issues that we hope compliance professionals and providers will also pay close attention to.”

The OIG’s own hospital compliance reviews are continuing, Grimm added, citing three areas of scrutiny in particular.

“We have work looking at hospital dental claims, … whether hospitals are correctly billing outpatient evaluation and management services labeled as ‘new patient’ versus ‘established patient,’ and … billings for hospice care that should be considered general inpatient care,” Grimm explained.

Furthermore, Grimm noted that the OIG is currently reviewing policies and practices to evaluate whether they are cost-effective or efficient. Specifically, she said, the OIG will be taking a look at how Medicare’s new inpatient admission criteria will impact hospital billing, Medicare payments, and patient copayments.

“We will also compare reimbursement for swing-bed services at critical access hospitals to the same level of care obtained at skilled nursing facilities to determine if Medicare could save money through different payment methodologies,” Grimm said. “(And) we’re also looking at quality and safety issues. We have work examining oversight of pharmaceutical compounding and oversight of hospital privileging (and) we are continuing to examine adverse events – whether medical care has caused harm to patients.  We have some interesting work looking at patient harm in inpatient rehabilitation facilities, and another study is focusing on harm from care in long-term-care hospitals.”

On the topic of Medicaid oversight, noting the program’s recent expansion in scope, Grimm noted that the OIG will be scrutinizing the accuracy of individual states’ eligibility determinations and whether states correctly apply enhanced federal payment matches brought about by the Patient Protection and Affordable Care Act (PPACA). 

“It (the PPACA) included a number of provisions that were designed to increase program integrity in Medicaid,” Grimm said. “We’ll be taking a look at how well these new tools are working.”

Key in that area, Grimm added, will be reviews of the national correct coding initiative, enhanced provider screenings, and whether providers are still participating in Medicaid even after being terminated under Medicare or under a state Medicaid plan.

With this past weekend marking the start of the 2015 PPACA open enrollment period, Grimm also was asked about the PPACA marketplaces and how they will be monitored.

“We have more than 30 audits and evaluations underway looking at four key marketplace issues: Payments – Are taxpayer funds being expended correctly for their intended purpose? Enrollment and eligibility determinations – Are the right people getting the right benefits? Management practices – Is the Department managing and administering marketplace programs effectively and efficiently? And security of consumer information – Is consumers’ personal information safe?” she said.

“For enrollment and eligibility issues, we will follow up on reports published this summer that highlighted deficiencies in internal controls that may prevent inaccurate eligibility determinations,” Grimm added. “We’ll also follow up to determine whether marketplaces are more equipped to resolve inconsistencies between self-reported information contained on insurance applications and data maintained by government sources.”   

In closing, Grimm urged providers nationwide to visit the OIG’s website – oig.hhs.gov – in order to leverage what she described as a variety of valuable compliance tools and resources.

‘Under ‘Compliance 101’ you’ll find more than a dozen training videos, as well as presentations and guidance documents. Some training materials are broadly applicable and some are tailored to specific audiences, like healthcare boards of directors and physicians,” Grimm said. “For a big-picture perspective, I recommend you also check out the Publications section of our website. In addition to the work plan, you’ll find OIG’s Strategic Plan here and as well as our assessment of the top management challenges facing HHS, among other helpful resources.”

Monitor Mondays broadcasts live on a weekly basis on RACmonitor. Register here.

About the Author

Mark Spivey is a national correspondent with www.racmonitor.com.

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Mark Spivey

Mark Spivey is a national correspondent for RACmonitor.com, ICD10monitor.com, and Auditor Monitor who has been writing and editing material about the federal oversight of American healthcare for more than a decade.

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