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Millions of people who were previously uninsured will gain health insurance coverage in 2014, thanks to the Patient Protection and Affordable Care Act (ACA) of 2010. The ACA, which enacted a range of new programs and made key changes to existing programs, is “driving significant growth” in Medicare and Medicaid enrollment,” stated Erin Bliss, director of external affairs with the Department of Health and Human Services Office of Inspector General (OIG), who joined the February 3 broadcast of “Monitor Monday.”

According to its just-released 2014 work plan, the OIG will begin to focus on the expanding Medicaid program and the operation of the new health insurance marketplaces, which include the federally-facilitated marketplace (FFM) and state-based marketplaces (SBMs).

“As enrollment and spending growth continue the OIG’s longstanding work of rooting out fraud and abuse will become a priority.” Bliss said.

Per the ACA provisions, 25 states and the District of Columbia are expanding Medicaid coverage to additional qualified adults. Other state governments are experiencing the “woodwork effect,” which refers to the fact that millions of people who are eligible but aren’t already enrolled will come out of the woodwork to enroll.

To ensure that taxpayer funds are spent for their intended purposes and that the marketplaces operate efficiently and effectively, the OIG will operate under a four-part strategy it developed. Bliss presented the following OIG strategy during the “Monitor Monday” broadcast.

Payment accuracy:

HHS must implement financial and payment systems to ensure accurate and timely payments to insurers of advance premium tax credits, cost-sharing reduction payments, and premium-stabilization payments. Insurers will begin receiving some of these payments in January 2014; other types of payments begin later. The OIG will, for example, evaluate the effectiveness of internal control over, and validity of payments for, advanced premium tax credits and cost-sharing reductions.

Eligibility systems:

The FFM and SBMs must verify consumers’ personal information; accurately determine eligibility for qualified health plans, tax credits, and cost-sharing reduction subsidies; and transmit complete, accurate, and timely eligibility information to insurers and consumers. OIG is assessing how well the internal controls are working to ensure this.

Contracts—planning, acquisition, contracting, management, and performance:

Contractors will continue to play a vital role in building, fixing and maintaining systems that underpin the marketplace. As Bliss reported, the “OIG plans a comprehensive look at the department’s efforts to implement and operate the FFM.”

Security of data and consumer information:

Effective marketplace operation requires “rapid, accurate, and secure integration of data from numerous federal and state sources and individuals who use the marketplaces,” according to the OIG’s work plan. Because these systems handle consumers’ sensitive personal information, OIG investigators will be involved in active monitoring against cyber security threats and fraud against consumers.

Hospital-Specific Projects

In addition to its various ACA-related projects, the OIG work plan lists its plans for Medicare Part A and Part B providers and suppliers. This

includes hospitals, nursing homes, hospices, home-health services, medical equipment and supplies, physicians, and many others. A review of the 2014 work plan contents makes it easy to see why Bliss refers to it as “robust” and calls the OIG’s planning process “dynamic” with adjustments made throughout the year to meet priorities and respond to emerging risks with the resources available.

In the case of hospitals, the OIG divides projects into one of the following: policies and practices, billing and payments, and quality of care and safety. Bliss explained that the policies and practices section, for example, includes a future review of the new inpatient admission criteria and how it affects payment and copayments. The OIG also will review:

* Selected inpatient and outpatient billing requirements followed by recommendations for recovery of overpayments

* Inpatient claims for mechanical ventilation

* Outpatient evaluation and management services billed at the new-patient rate

* Right heart catheterizations (RHC) and heart biopsies (new) billed during the same operative session to identify inappropriate payments when hospitals were paid for separate RHC procedures when the services were already included in payments for heart biopsies.

Several projects are listed under the work plan’s “quality of care and safety” section. It includes, for example, participation in projects with

quality improvement organizations and oversight of pharmaceutical compounding.

Bliss referred to a landmark study in which the OIG calculated the incidence of adverse events for hospitalized Medicare beneficiaries, assessed the preventability of such events, and estimated associated costs to Medicare. She indicated that the agency is now working on a similar project for nursing homes and new to 2014 will be one for inpatient rehabilitation facilities.

Use Work Plan as a Compliance Tool

Bliss and others in the OIG’s office “really hope that the work plan is an invaluable tool for ensuring compliance” and suggest that compliance officers and providers think about it this way.

“The OIG’s job is risk assessment and to develop audits and evaluations. We make difficult decisions on an ongoing basis about what are the most important vulnerabilities that need to be addressed. These are the same issues that we hope compliance professionals and providers will also pay close attention to. Consider the questions that the OIG is asking and ask the same questions as they apply to your own facilities and practices,” she advises.

Numerous tools and resources are available on the OIG’s website at www.oig.hhs.gov, including a compliance 101 program that includes training videos, podcasts, presentations, and more. Some tools are broad-based while others are meant for specific audiences.

About the Author

Janis Oppelt is an editor for MedLearn Publishing, a division of Panacea Healthcare Solutions, Inc.

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To comment on this article please go to editor@racmonitor.com


Janis Oppelt

Janis Oppelt was the former editorial director for MedLearn Publishing.

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