OIG Sets Enforcement Sights on Reform Efforts

The U.S. Department of Health and Human Services Office of Inspector General (OIG) doesn’t just scrutinize laboratories and other providers but is also charged with overseeing government agencies and health care reform efforts. While the Affordable Care Act (ACA) celebrated its 5th birthday last month, the OIG indicated in its Health Reform Oversight Plan that it plans to scrutinize aspects of the ACA’s implementation, particularly the health insurance marketplaces. Demonstrating just how big a focus the ACA is for the OIG, it noted that 27 percent of its 2014 discretionary funding was devoted to ACA oversight and it plans to give ACA issues similar priority in 2015. The OIG lists four items as key tactical considerations: “fighting fraud, waste, and abuse; promoting value, safety, and quality; securing the future; and advancing excellence and innovation.” Although the ACA is credited with providing 16 million Americans with health insurance and a host of other benefits, according to a White House press release celebrating the five-year anniversary, it is still running into opposition. Not only are the subsidies for the exchanges currently the subject of litigation before the U.S. Supreme Court in King v. Burwell but the OIG’s Oversight Plan targets the marketplaces providing insurance as “a primary focus” of reform oversight. Key focus areas relating to marketplaces include whether taxpayer funds are properly spent, “the right people [are] getting the right benefits” and personal information is secure. Additionally, the OIG plans to focus on the efficiency and effectiveness with which marketplace programs are managed. Future projects are anticipated to “address vulnerabilities in payment systems.” The OIG’s Oversight Plan also targets eligibility issues, including enrollment safeguards, premium tax credit eligibility verification, and inconsistencies in data regarding federal marketplace applicants. “[E]merging issues” likely to receive future attention include verification of employer information, hardship waiver eligibility and reviews of the second enrollment period. As to management of the marketplace programs, the OIG is concerned about oversight of federal contractors and review of “HHS’s management and implementation of the [federally facilitated Market-place] FFM from enactment of the ACA through the second enrollment period.” Future subjects for review may include financial reconciliation process and data collection relating to financial assistance payments, operation of premium stabilization programs and FFM user fees. The OIG also will review security of personally identifiable information at FFM and state marketplaces and is working with federal and local authorities to watch for cybersecurity threats and consumer fraud. In addition to the ACA related items included in the OIG’s 2015 Work Plan, the OIG says it expects to add five to 10 ACA related reviews to its agenda during 2015.
Other reform efforts under scrutiny In addition to the ACA marketplaces, the OIG is also concerned with reform in these four programs:

• Medicaid expansion
• Medicare payment and delivery reform (including the shift from volume to value based payment, shared savings, population based payment, and bundled and capitated payments)
• Medicare and Medicaid program integrity (including provider screening systems, provider terminations, payment suspensions and managed care encounter data) and
• public health programs.

Source: U.S. Department of Health and Human Services Office of Inspector General, Health Reform Oversight Plan, Fiscal Year 2015 (Feb. 2015) Takeaway: The OIG is not only concerned with laboratories and other providers’ compliance but also with efficient and effective administration of reform efforts.