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OIG Work Plan Monthly Review: May 2018

Of the seven new Work Plan items, none directly impact labs and lab services. However, one item on Medicare Part B reimbursement of outpatient cardiac and pulmonary rehab services may have an indirect impact on some of you. The other items may also affect some lab providers but in a much more tenuous way. Here is the complete rundown.

1. Medicare Part B Outpatient Cardiac & Pulmonary Rehabilitation Services

Issue: Previous OIG work found instances where Medicare Part B was billed for outpatient cardiac and pulmonary rehabilitation services that were not medically necessary or did not meet documentation requirements.

OIG Action: The OIG plans to determine whether payments for outpatient cardiac and pulmonary rehabilitation services were allowable and determine whether potential risks of improper billing and payment of these services continue to exist.

2. Effectiveness of HHS Hurricane Emergency Preparedness & Response Efforts in 2017

Issue: In 2017, HHS was given $5.97 billion in supplemental funds for emergency preparedness and response after Hurricanes Harvey, Irma and Maria, including $1.07 billion in discretionary and $4.9 billion in Medicaid funding.

OIG Action: The OIG will audit and assess the effectiveness of these efforts starting with the initiatives financed by the discretionary funding. Key question: Did the internal controls over emergency response and preparedness that were in place function effectively?

3. Healthcare Coalition (HCC) Partnerships with Non-Hospital-Based Facilities in Community Preparedness Efforts

Issue: HCCs, i.e., groups of public and private health care organizations, emergency preparedness planners, responders and other health officials in specified jurisdictions that receive funding through the Hospital Preparedness Program (HPP), are supposed to create emergency response plans addressing the needs of vulnerable populations, including persons with mental illnesses. But after the OIG found that non-hospital-based health care facilities commonly lacked comprehensive emergency response plans, CMS implemented new emergency preparedness requirements covering all facilities receiving Medicare or Medicaid reimbursement.

OIG Action: The OIG will examine the extent to which HCCs ensure “a successful whole community response” by integrating non-hospital-based facilities into their emergency preparedness activities and technological strategies. It will also assess Assistant Secretary for Preparedness and Response oversight and support, including coordination with CMS, of HCCs’ integration of non-hospital-based facilities.

4. Impact of Authorized Generics on Medicaid Drug Rebates

Issue: In implementing the Medicaid Drug Rebate Program provisions of the Affordable Care Act, CMS instructed primary manufacturers to include in their calculation of average manufacturer price (AMP) the sale of authorized generic drugs to secondary manufacturers in certain circumstances. Earlier OIG work has shown that including these sales in AMP calculations may significantly reduce the AMP, resulting in lower Medicaid rebates.

OIG Action: The OIG will examine selected drugs with authorized generics and determine how including the sales of authorized generic drugs to secondary manufacturers affects Medicaid drug rebates.

5. Noninvasive Home Ventilators (NHVs) – Compliance with Medicare Requirements

Issue: The OIG has noticed significant growth in Medicare billing for NHVs in the years since they reached the market.

OIG Action: The OIG will determine whether claims for NHVs were medically necessary for treatment of beneficiaries’ diagnosed illnesses and whether the claims complied with Medicare payment and documentation requirements.

6. Recommendation Follow-up: 2014 OIG Report: Vulnerabilities in the HHS Small Business Innovation Research (SBIR) Program

Issue: In 2011, the OIG found that 31% of HHS SBIR fund awardees had questionable or unverified eligibility for at least one requirement and that only of the four SBIR Operating Divisions did the required check for duplicative funding within HHS. None of the OpDivs cross-checked for duplicative awards across other federal agencies. In 2014, it made two recommendations to HHS:

  • Ensure compliance with SBIR eligibility requirements; and
  • Improve procedures to check for duplicative awards.

OIG Action: The OIG will review whether HHS has implemented these recommendations and achieved improvements in its OpDivs oversight operations.

7. States’ Procurement of Private Contracting Services for the Medicaid Management Information System (MMIS)

Issue: States have reportedly had issues with private MMIS contractors, including with initial procurements.

OIG Action: The OIG will determine if selected states followed applicable federal and state requirements for procuring private MMIS contracting services and claiming federal Medicaid reimbursement.

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