OIG Work Plan 2017 – An Introduction

OIG-Work-Plan-2017-Introduction

On November 15, 2016, the Office of Inspector General (OIG) released the OIG Work Plan 2017. Totaling over 100 pages this year, you can download the OIG 2017 Work Plan here on our website.  This is part of the OIG mission to protect the integrity of HHS programs and the health and welfare of the people served by those programs.  The OIG does this through a nationwide network of audits, investigations, and evaluations, as well as compliance, and educational activities.

The OIG assesses relative risks in HHS programs and operations to identify those areas most in need of attention and, accordingly, to set priorities for the sequence and proportion of resources to be allocated.

In 2016, the OIG Work Plan expanded the focus on delivery system reform, effectiveness of alternate payment models, coordinated care programs, and value-based purchasing. The OIG Work Plan 2017 describes OIG audits and evaluations that are underway, completed or planned and certain legal and investigative initiatives that will continue the efforts of their project plans.

Monitoring Medicare Payments for Clinical Diagnostic Laboratory Tests

  • Under the new OIG Work Plan 2017, the OIG is required to conduct an annual analysis of the top 25 laboratory tests by Medicare payments and analyze the implementation and effect of the new payment system required by PAMA (Protecting Access to Medicare Act). They will analyze Medicare payments for clinical diagnostic laboratory tests performed in 2016.  It will also monitor CMS’ implementation of the new Medicare payment system for these tests. This work will build upon the OIG’s previous analyses of Medicare Part B laboratory test payments in 2014 and 2015 and their review of CMS’s progress toward implementing the new Medicare payment system.

Medicare Part D Rebates Related to Drugs Dispensed by 340B Pharmacies

  • Under the OIG Work Plan 2017, the OIG will attempt to determine what could be saved if pharmaceutical manufacturers paid rebates for drugs dispensed through the Medicare Part D program at 340B covered entities and contract pharmacies. Currently, drug manufacturer rebates reduce the cost of the Part D Program to beneficiaries and the Government. Manufacturers frequently do not pay rebates for Part D prescriptions filled at 340B covered entities and contract pharmacies since they are already providing a discount on the purchase of the drug. The Medicare Part D program does not share in the purchase discounts. Savings could be realized if requirements similar to those of the Medicaid Drug Rebate Program that require manufacturers to pay rebates were adopted by the Medicare Part D program.

Selected Inpatient and Outpatient Billing Requirements

  • Under the OIG Work Plan 2017, the OIG will review Medicare payments to acute care hospitals to determine hospitals’ compliance with selected billing requirements and recommend recovery of overpayments.  This review will be part of a series of hospital compliance reviews that focus on hospitals with claims that may be at risk for overpayments. Prior OIG reviews and investigations have identified areas at risk for noncompliance with Medicare billing requirements.

OIG Work Plan 2017 – Reporting Overpayments

When a provider realizes an overpayment has occurred, they are allowed to investigate and confirm that an overpayment has been made before the 60-day reporting clock begins to run.  An overpayment generally includes any amounts a provider has received to which it arguably is not entitled and can include situations and misunderstandings for which providers often believe they should not be penalized for. For example:

  • Memorial Hermann Health System (MHHS), Texas, agreed to pay $5,652,628.00 for improperly submitted claims to Federal health care programs for certain outpatient services that automatically appended modifiers 59 (distinct procedure) or 91 (repeat lab test) to Current Procedural Terminology codes.
  • Med Solutions, LLC (Med Solutions), New Jersey, agreed to pay $429,683.40 for allegedly double billing Medicare Part B for vials of Remicade, a physician-administered injectable medication used to treat autoimmune diseases. Med Solutions was permitted to administer partial vials of Remicade to avoid product waste, but was not permitted to bill for the same vial more than once.

As you can imagine, based on the above noted overpayments resulting in self-disclosure, the largest body of work for the OIG involves investigating matters related to Medicare and Medicaid waste, fraud and abuse. That’s why it is important to have an effective corporate compliance program that includes auditing and monitoring activities, staff education and training, and other important OIG recommended guidelines.

The OIG Work Plan 2017 can be one source for health care organizations considering their own audit and monitoring activities as part of a Corporate Compliance Program.  It captures the areas the investigatory arm of HHS thinks represent areas of risk for HHS – and taxpayers!

When you need proven expertise and performance

Cindy Winn, MBA, CHSP

Ms. Cindy Winn has over 20 years of healthcare experience and expertise in operations, project management, and is certified as a HIPAA Security Professional (CHSP).

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