OIG Work Plan Update: New Items Added

As of August 2019, 12 new items have been added to the OIG Work Plan:

1. The first item issued from the OIG is titled, "Medicare Payments of Positive Airway Pressure Devices for Obstructive Sleep Apnea Without Conducting a Prior Sleep Study". An OIG analysis of the 2017 Comprehensive Error Rate Testing (CERT) program for positive airway pressure (PAP) device payments shows potential overpayments of $566 million. Claims for PAP devices used to treat obstructive sleep apnea (OSA) for beneficiaries who have not had a positive diagnosis of OSA based on an appropriate sleep study are not reasonable and necessary (Medicare National Coverage Determination Manual, Chapter 1, Part 4, § 240.4 and Local Coverage Determination (LCD) L33718). Medicare will not pay for items or services that are not "reasonable and necessary" (Social Security Act § 1862(a)(1)(A)). Here, the OIG will examine Medicare payments to durable medical equipment providers for PAP devices used to treat OSA to determine whether an appropriate sleep study was conducted. (expected issue date FY 2020)
2. The second item issued from the OIG is titled, "States' Medicaid Agency Claims for Indian Health Service Expenditures". The Federal government pays its share of a State's Medicaid expenditures based on the Federal Medical Assistance Percentage (FMAP), which varies depending on the State's relative per capita income. States' regular FMAPs range from a low of 50 percent to a high of 83 percent; however, States receive a 100-percent FMAP for expenditures related to services received through Indian Health Service (IHS) facilities. In Federal fiscal years 2016 through 2018, States claimed $6.6 billion in expenditures at the IHS services FMAP, all of which was federally funded. The OIG will analyze selected States' methodologies for identifying expenditures claimed at the IHS services FMAP and determine whether the States claimed these expenditures in accordance with Federal requirements. (expected issue date FY 2020)
3. The third item issued from the OIG is titled, "Review of the Medicare DRG Window Policy". Outpatient services directly related to an inpatient admission are considered part of the inpatient payment and are not separately payable by Medicare. The diagnosis-related group (DRG) window policy defines when CMS considers outpatient services to be an extension of inpatient admissions, and generally includes services that are (1) provided within the 3 days immediately preceding an inpatient admission to an acute-care hospital, (2) diagnostic services or admission-related nondiagnostic services, and (3) provided by the admitting hospital or by an entity wholly owned or operated by the admitting hospital. Building on previous OIG work, they will determine the number of admission-related outpatient services that were not covered by the DRG window policy in 2018, including services that were provided prior to the start of the DRG window and services that were provided at hospitals that shared a common owner. The OIG will also determine the amounts that Medicare and beneficiaries would have saved in 2018 if the DRG window policy had been updated to include more days and other hospital ownership structures. In addition, they will interview CMS staff to identify other payment models that CMS could use to pay for outpatient services related to inpatient admissions. (expected issue date FY 2020)
4. The fourth item issued from the OIG is titled, "Opioids in Medicaid: Review of Extreme Use and Overprescribing in the Appalachian Region". Opioid abuse and overdose deaths remain at crisis levels in the United States and the Appalachian region. In 2017, opioids were involved in nearly 48,000 overdose deaths nation-wide, and the opioid overdose death rate was 72 percent higher in Appalachian counties than non-Appalachian counties. These issues are of particular concern for Medicaid beneficiaries, who are more likely to have chronic conditions and comorbidities that require pain relief, especially those beneficiaries who qualify through a disability. Consistent with previous OIG work in Medicaid and Medicare Part D, they will identify beneficiaries who received extreme amounts of opioids through Medicaid, beneficiaries who appear to be doctor or pharmacy shopping, and prescribers associated with these beneficiaries. (expected issue date FY 2021)
5. The fifth item issued from the OIG is titled, "Medicare Market Shares for Diabetic Testing Strips from April to June 2019". Section 1847(b)(10)(B) of the Social Security Act (the Act) requires OIG to study and submit a report on the Medicare market share of diabetic testing strips (DTS) before each round of the Medicare competitive bidding program. These data briefs assist CMS in ensuring that bidding suppliers meet the statutory requirement located at section 1847(b)(10)(A) of the Act, known as the 50-percent rule. Section 50414 of the Bipartisan Budget Act of 2018 amended section 1847(b)(10)(A) by requiring that, for bids to furnish DTS on or after January 1, 2019, CMS must use both mail order and non-mail order data when assessing compliance with the 50-percent rule. Prior to that amendment, OIG reported only mail order data in its data briefs used for CMS's assessment of compliance with the 50-percent rule. For this series, the first data brief will determine the Medicare market share of mail order DTS for the 3-month period of April through June 2019. The second data brief will determine the Medicare market share of non-mail order DTS for the same 3-month period. This will be the fifth series of OIG data briefs describing the Medicare market share of DTS that OIG has produced since 2010 and the second series that will include both mail order and non-mail order DTS data. (expected issue date FY 2020)
6. The sixth item issued from the OIG is titled, "Nursing Homes: CMS Oversight of State Survey Agencies". CMS enters into agreements with State survey agencies (SAs) to conduct surveys to determine whether nursing homes are compliant with Medicare requirements. Recent reports by OIG found problems in SA performance, including not verifying whether nursing homes corrected deficiencies and not investigating complaints in a timely manner. CMS evaluates SA performance in fulfilling their surveying responsibilities, including through Federal monitoring surveys and performance thresholds described in the State Performance Standards System. When there is inadequate SA performance, CMS may impose a sanction or remedy, such as providing for training of survey teams, requiring the SA to submit a corrective action plan, or reducing the State's allotment of Federal financial participation. The OIG will describe CMS's efforts to work with SAs to improve performance by conducting interviews and reviewing supporting documentation about CMS's monitoring efforts. The OIG will also identify any challenges or barriers that may impede CMS's ability to help SAs improve performance. (expected issue date FY 2020)
7. The seventh item issued from the OIG is titled,"Nation-Wide Evaluation of the Prevention of Child Sex Trafficking in Foster Care". To be eligible to receive Federal funding under Title IV-E of the Social Security Act, States are required to submit State plans demonstrating that the State has developed policies and procedures related to identifying and providing services for children in foster care who are, or are at risk of becoming, a victim of sex trafficking. This study will evaluate the policies and procedures of all 50 States and the District of Columbia to determine (1) how States screen children in foster care to identify those who are, or are at risk of becoming, a victim of sex trafficking; and (2) how States determine appropriate services for children in foster care who are identified as, or are at risk of becoming, a victim of sex trafficking. The study will also examine the extent to which the Administration for Children and Families conducts oversight and provides guidance to States regarding children in foster care who are, or are at risk of becoming, a victim of sex trafficking. (expected issue date FY 2021)
8. The eighth item issued from the OIG is titled,"States' Prevention of Child Sex Trafficking in Foster Care". In 2013, the Administration for Children and Families reviewed statistics from several studies and found that up to 90 percent of children who were victims of sex trafficking had been involved with child welfare services, which include foster care. States are required by Federal law to develop policies and procedures related to identifying and providing services for children in foster care who are, or are at risk of becoming, a victim of sex trafficking. For select States, we will use foster care case file documentation to evaluate (1) the extent to which children were screened to determine whether they are, or are at risk of becoming, a victim of sex trafficking by using the States' policies and procedures; and (2) the extent to which children in foster care who are, or are at risk of becoming, a victim of sex trafficking were provided needed services. (expected issue date FY 2021)
9. The ninth item issued from the OIG is titled,"Use of Telehealth to Provide Behavioral Health Services in Medicaid Managed Care". Telehealth is the use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision, and information across distance. Telehealth can increase beneficiaries' access to healthcare and reduce healthcare spending. All 50 States and the District of Columbia currently provide some coverage under Medicaid of telehealth; however, limited information is available about how States use telehealth to provide behavioral health services to Medicaid managed care enrollees. This review will focus on selected States. It will analyze how these States and managed care organizations (MCOs) use telehealth to provide behavioral healthcare. It will also review selected States' monitoring and oversight of MCOs' behavioral health services provided via telehealth. Finally, it will identify States' and MCOs' practices on how to maximize the benefits and minimize the risks of providing behavioral healthcare via telehealth. (expected issue date FY 2020)
10. The tenth item issued from the OIG is titled,"Medicaid Assisted Living Services". Medicaid may provide assisted living services to beneficiaries who are medically eligible for placement in a nursing home but opt for a less medically intensive, lower-cost setting. These services may include personal care (e.g., assistance with dressing and bathing), homemaker services (e.g., housecleaning and laundry), personal emergency response services, and therapy services (i.e., physical, speech, and occupational). A 2018 Government Accountability Office (GAO) report indicated that improved Federal oversight of beneficiary health and welfare is needed in States' administration of Medicaid assisted living services. The OIG will determine whether assisted living providers are meeting quality-of-care requirements for Medicaid beneficiaries residing in assisted living facilities and whether the providers properly claimed Medicaid reimbursement for services in accordance with Federal and State requirements. (expected issue date FY 2020)
11. The eleventh item issued from the OIG is titled,"Medicare Part B Services to Medicare Beneficiaries Residing in Nursing Homes During Non-Part A Stays". Medicare pays physicians, non-physician practitioners, and other providers for services rendered to Medicare beneficiaries, including those residing in nursing homes (NHs). Most of these Part B services are not subject to consolidated billing; therefore, each provider submits a claim to Medicare. Since the 1990s, the OIG has identified problems with Part B payments for services provided to NH residents. An opportunity for fraudulent, excessive, or unnecessary Part B billing exists because NHs may not be aware of the services that the providers bill directly to Medicare, and because NHs provide access to many beneficiaries and their records. The OIG will determine whether Part B payments to Medicare beneficiaries in NHs are appropriate and whether NHs have effective compliance programs and adequate controls over the care provided to their residents. (expected issue date FY 2020)
12. The twelfth item issued from the OIG is titled,"Review of Medicare Facet Joint Procedures". Facet joint injections are an interventional technique used to diagnose or treat back pain. Several previous reviews found significant billing errors in this area, including a prior OIG review. The OIG will again review whether payments made by Medicare for facet joint procedures billed by physicians complied with Federal requirements (Social Security Act, § 1833(e), 42 CFR § 424.32(a)(1), and 42 CFR §414.40). (expected issue date FY 2020)