Between August and September 2018, the Department of Health and Human Services (HHS) Office of Inspector General (OIG) added fourteen new items to its Work Plan, covering a variety of hot topics. Some of the new additions related to the Centers for Medicare & Medicaid Services (CMS) are excerpted and summarized below.
Review of States’ Oversight of Opioids
In the August 2018 update, the OIG added a review of data collected by the Centers for Disease Control and Prevention to ascertain any opioid overdose trends from 2013 through 2016. The review, only to affect selected states, will include an analysis of policies and procedures, data analytics, and outreach in relation to opioid prescribing and the monitoring of opioid abuse.
CMS Oversight of Nursing Facility Staffing Levels
The OIG will examine nursing staff levels reported to the Payroll-Based Journal to ensure accuracy and that facilities are meeting their staffing requirements. Staffing requirements for nursing facilities that receive Medicare and Medicaid payments vary, and the facilities are required to provide “sufficient” licensed nursing services 24 hours per day, including a registered nurse for at least eight consecutive hours each day.
Hospital Compliance with Medicare Transfer Policy
The OIG plans to review whether Medicare appropriately paid hospitals’ inpatient claims subject to the post- acute care transfer policy when either: patients resumed home health services after discharge or hospitals applied condition codes to claims to receive a full diagnosis-related group (DRG) payment. CMS pays acute care hospitals for inpatient stays under Medicare Part A based on prospective rates. This means that when a hospital discharges a beneficiary, the hospital receives the full amount for the corresponding DRG. However, if a hospital transfers a beneficiary to another facility or to home health, services are then paid at a graduated per diem rate not to exceed the full DRG payment. A hospital can apply specific condition codes to the claim and receive the full DRG payment for transfers to home health services.
Physician Billing for Critical Care Evaluation and Management Services
Medicare pays physicians for critical care services based on the number of minutes they spend with critical care patients. While there is no strict location requirement as to where physicians provide critical care services, services are typically provided in an intensive care or emergency department. OIG will be examining whether Medicare payments for critical care are appropriate and paid in accordance with Medicare requirements.
Testing of Affordable Care Act Website and Associated Systems
The OIG will be conducting security testing on the healthcare.gov website and the information technology infrastructure for the Federally Facilitated Marketplace established under the Affordable Care Act to determine whether CMS has implemented effective information security controls.
Medicare Payments for Clinical Diagnostic Laboratory Tests
Under the Protecting Access to Medicare Act of 2014, the OIG is required to release the annual analysis of the top 25 laboratory test expenditures for 2017.
Report on Medicare Market Share of Diabetic Test Strips
Before each round of the Medicare competitive bidding program, the OIG is required to report on the Medicare market share of both mail order and non-mail-order diabetic test strips (DTS). The OIG will be releasing two data briefs, one exploring the Medicare market share of mail order diabetic test strips from the period of April through June 2018, while the other will review the Medicare market share of non-mail-order diabetic test strips for the same three-month period.