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OIG June 2018 Work Plan Update

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The OIG added eight new items to its Work Plan in the June 2018 update. Among the items addressed are contingency planning for information technology systems, denials and appeals in Medicare Part D, review of certain home health claims for services, inappropriate denial of services and payment in Medicare Advantage, national background checks, and Accountable Care Organizations' strategies aimed at reducing spending and improving quality.

CMS's Contingency Planning for Information Technology Systems

The OIG will review whether CMS's contingency planning for its information technology systems is sufficient to ensure continuity of operations, meet essential functions, and comply with federal requirements.

Denials and Appeals in Medicare Part D

CMS pays for Medicare Part D benefits on a capitated basis, which can create an incentive for an insurer to deny access to services or payments in order to increase profits. The OIG plans to review the extent to which denials of Part D benefits or payments were overturned at each level of appeal, and examine variations in appeals and overturned denials across Part D contracts.

Review of Home Health Claims for Services with Five to Ten Skilled Visits

A home health agency (HHA) receives a standardized per-visit payment based on visit type when providing four or fewer visits from a skilled service provider, referred to as Low Utilization Payment Adjustments. When an HHA provides a fifth visit, it will receive a full 60-day payment based on episode of care. The OIG plans to review documentation to determine whether HHAs that submitted home health claims with five to ten visits had met the conditions for coverage and other federal guidance.

Inappropriate Denial of Services and Payment in Medicare Advantage

CMS pays for Medicare Advantage benefits on a capitated basis, which can incentivize an insurer to deny access to services or payments in order to increase its profits. The OIG plans to review medical records to determine the extent to which beneficiaries and providers were denied preauthorization or payment for medically necessary services covered by Medicare.

National Background Check Program: Assessment of Concluded State Grant Programs in 2017

The Patient Protection and Affordable Care Act (ACA) authorizes CMS to provide grants to states for purposes of performing background checks of prospective employees and providers of long term care services. As required by the ACA, the OIG will determine the outcomes of those grant programs, including whether the background checks led to any unintended consequences.

Medicare Part B Payments for End-Stage Renal Disease Dialysis Services

The OIG plans to continue claims reviews of Medicare Part B dialysis services provided to beneficiaries with end-stage renal disease because prior OIG work identified inappropriate Medicare payments for such services. For example, the OIG previously identified unallowable Medicare payments for treatments not furnished or documented, services provided with insufficient documentation to support medical necessity, and services that were not ordered by a physician or that were ordered by a physician who was not treating the patient.

State and Territory Response and Recovery Activities for the 2017 Hurricanes

The OIG will determine whether state and territory emergency preparedness plans included necessary activities to provide ongoing response and recovery operations, including an assessment of the response and activities related to the 2017 hurricanes: Harvey, Irma, and Maria.

Accountable Care Organizations' Strategies Aimed at Reducing Spending and Improving Quality

The OIG will identify Accountable Care Organizations' (ACO) strategies for reducing spending and improving quality by describing such strategies in different services areas, such as hospitals and nursing homes. The OIG will also identify ACO strategies for working with physicians, engaging beneficiaries, managing the care of beneficiaries needing high-cost and complex care, and using data and technology.

Announced Agency Title Component Report Number(s)
June 2018 Centers for Medicare & Medicaid Services CMS's Contingency Planning for Information Technology Systems Office of Audit Services W-00-18-42023
June 2018 Centers for Medicare & Medicaid Services Denials and Appeals in Medicare Part D Office of Evaluation and Inspections OEI-09-16-00411
June 2018 Centers for Medicare & Medicaid Services Review of Home Health Claims for Services With 5 to 10 Skilled Visits Office of Audit Services W-00-18-35813
June 2018 Centers for Medicare & Medicaid Services Inappropriate Denial of Services and Payment in Medicare Advantage Office of Evaluation and Inspections OEI-09-18-00260
June 2018 Centers for Medicare & Medicaid Services National Background Check Program: Assessment of Concluded State Grant Programs in 2017 Office of Evaluation and Inspections OEI-07-18-00290
June 2018 Centers for Medicare & Medicaid Services Medicare Part B Payments for End-Stage Renal Disease Dialysis Services Office of Audit Services W-00-18-35811
June 2018 Administration for Children and Families, CDC, & HRSA State and Territory Response and Recovery Activities for the 2017 Hurricanes Office of Audit Services W-00-18-59438
June 2018 Centers for Medicare & Medicaid Services Accountable Care Organizations' Strategies Aimed at Reducing Spending and Improving Quality Office of Evaluation and Inspections OEI-02-15-00451


Reviewed by Kristin Cilento Carter, 410.862.1109, kcarter@bakerdonelson.com.

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