The Department of Health and Human Services (HHS) Office of Inspector General (OIG) announced several new changes in its Work Plan update for November 2022. The OIG Work Plan forecasts the projects that OIG plans to implement over the foreseeable future. These projects usually include OIG audits and evaluations. Below are the highlights from the Work Plan update of which providers and suppliers should take notice.
First, OIG will conduct a targeted audit of Medicaid nursing facilities’ use of funds related to direct patient care. In carrying out this audit, OIG plans to select three facilities in selected states to determine what percentage of Medicaid nursing facility revenue is being expended on direct patient care. The three facilities selected for review will be composed of one of each of the following types: for-profit, not-for-profit, and governmental.
Second, OIG will perform a nationwide audit of inpatient rehabilitation facilities (IRFs). In prior years, IRF claims audits and Hospital Compliance audits that include IRF claims have revealed alleged high error rates related to IRF stays which did not support that the IRF care was reasonable and necessary in accordance with Medicare requirements. In response to these findings, IRF stakeholders have asserted that Medicare audit contractors and OIG have misconstrued the IRF coverage regulations. OIG plans to utilize this planned nationwide audit to better understand which claims IRFs believe are properly payable by Medicare and whether there are areas in which CMS can clarify Medicare IRF claims payment criteria. This audit will be an independent performance audit in accordance with Generally Accepted Government Auditing Standards.
Third, OIG will review Medicare payments for trauma claims, with a focus on medical necessity. OIG has also indicated that it found that some providers have allegedly received trauma team activation payments without proper designation or verification. Currently, CMS does not track which providers are designated or verified as trauma centers. Under this review, OIG will determine the amount of Medicare overpayments and Medicare charges that affect future hospital payments and will identify providers that are not trauma centers or that billed for medically unnecessary trauma team activations.
Fourth, OIG will produce a report analyzing the impact of discarded-drug refunds on biosimilar drugs. Manufacturers of certain single-dose containers or single-use package drugs, including biosimilar products, payable under Medicare Part B are generally required to provide a refund for the discarded amounts of such drugs. OIG’s report will determine the impact of discarded-drug refunds on licensure, market entry, market retention, and marketing of biosimilar drugs and will be submitted to Congress.
Lastly, OIG will review the National Institutes of Health (NIH) grant post-award closeout process. A closeout of an award is the process by which NIH determines that all applicable administrative actions and all required work under an award have been completed by the recipient and NIH. Prior OIG reviews have identified issues regarding this process, and OIG plans to use this review to determine whether NIH closed its grants in accordance with Federal requirements and departmental guidance, as well as determine which actions NIH took to address noncompliance with closeout requirements.
For over 35 years, Wachler & Associates has represented healthcare providers and suppliers nationwide in a variety of health law matters, and our attorneys can assist providers and suppliers in understanding new developments in healthcare law and regulation. If you or your healthcare entity has any questions pertaining to OIG reviews or healthcare compliance, please contact an experienced healthcare attorney at 248-544-0888 or firstname.lastname@example.org.