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Transcript for audio podcast: OIG Outlook 2013: Deputy IG for Evaluation and InspectionS, Stuart Wright

From the Office of Inspector General of Department of Health and Human Services

http://www.oig.hhs.gov

[Roberta Baskin] Leading the office of Evaluation and Inspections, which is like the academic branch of OIG's work, is Deputy Inspector General, Stuart Wright. And welcome to you Stuart, and let's just talk about those areas that you're going to focus on in the year ahead.

[Stuart Wright] Sure, thank you for having me. In terms of my office we conduct studies or evaluations of the department's programs. We approach our reviews by looking for instances of fraud, waste and abuse and review programs such as Medicare and Medicaid to insure that they're working effectively and in accordance with program requirements. In addition, we look at other areas of the program including FDA, CDC and NIH. Today, I'd like to talk to you about three areas: contractors, prescription drugs and quality of care.

[Roberta Baskin] Well, let's start with contractors and I know that they play a big role in oversight, but can you talk a little bit about what some of the vulnerabilities are that you've seen in the past?

[Stuart Wright] Certainly. We've done a large body of work related to contractors. These entities play critical functions for Medicare. They process all of the claims. They detect payment errors and they perform payment safeguard functions in terms of looking for instances of fraud, for purposes of making referrals to law enforcement. Over the years, we found a number of issues associated with these entities. For example, we found in some instances low numbers of proactive case development, low numbers of referrals to law enforcement and we found other problems associated with lack of access to data and inconsistent definitions related to broad terms.

[Roberta Baskin] How are you going to build on that work in terms of 2013?

[Stuart Wright] We plan a number of studies to look at the actual operations to determine whether these entities are operating in terms of what their supposed to be doing for the government. In addition, we plan to look at CMS's oversight of these entities. We also plan to look at recovery audit contractors, which are relatively new entities designed to detect and recover overpayments.

[Roberta Baskin] What about prescription drugs and Medicare? It's a huge program for your concern.

[Stuart Wright] Sure, with respect to prescription drugs or Part D of the program, we've done a number of oversight reviews looking at data, looking at the appropriateness of payments. In a recent review we reviewed all claims submitted from 60,000 retail pharmacies and identified 2600 pharmacies that had questionable billing characteristics.

[Roberta Baskin] Twenty six hundred.

[Stuart Wright] Twenty six hundred. These entities billed more than 5 billion dollars to the Medicare program and we identified instances where there were large numbers of prescriptions by individuals, you know, beneficiaries and other sorts of anomalies when those pharmacies were compared to their peers. We want to build on that work by continuing to look for payment errors in terms of duplicate payments. We plan to look at HIV/AIDS drugs and other oversight, you know, issues associated with that part of the program.

[Roberta Baskin] Saving money is obviously a theme in OIG's work, but quality of care as you mentioned, that's important, because we're talking about saving lives. What kind of work are you planning on that?

[Stuart Wright] In the last area, quality of care, we've obviously done a large body of work over the years and this has been a top priority for us. Recently we raised many concerns associated with the use of antipsychotic drugs in the nursing home population. In addition, in a separate review, we reviewed the care that Medicare beneficiaries received once they were admitted to hospitals and found that 13 percent of beneficiaries actually received care that was harmful and could result in permanent harm.

[Roberta Baskin] With 13 percent?

[Stuart Wright] Thirteen percent. In addition to those beneficiaries we found another 13 percent that had care that resulted in temporary harm. We plan to build on that work and review the care that Medicare beneficiaries receive once they're discharged from the hospital to other post-acute care settings, including skilled nursing facilities. We also plan to look at how CMS plans to handle poor performing nursing homes and look again at whether or not patients in nursing homes are being readmitted to hospitals and whether or not those readmissions were preventable.

[Roberta Baskin] Lots to do in 2013. Thank you Stuart Wright for giving us a glimpse of your priorities on evaluations in the coming year.

[Stuart Wright] Great, thank you.

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