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Transcript for audio podcast: OIG Outlook 2014 - Full Presentation

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

[Roberta Baskin] Welcome to OIG Outlook 2014. I'm Roberta Baskin, Director of Media Communications for the Office of Inspector General. The OIG oversees the complex world of Federal health care programs, and our 2014 Work Plan is a blueprint of our oversight and enforcement efforts. They're designed to protect both the people who rely on those health care programs and the taxpayers who pay for them. Over the next half-hour, our leadership will discuss those plans for the year ahead. But first, we'll hear from our top leadership at OIG: our Inspector General Dan Levinson and our Principal Deputy Inspector General, Joanne Chiedi. Dan?

[Dan Levinson] Hello and welcome. Our mission here at the Office of Inspector General is to protect the integrity of over 300 health and human services. For over 30 years, we have fought against fraud, waste and abuse. In so doing, we work to protect the millions of Americans who rely on health and human services programs and the investment of our taxpayers. This is a period of great transition in health care as insurance marketplace models are introduced and as payment models transition from volume- to value-based. These transitions intend to produce higher quality of care at lower costs. OIG's oversight of new health insurance marketplaces will focus on four primary areas of risk: payment accuracy, eligibility controls, contracting oversight, and privacy and security issues. Many new models place great reliance on data and health information technology. We will continue to focus on the use of health information technology, including electronic health records. Where vulnerabilities are detected, we will offer recommendations for improvement. Our work is built on the core values of relevance, impact, customer focus and innovation. Roberta...

[Roberta Baskin] Thanks, Dan. Those core values lead right into our Principal Deputy Inspector General, Joanne Chiedi, introducing our shared goals to drive positive change in 2014 and beyond. Joanne?

[Joanne Chiedi] Thanks, Roberta. The Office of Inspector General has responsibility for overseeing HHS programs that account for 25 cents of every Federal dollar spent. We approach our mission by focusing on three key goals. Goal one is to fight fraud, waste and abuse. In this program, you'll hear about our planned efforts to fight fraud and abuse in areas such as prescription drugs, and home- and community-based services. Goal two is to promote quality, safety and value. A key focus of our planned work is on the quality and care of nursing homes and how often beneficiaries are harmed during their stay in nursing homes. Goal three is to secure the future of HHS programs. Health IT will remain a top priority. Continued oversight is needed to guard against misuses that could result in improper payments and substandard quality. OIG will continue to remain nimble and responsive to changes as we conduct our oversight and assessments of new and existing programs in HHS. Over the next half-hour, you'll be learning more about OIG's goals in 2014 and beyond, from our deputy inspectors general. Thank you for tuning in.

[Roberta Baskin] The Office of Audit Services is the largest civilian audit organization in the Federal government. Its Deputy Inspector General is Gloria Jarmon. Welcome, Gloria. You lead some 600-plus auditors. Talk about the issue on everyone's mind: the Affordable Care Act. How do you plan to do oversight?

[Gloria Jarmon] Well, Roberta, we actually have a strategic approach in HHS OIG for this work, where we're focusing on areas initially of highest risk. And those areas include looking at the payment accuracy. We're also looking at enrollment eligibility. We're looking at contract management issues, security issues. We have other work that relates to grants under the Affordable Care Act and additional work in the Medicaid area.

[Roberta Baskin] And what type of work are you required to do, required by Congress?

[Gloria Jarmon] We actually have a report that's required by July 1st, where we will be reporting on the effectiveness of the procedures and safeguards to prevent the enrollment of inaccurate or fraudulent applicants into the health plans that are part of the marketplaces.

[Roberta Baskin] What type of coordination -- given this big picture, what type of coordination do you have to do with other Federal agencies?

[Gloria Jarmon] It involves a lot of coordination because, as you can imagine, there's several other auditors who are also doing work in this area, including GAO, IRS auditors, and most of the state auditors are doing work in this area. So, we coordinate closely with them to make sure our work compliments each other and is overall very comprehensive.

[Roberta Baskin] In the intro, Joanne Chiedi mentioned improper payments as one of our key goals. Tell us about that audit work.

[Gloria Jarmon] We do a lot of work related to improper payments here at HHS. For one thing, the department has the largest number of reported improper payments in the Federal government, over $65 billion, which is over half of the reported improper payments government-wide. So, it's very important that we're working closely with the department to have recommendations to help reduce that number.

[Roberta Baskin] HHS is also the largest grant-making organization in the Federal government, awarding over 78,000 grants last year, totaling more than $340 billion. This has to be a huge area of your oversight work.

[Gloria Jarmon] Yes, it is. We do a lot of work related to grants oversight, also. As mentioned, we're doing work on the Affordable Care Act grants, but we're also doing work on grants that were made related to Hurricane Sandy, where there's grant money that went to HeadStart, mental health services. Our overall interest in doing this oversight work of grants is to make sure that the money went to the right people and is being spent properly.

[Roberta Baskin] HHS also awards a large number of contracts: over $19 billion in 2013. What are your oversight plans for contracts?

[Gloria Jarmon] Our oversight plans for contracts, since we're also doing work in that area related to the Affordable Care Act, where we're looking at contractor performance and management. We're looking at what should have happened, what did happen and what are some of the lessons learned, related to contract management and performance.

[Roberta Baskin] What about Medicare oversight? What would you be highlighting in the year ahead?

[Gloria Jarmon] Medicare is, as you can imagine, is a large area of our work. We continue to do work related to hospital compliance, like we did in 2013. And we're also doing compliance work at home health agencies. And those are just a couple of examples of the work we've been doing in that area.

[Robert Baskin] And with the Medicaid expansion under the Affordable Care Act, what are you looking out for there?

[Gloria Jarmon] In the Medicaid area, as in past years, we do a lot of oversight work related to Medicaid, and we will continue to do that. We will be doing additional oversight because of the impact of the Affordable Care Act. But some of the work that we do in the Medicaid area we'll be doing in 2014 includes looking at state drawdowns, to make sure the amount drawed-down can be compared to how much was spent by the states. And we're also looking at whether rebates have been collected by the states related to the pharmaceutical administered drugs.

[Roberta Baskin] Thank you, Gloria, for this little glimpse of your audit work priorities. You and your auditors are going to have a very busy year ahead.

[Gloria Jarmon] Thank you, Roberta.

[Roberta Baskin] Now a look at the work of the Office of Evaluation and Inspections, led by Deputy Inspector General Stuart Wright. Stuart's in charge of what we think of as the academic branch of OIG. Medicare and Medicaid command the majority of OEI's time, but what are some other arenas that you do evaluations for?

[Stuart Wright] Well, the majority of our work does pertain to Medicare and Medicaid. We do evaluation work across the department's program. So we also look at FDA, NIH and CDC.

[Roberta Baskin] Now, how do you choose the types of evaluations that you're going to tackle in 2014?

[Stuart Wright] We select our evaluations based on risk in accordance with organizational goals. We look at areas with fraud, waste and abuse in mind, and we also look to see whether departmental programs are working as they're intended to work.

[Roberta Baskin] Well, out of the huge bandwidth that you have, what are three areas that you're going to focus on for evaluations in the year ahead?

[Stuart Wright] Three areas that we're going to focus on would be quality of care, accuracy of payments and access to care.

[Roberta Baskin] The work that you've done on adverse events and patient harm has gotten a lot of attention. Just briefly share some of those findings.

[Stuart Wright] Sure. We previously reported on the extent to which adverse events -- these are instances where patient harm actually occurs in the hospital setting. We analyzed Medicare beneficiaries to determine how frequently how that occurred and found that more than 13 percent of beneficiaries actually had an adverse event occur to them in the hospital.

[Roberta Baskin] And in the year ahead, you're going to be expanding that work into nursing homes. Give us some headlines on that.

[Stuart Wright] Sure. We'll be expanding that work to look at adverse events in skilled nursing facilities. In addition, we will assess the extent to which those events could have been preventable, and we will assess the Medicare costs associated with those adverse events.

[Roberta Baskin] Your Medicare evaluation and management work looks at very small dollars, like a hundred dollars, but it really adds up. What's the significance?

[Stuart Wright] You're correct, Roberta. While evaluation and management's codes -- these are the services that Medicare pays for doctor visits -- are small, they add up to approximately $33 billion a year in payments.

[Roberta Baskin] Thirty-three billion a year.

[Stuart Wright] Correct. We previously reported on the trends in Medicare payments and the extent to which physicians consistently billed at the highest code levels. We will now be reporting on the extent to which those codes are accurate in terms of Medicare payments and the extent to which Medicare paid for services that they shouldn't have been paying.

[Roberta Baskin] And finally, your Medicaid managed care access work, what kinds of assessments will you be doing with the states?

[Stuart Wright] During the upcoming year, we will be assessing the extent to which states place requirements on their Medicaid managed care networks in terms of ensuring that beneficiaries have access. In addition to looking at what states have, in terms of requirements and the oversight that they perform with respect to those requirements, we will actually be assessing the extent to which beneficiaries can schedule appointments with providers.

[Roberta Baskin] And so, what's the impact of that on patients?

[Stuart Wright] Obviously, there's a real quality of care impact. Beneficiaries need to be able to schedule appointments timely, when they need care.

[Roberta Baskin] Thanks, Stuart, for sharing these insights on what you can anticipate in 2014 for OIG's upcoming evaluations and inspections.

[Stuart Wright] Thank you, Roberta.

[Roberta Baskin] Next, we'll hear from the head of the Office of Management and Policy about delivering the needed resources to support our mission. Welcome to Deputy Inspector General Paul Johnson. Paul, briefly explain what it means to deliver the tools needed across OIG, from auditors to special agents.

[Paul Johnson] Sure. People are the heartbeat of our organization at OIG. We have people across the organization who have vast expertise in HHS programs. With that expertise, they also have specific needs to do their jobs on a daily basis. So, what we do in our office is we work in partnership with people across OIG to make sure they have the resources and the systems that they need to complete their mission.

[Roberta Baskin] One of OIG's goals is advancing excellence and innovation. How do you plan to do that in the upcoming year?

[Paul Johnson] Really, by the very nature of our work, we do that every day. We partner with HHS programs across the nation, and our people bring their expertise and bring innovation and excellence, so we seed innovation in HHS on a daily basis.

[Roberta Baskin] Another big focus for OIG is data analysis. How is it supporting our fraud-fighting efforts?

[Paul Johnson] Sure. One of the first things we do is we partner with HHS programs to get the data that is most critical. Then we perform analysis of that data. We look at trends. We look for spikes. We look for decreases. We look for trends across the whole system of data. And from that, we can make conclusions about where we should target our resources. Sometimes we see increases in payments in programs, and then we'll do the next step: we'll target our resources to those areas so we can have the greatest impact. A great example of that is our Medicare Fraud Strike Forces. In these areas, we're able to target our resources, and we're seeing the results on that based on data analysis.

[Roberta Baskin] Well, in addition to fighting fraud, how else is OIG using data?

[Paul Johnson] It's really an agency-wide initiative. Across OIG, all of our staff is looking for data to use, to best target our work, so we can have the greatest impact.

[Roberta Baskin] Well, give us an example of how data analytics has had an impact.

[Paul Johnson] In the mental health area, we've been able to see great decreases in payments.

[Roberta Baskin] In community mental health centers?

[Paul Johnson] Community mental health centers. Absolutely. We've been doing a lot of work in community mental health centers over the years with our partners. Now we're able to take data, look at the decrease in payments, and we're talking about decreases of hundreds of millions of dollars. And that tells us that payments are going to the right providers, who are providing the right service to the public.

[Roberta Baskin] I hate to ask, but what are the challenges ahead in 2014?

[Paul Johnson] Like most Federal agencies, resources have been a challenge over the last couple of years. But we are working very hard to meet those challenges. Our staff is being innovative and looking for ways to ensure excellence in everything we do. So, we're very excited about the future.

[Roberta Baskin] Thank you, Paul, for your enthusiastic support, as well as sharing the challenges that we face in the coming year.

[Paul Johnson] Thanks, Roberta.

[Roberta Baskin] Turning now to our law enforcement efforts, Gary Cantrell is our top cop in health care, leading our Office of Investigations with some 500 special agents across the country. Welcome, Gary. I know that I can't ask you who will be investigated in the year ahead, so just start with a quick look back at what your investigative work accomplished last year.

[Gary Cantrell] Last year, our investigations resulted in outstanding outcomes. We had a record number of criminal convictions. We had a record number of civil actions, resulting in almost 5 billion dollars in investigative receivables.

[Roberta Baskin] Well, with fewer resources now, does data-driven enforcement play a bigger role?

[Gary Cantrell] We continue to use data to operate more efficiently and effectively. First of all, we've used it to allocate our resources in areas where we've seen fraud hotspots. So, this is illustrated by our Medicare Fraud Strike Force, as they're located in nine cities throughout the country. So, we work with our law enforcement partners, basing our operations in fraud hotspots, and we've found that that's been a very effective tool. And we also use data every day in the course of our investigations to shift through these cases, which can be very complex, much more quickly and efficiently.

[Roberta Baskin] So give us a sense of what kinds of trends you're following.

[Gary Cantrell] Well, we've seen some major trends, fraud trends, related to prescription drugs. And not only in the area of pain medication abuse, which we've seen over the last several years, but we're also seeing fraud schemes related to just pure financial greed, interest in stealing money from the government: billing for drugs that aren't necessary, that are expensive and never even dispensing them. So, this is both a concern for patient harm, where there's been abuse of these pain medications, and also a financial risk for the government.

[Roberta Baskin] Well, take us behind closed doors to home health and personal care services. What kinds of schemes are you seeing there?

[Gary Cantrell] Home-based services are another area where we see a lot of fraud. Unfortunately, many patients are home-bound and they need to have care provided to them in their homes. All too often, services are not being provided. The necessary services are never delivered. And in some cases, it's delivered, but it's not necessary. So, the patients aren't actually home-bound and shouldn't be receiving services in the home. That's done sometimes by paying kickbacks to induce individuals to participate in these schemes.

[Roberta Baskin] Well, you've touched on patient harm, but we say so much about dollars saved or dollars lost. Talk a little bit more about patient harm. Give us an example.

[Gary Cantrell] Yeah. Unfortunately, many of our investigations -- it's not just a financial crime. Patients are being put in harm's way. The most egregious example that we've seen in the last year was a radiology tech, working in a hospital to divert drugs for his own abuse, was taking necessary pain medications from the patients, using the syringe, and then it was being re-used to provide saline solution to patients who needed pain medication. All the while, he was infected with Hepatitis C, infecting over 40 patients in multiple states, throughout the country. Twenty of those patients were Medicare patients, and three of them were Medicaid patients. When we identify cases like this where our patients are being put in harm's way, we will pursue these aggressively and take action swiftly.

[Roberta Baskin] That is a really shocking example. Since the Affordable Care Act is so much in the spotlight, what kinds of concerns do you have on the enforcement side there?

[Gary Cantrell] Well, we're monitoring for fraud schemes related to the Affordable Care Act. And right now, we're trying to educate consumers to ensure that they're not the victims of these fraud schemes. Identity theft is certainly something we're concerned about and we're watching for. And we will also pursue any allegations of fraud relating to Affordable Care Act or consumer fraud very aggressively.

[Roberta Baskin] Gary, thanks for sharing some of the trends that you're seeing and what your enforcement priorities look like for 2014.

[Gary Cantrell] Thank you.

[Roberta Baskin] Finally, we hear from the Chief Counsel of the Office of Counsel to the Inspector General. Leading a full service in-house law firm is our top lawyer, Greg Demske. And Greg leads a team of lawyers overseeing compliance and protecting government health care programs from fraud. Welcome, Greg, and just say a few words about your role across all of OIG.

[Greg Demske] Sure, Roberta. First, we are the lawyers for OIG, which means we're advising the investigators, auditors, evaluators on the work that they're doing, day to day. And that's similar to what OIG's Counsel's Offices would do across government. But in addition to that, we have some special responsibilities. For example, we have administrative enforcement authority to exclude providers from participating in Federal health care programs.

[Roberta Baskin] Very important.

[Greg Demske] And also to issue civil money penalties, or CMPs, against those who commit fraud against our programs.

[Roberta Baskin] You also provide guidance to the entire health care community. What are some examples of that?

[Greg Demske] That's right. That's one of our other special responsibilities: guidance. And Congress has required us to give some guidance. For example, under the anti-kickback statute -- this is a statute that is very broad and covers the entire health care arena -- we are required to issue safe harbor regulations and advisory opinions that help define the contours of that broad statute. But in addition to what we're required to do, OIG has a longstanding commitment to providing guidance to providers who are trying to do the right thing and promote compliance from within. So, for example, we've issued compliance program guidance, fraud alerts, bulletins, videos; all of which is available on the website.

[Roberta Baskin] What are some significant changes to regulations that you're proposing in the year ahead?

[Greg Demske] Well, we have regulations that govern some of the guidance that we provide but also our enforcement actions. And we don't issue a lot of regulations in OIG, but in 2014, we plan to issue proposed regulations in three areas: CMPs, exclusions and safe harbors. And these proposed regulations will really update and modernize what we already have in place and address changes to the law, saying the Affordable Care Act or other provisions. And we'll get public comment, which will allow us to bring our regulations up to date.

[Roberta Baskin] Looking ahead, what are some ways that you'll be using your administrative enforcement authorities?

[Greg Demske] Well, I see two trends that have started and will continue even more so in the future. One, we are using data and working with the auditors and evaluators, as well as investigators in OIG, to identify areas where we should look to do administrative enforcement, but also, particular subjects that we should pursue. And secondly, we are concentrating, more than ever, on bringing cases where the enforcement action supports guidance we've given. So, for example, if we've said certain conduct is problematic and violates the law, we're going to look to pursue cases for those people who violate that guidance. That's designed to provide a level playing field for those providers that are playing by the rules.

[Roberta Baskin] You do a lot of outreach to the provider community. So, what are some new ways that you'll promote compliance?

[Greg Demske] Well, in addition to the ones that I mentioned before, one of the areas that we provided guidance to in the past is for boards of directors at health care entities. And we've provided free documents in the past, but we've continued to hear from compliance officers that there's a need for more guidance for members of boards of directors. So, we plan in 2014 to issue new guidance in that area. And, really, all the guidance that we provide recognizes, number one, that we can't be everywhere. We can't be the cop on the beat, looking over the shoulder of every provider. And secondly, that the vast majority of providers are trying to comply with the law in a complex regulatory environment. So, we're going to try to give them the tools to comply from the provider side.

[Roberta Baskin] Great point. Thank you, Greg Demske, for wrapping up our program with how your lawyers promote compliance, protect the public and hold those accountable who steal from Federal health care programs. And thank you, again, to all of OIG's leadership for their contributions to this program. Please visit our website for an in-depth look at our oversight work and many resources. To stay connected to OIG's work, please sign up for our email updates and follow us on Twitter. Thanks for watching and have a healthy and happy 2014.


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