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Management Issue 1:
Implementing the Affordable Care Act

Why This Is a Challenge

The Department is implementing and administering new programs under the Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010 (ACA) involving billions of dollars in grants, loans, and benefits payments. These programs include the Affordable Insurance Exchanges, the Consumer Operated and Oriented Plan Program, the Pre-Existing Condition Insurance Plan, the Early Retiree Reinsurance Program, the Prevention and Public Health Fund, the Center for Medicare and Medicaid Innovation, and others. In addition, the ACA enacted numerous changes and additions to existing Department programs, including Medicare and Medicaid. Noteworthy examples include novel programs, such as the Medicare Shared Savings Program, designed to improve quality and reduce cost through health care delivery and payment reform.

Responsibility for implementing ACA provisions, administering new and changed programs, and/or overseeing ACA funding rests with components across the Department, including the Centers for Medicare & Medicaid Services (CMS), the Office of the Secretary, the Health Resources and Services Administration (HRSA), the Food and Drug Administration (FDA), the National Institutes of Health (NIH), the Administration on Aging, the Centers for Disease Control and Prevention (CDC), the Indian Health Service (IHS), the Agency for Healthcare Research and Quality, and the Office of Inspector General (OIG). Many programs require close coordination between the Department and other federal and State agencies. Additional ongoing implementation and operational challenges include the magnitude, complexity, and novelty of programs; compressed implementation timelines; and marketplace dynamics.

Focusing on integrity in these programs is essential to ensuring that they operate with economy and efficiency and are free from fraud, waste, and abuse. The Department and its partners must identify and mitigate program vulnerabilities and prioritize oversight resources. The Department must also ensure that providers, insurers, employers, and program beneficiaries understand their rights, responsibilities, and obligations under the new law.

Progress in Addressing the Challenge

The Department and its partners have issued and are continuing to issue regulations and other guidance for ACA programs. The Department has made a range of resources available on its Web site to inform the public about these programs and is working with States and other entities to identify potential program vulnerabilities and set up guidelines and systems to mitigate risks. The Department has continued to fortify its infrastructure to support the implementation, administration, and oversight of new and expanded programs. OIG has provided technical assistance to CMS and other Department components to assist in identifying and preventing program integrity vulnerabilities. Moreover, OIG plans to examine several ACA programs in fiscal year (FY) 2012, including the Early Retiree Reinsurance Program, the Prevention and Public Health Fund, and ACA-funded Community Health Centers. Additional progress related to the ACA is described elsewhere in these challenges.

What Needs To Be Done

The Department and its partners must be vigilant in identifying and addressing existing and emerging fraud, waste, and abuse risk areas in ACA-related programs. The Department should continue to apply lessons learned about accountability, transparency, compliance, and risk management from its American Reinvestment and Recovery Act (Recovery Act) and other program experiences to ACA implementation and oversight. The Department should also continue to train staff overseeing ACA grants and contracts on effective internal controls and best practices for preventing and detecting fraud, waste, and abuse. Data systems supporting ACA programs must be scrutinized for accuracy and completeness, as well as compliance with security and privacy rules. The Department, including OIG, should continue to implement the full complement of program integrity provisions in the ACA and identify the most effective ways to use new oversight authorities and tools. The Department should continue its efforts to provide stakeholders with clear guidance about ACA programs.

Additional recommendations for addressing ACA-related vulnerabilities appear elsewhere in these challenges.

Key OIG Resources

Management Issue 2: Preventing and Detecting Medicare and Medicaid Fraud

Office of Inspector General, U.S. Department of Health and Human Services | 330 Independence Avenue, SW, Washington, DC 20201