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Active Work Plan Items

Work Plan Home | Recently Added | Work Plan Archive

Active Work Plan Items reflect OIG audits, evaluations, and inspections that are underway or planned. Search the Work Plan using any words or numbers or download the Active Work Plan Items into a spreadsheet.

Announced or Revised Agency Title Component Report Number(s) Expected Issue Date (FY) Summary Tags
Announced or Revised Agency Title Component Report Number(s) Expected Issue Date (FY) Summary Tags
November 2022 National Institutes of Health NIH Grant Closeout Process Office of Audit Services WA-23-0001 (W-00-23-59475) 2023 The National Institutes of Health (NIH) invests approximately $41.7 billion annually in medical research and is the largest Federal funding source for health research and development. Prior OIG work identified issues regarding NIH's grant post-award closeout processes. 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 (45 CFR § 75.381). We will determine whether NIH closed its grants in accordance with Federal requirements and departmental guidance. We will also determine which actions NIH took to address noncompliance with closeout requirements. Departmental Operational Issues, Financial Stewardship, Grants
November 2022 Administration for Children and Families States' Oversight of Residential Facilities To Protect Children From Maltreatment Office of Evaluation and Inspections OEI-07-22-00530 2024 States monitor and license federally funded residential facilities for children, but policymakers and the media have reported on incidents of child abuse and neglect (collectively referred to as maltreatment) that raise concerns about the effectiveness of States' oversight efforts to protect children in these settings. We will interview State child welfare and licensing agencies to assess how they monitor and address reports of maltreatment in child residential facilities. Identification of gaps in State oversight of residential facilities for children and potential promising practices (e.g., innovative policies or activities that could help address maltreatment) could help the Administration for Children and Families and States improve their oversight and better protect the children placed in these facilities. Quality of Care, Children and Families, Grants
November 20222 Centers for Medicare and Medicaid Services Inpatient Rehabilitation Facility Nationwide Audit Office of Audit Services WA-22-0014 (W-00-22-35891) 2024 Inpatient rehabilitation facilities (IRFs) provide intensive inpatient rehabilitation therapy for patients who have complex nursing, medical management, and rehabilitation needs that require hospital-level treatment in an inpatient environment. In fiscal year 2021, Medicare paid approximately $8.7 billion for 373,000 IRF stays nationwide. The Centers for Medicare & Medicaid Services (CMS) has consistently found high IRF error rates through its Comprehensive Error Rate Testing program. For an IRF claim to be considered reasonable and necessary, it must meet certain coverage and documentation requirements. We issued a nationwide audit of IRF claims in September 2018, Many Inpatient Rehabilitation Facility Stays Did Not Meet Medicare Coverage and Documentation Requirements (A-01-15-00500), that found that medical record documentation for 175 of 220 sampled IRF stays did not support that the IRF care was reasonable and necessary in accordance with Medicare requirements. Our Hospital Compliance audits also frequently include IRF claims and have similarly found high error rates. In response to these findings, IRF stakeholders have stated that Medicare audit contractors and OIG have misconstrued the IRF coverage regulations. To better understand which claims IRFs believe are properly payable by Medicare, OIG needs more information from the IRF stakeholders. We plan to determine whether there are areas in which CMS can clarify Medicare IRF claims payment criteria. In addition, we will follow up on recommendations from our prior IRF audit, A-01-15-00500. We believe data and input from IRF stakeholders are critical to identifying any specific areas that might require clarification and will result in more meaningful recommendations and a greater positive impact on the program. This audit will be an independent performance audit in accordance with Generally Accepted Government Auditing Standards. Financial Stewardship, Hospitals, Medicare A
November 2022 Health Resources and Service Administration Access to Medications for Opioid Use Disorder at Health Centers Office of Evaluation and Inspections OEI-BL-22-00520 2024 Access to medications for opioid use disorder (MOUDs) is essential for addressing the opioid epidemic in the United States. However, patients continue to encounter barriers to accessing affordable and quality treatment services. OIG will examine access to MOUDs through health centers funded by the Health Resources and Services Administration (HRSA). Health centers play a pivotal role in expanding access to MOUDs in the primary care setting because they provide high-quality and comprehensive care regardless of patients' ability to pay. HRSA has also awarded funding to health centers to expand access to substance use disorder treatment. This study will provide critical information on expanding MOUD access through HRSA's Health Center Program. We will examine how many health centers provide MOUD services, which types of services they provide (e.g., specific medications and behavioral health services, such as counseling), and how many patients health centers are treating with MOUDs. We will also examine the factors that may either facilitate or hinder the provision of MOUDs at health centers. Mental Health, Physician and Healthcare Practitioners, Prescription Drug, Public Health Issues, Quality of Care, Substance Abuse Disorders, Other Minorities, Grants, Medicaid, Medicare D, Private Insurance
November 2022 Centers for Medicare and Medicaid Services Review of Medicare Payments for Trauma Claims Office of Audit Services WA-23-0004 (W-00-23-35893) 2024 There have been concerns about trauma centers improperly billing for trauma team activation that is not medically necessary. In addition, we found some providers have received trauma team activation payments without proper designation or verification. Currently, CMS does not track which providers are designated or verified as trauma centers. We will determine the amount of Medicare overpayments and Medicare charges that affect future hospital payments, and we will identify providers that are not trauma centers or that billed for medically unnecessary trauma team activations. Financial Stewardship, Hospitals, Medicare A, Medicare B
November 2022 Centers for Medicare and Medicaid Services Reported Impact of Discarded-Drug Refunds on Biosimilar Drugs Office of Audit Services WA-23-0005 (W-00-23-35894) 2024 Section 90004 of the Infrastructure Investment and Jobs Act (the Act) requires manufacturers of certain single-dose containers or single-use package drugs, including biosimilar biologic products, payable under Medicare Part B to provide a refund for the discarded amounts of such drugs. In addition, section 90004 of the Act requires OIG, after consultation with CMS and the Food and Drug Administration, to submit a report to Congress on any reported impact that section 90004 may have on the licensure, market entry, market retention, or marketing of biosimilar biologic products. As such, we will determine the reported impact of discarded-drug refunds on licensure, market entry, market retention, or marketing of biosimilar drugs and submit a report to Congress. Prescription Drug, Medicare B
November 2022 Centers for Medicare and Medicaid Services 2022 Performance Data for the Senior Medicare Patrol Projects Office of Evaluation and Inspections OEI-02-23-00150 2023 This memorandum report presents performance data for the Senior Medicare Patrol projects, which receive grants from the Administration for Community Living to recruit and train retired professionals and other senior citizens to recognize and report instances or patterns of health care fraud. OIG has collected these performance data since 1997. tags
November 2022 Centers for Medicare and Medicaid Services Medicare Part B Drug Payments: Impact of Price Substitutions Based on 2021 Average Sales Prices Office of Evaluation and Inspections OEI-03-23-00120 2023 When Congress established average sales price (ASP) as the basis for Medicare Part B drug reimbursements, it also provided a mechanism for monitoring market prices and limiting potentially excessive Medicare payment amounts. The Social Security Act mandates that OIG compare ASPs with average manufacturer prices (AMPs). If OIG finds that the ASP for a drug exceeds the AMP by 5 percent in the two previous quarters or in three of the previous four quarters, the Secretary of HHS may substitute the reimbursement amount with a lower calculated rate. Over the past decade, OIG has produced annual reports aggregating the results of mandated quarterly ASP-to-AMP comparisons. This annual report will quantify the savings to Medicare and its beneficiaries that are a direct result of CMS's price substitution policy based on 2021 ASPs and may offer recommendations for Medicare to achieve additional savings. tags
November 2022 Centers for Medicare and Medicaid Services Comparison of Average Sales Prices and Average Manufacturer Prices Office of Evaluation and Inspections OEI-03-23-00070;
OEI-03-23-00080;
OEI-03-23-00090;
OEI-03-23-00100
2023 When Congress established average sales price (ASP) as the basis for Medicare Part B drug reimbursement, it also provided a mechanism for monitoring market prices and limiting potentially excessive Medicare payment amounts. The Social Security Act mandates that the OIG compare ASPs with average manufacturer prices (AMPs). If OIG finds that the ASP for a drug exceeds the AMP by 5 percent in the two previous quarters or three of the previous four quarters, the Secretary of HHS may substitute the reimbursement amount with a lower calculated rate. These quarterly memos summarize the results of OIG's comparison analysis based on ASP and AMP data. The memo specifically reports the number of drugs OIG identified that met the criteria for substitution of a lower reimbursement amount. OIG Statutory Authority and Regulatory Matters; Prescription Drug; Elderly; Medicare B
November 2022 Centers for Medicare and Medicaid Services Ensuring Dual-Eligible Beneficiaries' Access to Drugs Under Part D: Mandatory Review Office of Evaluation and Inspections OEI-05-23-000130 2023 Dual-eligible beneficiaries are enrolled in Medicaid but qualify for prescription drug coverage under Medicare Part D. As long as Part D plans meet certain limitations outlined in 42 CFR § 423.120, Part D plan sponsors have discretion to include different Part D drugs and drug utilization tools in their formularies. We will review the extent to which drug formularies developed by Part D plan sponsors include drugs commonly used by dual-eligible beneficiaries as required. The Affordable Care Act, § 3313, requires OIG to conduct this review annually. tags
November 2022 Centers for Medicare and Medicaid Services Audit of Medicaid Nursing Facility Use of Funds Related to Direct Patient Care Office of Audit Services WA-23-0003 (W-00-23-31568) 2023 Improving safety, quality, and transparency of Medicaid nursing facility care is a top priority to ensure that seniors, people with disabilities, and others living in nursing homes receive reliable, high-quality care. States have broad flexibility when establishing Medicaid base and supplemental payments to provide adequate, performance-driven nursing facility rates. We will judgmentally select three facilities in selected States (one each from the following facility types: for-profit, not-for-profit, and governmental) to determine what percentage of Medicaid nursing facility revenue is being expended on direct patient care. Financial Stewardship, Nursing Homes, Nursing Facilities, and Assisted Living Facilities, Quality of Care, People with Disabilities, Elderly, Medicaid
October 2022 Centers for Medicare and Medicaid Services OIG Oversight of Medicaid Fraud Control Units Office of Evaluation and Inspections OEI-06-22-00420;
OEI-06-22-00430;
OEI-07-22-00370
2023 The 53 Medicaid Fraud Control Units (MFCUs)-located in the 50 States, the District of Columbia, Puerto Rico, and the Virgin Islands-investigate and prosecute Medicaid provider fraud as well as complaints of abuse or neglect in health care facilities, board and care facilities, and of Medicaid beneficiaries in noninstitutional or other settings. OIG provides oversight for MFCUs and administers a Federal grant award to fund a portion of each MFCU's operational costs. OIG, in exercising oversight for MFCUs, annually recertifies each MFCU and assesses each MFCU's performance and compliance with Federal requirements. OIG also provides technical assistance and training, and identifies effective practices in MFCU management and operations. We will perform onsite reviews of a sample of MFCUs. We will also issue an annual report that will analyze the statistical information that was reported by MFCUs, describing in the aggregate the outcomes of MFCU criminal and civil cases. The report will also identify trends in MFCU case results. OIG Statutory Authority and Regulatory Matters, Medicaid
October 2022 Centers for Medicare and Medicaid Services Potentially Preventable Hospitalizations of Medicare-Eligible Skilled Nursing Facility Residents Office of Audit Services WA-23-0002 (W-00-23-35892) 2024 Prior OIG work identified nursing facilities with high rates of Medicaid enrollee transfers to hospitals for a urinary tract infection (UTI), a condition that is often preventable and treatable in the nursing facility setting without requiring hospitalization. The audits disclosed that the nursing facilities often did not provide UTI prevention and detection services in accordance with its residents' care plans, increasing the residents' risk for infection and hospitalization. Previous CMS studies found that five conditions (pneumonia, congestive heart failure, UTIs, dehydration, and chronic obstructive pulmonary disease/asthma) constituted 78 percent of the long-term care resident transfers to hospitals. Additionally, sepsis is often considered a preventable condition when the underlying cause of sepsis is preventable. OIG's review of claims shows that skilled nursing facility (SNF) residents often present with one of these six conditions (pneumonia, congestive heart failure, UTIs, dehydration, chronic obstructive pulmonary disease/asthma, and sepsis) on inpatient hospitalization. We will review inpatient hospitalizations of SNF residents with any of these six conditions and determine whether the SNF provided services to residents in accordance with their care plans and professional standards of practice (42 CFR §483.21 and 42 CFR § 483.25). Hospitals, Nursing Homes, Nursing Facilities, and Assisted Living Facilities, Quality of Care, Elderly, Medicare A, Medicare B
October 2022 Centers for Medicare and Medicaid Services Implementing Average Sales Price Reporting Requirements for Skin Substitutes Office of Evaluation and Inspections OEI-BL-23-00010 2023 Before 2022, average sales price (ASP) reporting requirements applied only to Part B drugs subject to Medicaid rebate agreements. However, manufacturers of skin substitutes-used in the treatment of wounds-generally did not participate in the Medicaid drug rebate program and thus were not required to report ASPs. Congress addressed this reporting gap through the Consolidated Appropriations Act, 2021, with an implementation date of January 1, 2022. Preliminary analysis indicates that: (1) several manufacturers of skin substitutes did not report ASPs as required and (2) CMS has not uniformly set payment amounts using ASPs for cases in which manufacturers reported such data. Given that Medicare Part B spends more than $1 billion per year on skin substitutes, this Early Alert will seek to quickly identify and address reporting and implementation issues. Financial Stewardship, Prescription Drug, Elderly, Medicare B
October 2022 Centers for Disease Control and Prevention Recipients' Use of President's Emergency Plan for AIDS Relief Funds Office of Audit Services W-00-23-57300 2023 As a key implementing partner CDC works side by side with ministries of health, civil and faith-based organizations, private sector organizations, and other on-the-ground partners to improve methods for finding, treating, and preventing HIV. CDC received more than $5.4 billion for FY 2019 through 2021 (about 97 percent of the funds received by HHS during the three FYs) to accelerate HIV treatment and prevention worldwide by using public health, innovation, and data-driven approaches to achieve the global goal of HIV/AIDS epidemic control. To date, HHS-OIG has conducted 21 audits of recipients in 8 countries on 2 continents (Africa and Asia). OIG's PEPFAR oversight has helped grant recipients learn important grant and program integrity lessons that apply to ongoing and future responses to infectious diseases. In previous audits of foreign PEPFAR recipients, OIG identified unallowable expenditures, inadequate accounting systems, and internal control weaknesses. We will determine whether selected foreign or domestic recipients: (1) managed and expended PEPFAR funds in accordance with award requirements, and (2) have controls to mitigate potential risk to the PEPFAR program. Public Health Issues, Grants
October 2022 Centers for Disease Control and Prevention CDC Oversight of the President's Emergency Plan for AIDS Relief Funds Office of Audit Services W-00-23-57301 2023 The Centers for Disease Control and Prevention (CDC) has been working to combat HIV since the start of the HIV epidemic. As an implementing agency of the President's Emergency Plan for AIDS Relief (PEPFAR), CDC works side by side with foreign ministries of health and other partners to improve methods for finding, treating, and preventing HIV. CDC received more than $5.4 billion for FY 2019 through FY 2021 (about 97 percent of the funds received by HHS during the three FYs) to accelerate HIV treatment and prevention worldwide by using public health, innovation, and data-driven approaches to achieve the global goal of HIV epidemic control. To date, HHS-OIG has conducted 10 audits of CDC's PEPFAR oversight operations in 5 countries on 3 continents (Africa, Asia, and North America). OIG's PEPFAR oversight has helped CDC and other HHS staff members learn important grant and program integrity lessons that apply to ongoing and future responses to infectious diseases. In previous audits of CDC offices in the U.S. and foreign countries, OIG identified noncompliance with policies, inadequate monitoring of recipients, and internal control weaknesses in the awarding of PEPFAR funds. We will determine whether CDC: (1) effectively awarded, monitored and accounted for PEPFAR funds in accordance with Federal and departmental requirements, and the Office of the U.S. Global AIDS Coordinator and Global Health Diplomacy guidance; and (2) followed established processes for the reprogramming and/or the redirection of PEPFAR funds used for COVID-19. The audit of controls over reprogramming and/or redirection of PEPFAR funds for COVID-19 will be a collaborative audit conducted by HHS-OIG and the U.S. Agency for International Development's OIG. Each OIG will issue a separate report. COVID-19, Public Health Issues, Grants
October 2022 CDC, FDA, NIH Mandatory Review of HHS Agencies' Annual Accounting of National Drug Control Program Funds Office of Audit Services W-00-23-52312 2023 The Office of National Drug Control Policy circular: National Drug Control Program Agency Compliance Reviews requires agencies expending funds on National Drug Control Program activities to submit an accounting of such funds made during the previous fiscal year (21 U.S.C. § 1704). The policy also requires that an agency submit with its annual accounting an authentication provided by the agency's OIG that expresses a conclusion on the reliability of the agency's assertions. The circular states that if in an agency's prior year drug-related obligations were less than $50 million, the agency would not be subject to these authentication requirements. We will review how HHS agencies complied with this circular and will submit the authentication with respect to the HHS agencies' annual accounting, beginning with FY 2020, once every three years. OIG Statutory Authority and Regulatory Matters, Substance Abuse Disorders, Other Funding
September 2022 Centers for Medicare and Medicaid Services Medicaid Managed Care Plans' Focus on Fraud Referrals Office of Evaluation and Inspections OEI-03-22-00410 2024 For Medicaid managed care, States contract with private health insurance companies, or managed care plans, that have the primary responsibility for processing, paying, and monitoring the claims of providers in their networks. As such, managed care plans play a critical role in safeguarding Medicaid program integrity. According to Federal regulations, State contracts with managed care plans must require that plans promptly refer any potential fraud, waste, or abuse to State Medicaid agencies or Medicaid Fraud Control Units (MFCUs). However, both OIG and CMS have ongoing concerns about managed care plans' efforts to combat fraud, including concerns about a lack of fraud referrals. This evaluation will determine the number of potential fraud referrals managed care plans made to States, MFCUs, and other entities; determine whether managed care plan processes support the referral of potential fraud; and identify the factors that influence whether managed care plans make referrals. This work may identify ways to increase the total number of managed care plan referrals and ensure the quality and timeliness of referrals. Financial Stewardship, Managed Care, Medicaid
September 2022 Centers for Medicare and Medicaid Services Hospital Price Transparency Office of Audit Services WA-22-0013 (W-00-22-35890) 2023 CMS issued a final rule effective January 1, 2021, to improve transparency in health care costs by requiring hospitals to make their prices readily available for consumers. The rule applies to all hospitals regardless of how they are paid. CMS's final rule provided specific instructions on which items were to be included on the list as well as gross charges for each item or service, payer-specific negotiated charges for each item or service, the discounted cash price, and codes used by a hospital to identify each item or service. CMS has also outlined its monitoring and enforcement plan to ensure hospital compliance. Potential actions CMS may take for noncompliance include providing a written warning listing violations, requiring a hospital to create a corrective action plan, and imposing civil monetary penalties.

To evaluate CMS's monitoring and enforcement of the hospital price transparency rule, we will review the controls in place at CMS and statistically sample hospitals to determine whether CMS's controls are sufficient to ensure that hospital pricing information is readily available to patients as required by Federal law. Additionally, if hospitals are not in compliance with CMS's rule for listing their charges, we will contact the hospitals to determine the reason for noncompliance and determine whether CMS identified the noncompliance and imposed consequences on the hospitals.
Financial Stewardship, Hospitals, Medicare A
September 2022 Centers for Medicare and Medicaid Services Inpatient Rehabilitation Facility Nationwide Audit Office of Audit Services WA-22-0014 (W-00-22-35891) 2024 Inpatient rehabilitation facilities (IRFs) provide intensive inpatient rehabilitation therapy for patients who have complex nursing, medical management, and rehabilitation needs that require hospital-level treatment in an inpatient environment. For an IRF claim to be considered reasonable and necessary, IRFs must meet certain coverage and documentation requirements. Our prior OIG audits have identified billions of dollars in overpayments for IRF claims. We plan to determine whether there are areas where CMS can clarify Medicare IRF claims payment criteria. In addition, we will follow up on recommendations from our prior IRF audit, A-01-15-00500. Financial Stewardship, Hospitals, Medicare A
September 2022 Administration for Children and Families Protecting Children in Foster Care From Identity Theft Office of Evaluation and Inspections OEI-07-22-00510 2024 The more than 600,000 children served by U.S. foster care each year are especially vulnerable to identity theft because their personally identifiable information can be accessed by the many adults they encounter during their time in care, including noncustodial family members, foster parents, and social services personnel. Congress enacted two laws that include requirements intended to protect children in foster care from identity theft: the Child and Family Services Improvement and Innovation Act and the Preventing Sex Trafficking and Strengthening Families Act. These laws require States to conduct annual credit checks for children aged 14 or older in foster care and to help these children interpret and resolve any inaccuracies identified in credit reports. The surge in reports of identity theft and stakeholder concerns could indicate that credit checks and the resolution of credit reports may not be occurring as required by Federal law. We will evaluate records of children in foster care to determine the extent to which, in calendar year 2021: (1) State child welfare agencies implemented practices to conduct credit checks for children in foster care, (2) State child welfare agencies identified children in foster care who had credit reports that indicated identity theft, (3) State child welfare agencies supported children in foster care in interpreting credit reports and resolving cases of identity theft, and (4) the Administration for Children and Families recommended and States took preventative measures to protect children in foster care from identity theft. We will also examine demographic data to determine whether there are disparities in the provision of credit checks, the prevalence of identity theft, or the provision of preventative measures. Financial Stewardship, Quality of Care, Children and Families, Grants
August 2022 Indian Health Service Audit of Internal Controls in Place To Identify, Record, and Track Indian Health Service Sanitation Facilities Construction Program Costs Office of Audit Services WA-22-0009 (W-00-22-59474) 2023 Under the Infrastructure Investment and Jobs Act, Congress allocated $3.5 billion to the Indian Health Service (IHS) Sanitation Facilities Construction (SFC) Program to provide American Indian and Alaska Native (AI/AN) homes and communities with essential water supply, sewage disposal, and solid waste disposal facilities. The IHS Sanitation Deficiency System (SDS) is an inventory of sanitation projects developed to address existing sanitation deficiencies in AI/AN communities. As of December 31, 2021, the SDS showed 1,513 sanitation projects totaling $3.4 billion in eligible costs and $735 million in ineligible costs. Ineligible costs are the costs associated with serving commercial, industrial, or agricultural establishments, including nursing homes, health clinics, schools, hospitals, hospital quarters, and non-AI/AN homes. Our audit will determine whether IHS has internal controls to: (1) identify, record, and track project costs in the SDS and (2) ensure that appropriated funds are not used for ineligible SFC project costs. Departmental Operational Issues, Financial Stewardship, Public Health Issues, Native Americans, Grants
August 2022 Centers for Medicare and Medicaid Services Skilled Nursing Facilities' Medicare Payments to Related Parties Office of Audit Services WA-22-0004 (W-00-22-35887) 2023 Understanding skilled nursing facilities' (SNFs') costs is crucial to understanding the factors that contribute to nursing home performance and how nursing homes deliver care to beneficiaries. The cost of services, facilities, and supplies furnished to a provider by an organization related to the provider by common ownership or control may be included in the allowable cost of the provider in an amount equal to the related organization's cost. However, such cost must not exceed the price of comparable services, facilities, and supplies that could be purchased elsewhere. Medicare requires that a reported amount be the lower of either the actual cost to the related organization or the market price for comparable services, facilities, or supplies, thereby removing any incentive to realize profits through these transactions. We will determine whether SNFs are reporting related-party costs in accordance with Federal regulations. We will also determine whether a SNF's allocation of Medicare funds could impact beneficiary care, such as whether overhead costs might have increased while allocations for patient care decreased, potentially reducing care. Financial Stewardship, Nursing Homes, Nursing Facilities, and Assisted Living Facilities, Medicare A
August 2022 Office of the Secretary Reporting of Security Incidents by HHS-Contracted Service Providers Office of Audit Services W-00-22-42042 2023 In accordance with the Federal Information Security Management Act and OMB Circular A-130, Federal agencies are required to ensure external service providers that are processing, storing, or transmitting Federal information or operating information systems on behalf of the Federal Government meet the same security requirements as Federal agencies. These requirements include policies and procedures for detecting and reporting security incidents. We will conduct an audit to evaluate the effectiveness of controls at selected HHS divisions to ensure service providers are identifying and reporting cybersecurity incidents. The purpose of this audit is to determine whether HHS has effective controls that ensure service providers identify and report cybersecurity incidents in a timely manner. Information Technology and Cybersecurity, Other Funding
August 2022 Centers for Medicare and Medicaid Services CMS's Emergency Preparedness Related to Clinical Laboratories During the COVID-19 Public Health Emergency Office of Audit Services WA-22-0010 (W-00-22-35889) 2023 Laboratory tests are a critically important part of early detection, diagnosis, monitoring, and treatment of disease. During public health emergencies or disasters, CMS has the authority to provide regulatory flexibilities and waivers to ensure that Medicare beneficiaries continue to have access to needed health care. To help health care providers and suppliers prepare for these emergencies or disasters, CMS adopted a final rule (the Emergency Preparedness Rule) in September 2016. The rule required those providers and suppliers to: (1) plan adequately for both natural and manmade disasters; (2) coordinate with Federal, State, Tribal, and regional and local emergency preparedness systems; and (3) adequately prepare to meet the needs of patients during disasters and emergency situations. The rule covers 17 facility types (e.g., hospitals, hospices, and long-term care facilities) but does not cover clinical laboratories. Continued laboratory testing during a public health emergency as well as timely and reliable testing for novel infectious diseases are important for the health of Medicare beneficiaries. Effective testing for novel infectious diseases (including COVID-19) are essential in helping to slow the spread of these diseases by identifying those who are infected and enabling treatment or isolation if needed. We will conduct an audit to determine whether CMS's emergency preparedness for clinical laboratories could be improved. Specifically, we will look at CMS's emergency preparedness to ensure that: (1) beneficiaries maintain access to all types of laboratory tests, including laboratory tests for novel infectious diseases during a public health emergency, and (2) laboratories have the ability to develop and deliver timely and accurate testing for novel infectious diseases during a public health emergency.

COVID-19, Emergency Preparedness and Response, Laboratories, Public Health Issues, Elderly, Medicare B
August 2022 Centers for Medicare and Medicaid Services PRAC Collaboration on Health Care Personnel Shortages: Personnel Shortages at Nursing Homes Office of Audit Services WA-22-0011 (W-00-22-31566) 2023 The Coronavirus Aid, Relief, and Economic Security Act created the Pandemic Response Accountability Committee (PRAC). PRAC's mission is to promote transparency and support coordinated oversight of the Federal Government's COVID-19 response in order to prevent and detect fraud, waste, abuse, and mismanagement, and to mitigate major risks that cross program and agency boundaries. PRAC members include Offices of Inspectors General (OIGs) at Federal agencies, some of which operate, utilize, or are otherwise impacted by health care programs. Within PRAC, a Health Subgroup has identified health care personnel as a resource critical to the Federal Government's COVID-19 response efforts. HHSOIG will work with PRAC to produce a report that describes health care personnel shortages in Federal, health-related programs operated or overseen by various Federal agencies and summarize best practices for hiring and retaining health care personnel for possible implementation. This project will involve coordinating with OIGs from multiple agencies. HHS-OIG will focus on personnel shortages at nursing homes. COVID-19, Emergency Preparedness and Response, Nursing Homes, Nursing Facilities, and Assisted Living Facilities, Public Health Issues, Quality of Care, Elderly, Medicaid, Medicare A
August 2022 Centers for Medicare and Medicaid Services Medicare Payments for Clinical Diagnostic Laboratory Tests in 2021 Office of Evaluation and Inspections OEI-09-22-00400 2023 Medicare is the largest payer of clinical laboratory services in the United States. Medicare Part B covers most lab tests and pays 100 percent of allowable charges. The Protecting Access to Medicare Act of 2014 (PAMA) requires CMS to set payment rates for lab tests using current charges in the private health care market, under Title XVIII of the Social Security Act (Pub. L. No. 113-93 § 216(c)(2)(A)). On January 1, 2018, CMS began paying for lab tests under the new system mandated by PAMA. PAMA requires OIG to publicly release an annual analysis of the top 25 laboratory tests by expenditures. In accordance with the Act, we will publicly release an analysis of the top 25 laboratory tests by expenditures for 2021. COVID-19, Laboratories, Medicare B
August 2022 Centers for Medicare and Medicaid Services States' Medicaid Eligibility and Enrollment Actions Concluding the COVID-19 Public Health Emergency Office of Audit Services WA-22-0012 (W-00-22-31567) 2024 In response to the COVID-19 pandemic, section 6008 of the Families First Coronavirus Response Act (FFCRA) provides a temporary increase of 6.2 percentage points to each qualifying State's and Territory's Federal Medical Assistance Percentage (FMAP), effective January 1, 2020. To receive the increased FMAP, FFCRA requires States to provide benefits to individuals who were enrolled in Medicaid at the start of the COVID-19 public health emergency (PHE) or become enrolled in Medicaid during the emergency period. These individuals should remain eligible for Medicaid through the last day of the month in which the COVID-19 PHE ends (continuous enrollment period), unless the individual requests a voluntary termination of eligibility, or the individual ceases to be a resident of the State. Within the 12-month period in which the COVID-19 PHE ends, States must initiate all renewals, post-enrollment verifications, and redeterminations for all individuals enrolled when the continuous enrollment expires. At the conclusion of the COVID-19 PHE, we will review the States' required Medicaid eligibility and enrollment actions. We will determine whether States completed pending Medicaid eligibility and enrollment actions in accordance with CMS requirements that take effect after the COVID-19 PHE. COVID-19, Departmental Operational Issues, Medicaid
Revised National Institutes of Health Audit of National Institutes of Health's Data Integrity Controls for the Sequence Read Archive Data Office of Audit Services WA-22-0005 (W-00-22-42043) 2023 The National Center for Biotechnology Information (NCBI), part of the National Library of Medicine, hosts one of the National Institutes of Health's largest and most diverse datasets, the Sequence Read Archive (SRA). SRA is a broad collection of experimental DNA and RNA sequences that represent genome diversity. In 2019, SRA held 9 million records in 2 formats. The original format (23 petabytes) is received by NCBI from submitters and is instrument and experiment specific; these data are stored to tape. NCBI then transforms these original data into standard SRA normalized format (12.7 petabytes) for redistribution. Through this SRA normalized database, which is cloud based and accessed via NCBI servers, researchers can search metadata to locate the sequence reads for further analyses. SRA usage follows International Nucleotide Sequence Database Collaboration principles, which state that data are shared without restriction, that the individual submitting the data must be the owner of the data, and that ownership of the data remains with the submitter even after submission. This audit will concentrate on system integrity controls, including malicious code protection and data input validation as well as other Federal requirements for normalizing and archiving SRA data. The audit objective will be to determine whether NIH has implemented adequate system integrity controls to ensure the reliability of SRA data. Public Health Issues, Other Funding
July 2022 Centers for Medicare and Medicaid Services Congressional Mandate: Noncovered Versions of Part B Drugs Office of Evaluation and Inspections OEI-BL-22-00380 2023 Under the Consolidated Appropriations Act, 2021, Congress enacted provisions requiring CMS to remove noncovered, self-administered versions of Cimzia and Orencia from Part B payment amount calculations beginning in July 2021. Through the same legislation, Congress required OIG to conduct periodic studies to identify additional instances in which including noncovered versions of a drug were increasing Part B reimbursement amounts. In response, OIG will conduct a study every 6 months to: (1) identify any Part B drugs that have a payment amount based in part on noncovered, self-administered versions of the drug; and (2) determine whether payment amounts would have decreased or increased if noncovered, self-administered versions had been removed from payment amount calculations. Financial Stewardship, OIG Statutory Authority and Regulatory Matters, Prescription Drug, Elderly, Medicare B
July 2022 Indian Health Service Audit of Indian Health Service's Coordination of National and Regional Supply Service Center Operations to Distribute Supplies to Facilities Office of Audit Services WA-22-0002 (W-00-22-59471) 2023 The Indian Health Service (IHS) provides a comprehensive health service delivery system for approximately 2.6 million American Indians and Alaska Natives who belong to 574 federally recognized Tribes in 37 States. IHS has a decentralized management structure that consists of two major components: headquarters offices in Rockville, Maryland, and 12 area offices.

IHS's National Supply Service Center (NSSC) serves as the distribution warehouse and supply distribution management center for IHS by providing supply support services and medical supplies to IHS Federal and Tribal Hospitals, Tribal health programs, and Urban Indian Organization health care centers in all 12 IHS areas. The NSSC Director reports to the Area Director of the Oklahoma City Area. Within IHS, but separate from NSSC, the Navajo Area operates a Regional Supply Service Center (RSSC), located in Gallup, New Mexico. The RSSC Director reports to the Area Director of the Navajo Area and has no reporting relationship to NSSC. RSSC provides medical supplies to the Navajo, Albuquerque, and Phoenix IHS areas. Facilities in these three areas can order and receive supplies from both NSSC and RSSC. In a related audit, we are examining NSSC's distribution of medical supplies and equipment during the COVID-19 pandemic.

Our objective is to determine whether IHS coordinated NSSC and RSSC operations to distribute supplies to facilities in an effective manner from January 1, 2019, through March 31, 2022.
Departmental Operational Issues, Emergency Preparedness and Response, Native Americans
July 2022 Centers for Disease Control and Prevention Audit of CDC's COVID-19 'Vaccinate with Confidence' Strategy Office of Audit Services WA-22-0007 (W-00-22-59473) 2024 HHS announced the availability of $1 billion in supplemental American Rescue Plan Act of 2021 (ARP) (P.L. 117-2) funding for the Centers for Disease Control and Prevention (CDC) to support its COVID-19 strategy, "Vaccinate with Confidence: Strategy to Reinforce Confidence in COVID-19 Vaccines," which includes building trust, empowering health care personnel, and engaging communities and individuals. CDC defines "vaccine confidence" as the belief that vaccines work, are safe, and are part of a trustworthy medical system. Strong confidence in COVID-19 vaccines within communities could lead to more adults, adolescents, and children getting vaccinated. From the $1 billion in supplemental funding, CDC awarded State, Tribal, local, and Territorial (STLT) recipients a combined $250 million for developing and implementing a vaccine confidence strategy, supporting efforts to build vaccine confidence, and conducting outreach to build trust in COVID-19 vaccines, the health care personnel who provide them, and the system that approves and distributes them. These funds may be used for television, radio, internet, and other media and communications technologies; used for in-person activities; be focused to address specific needs of communities and populations with low vaccination rates; and include the dissemination of scientific and evidence-based, vaccine-related information. For the first audit, we will determine how much of each STLT recipient's award had been expended at the time of our audit, identify the best practices used and potential barriers STLT recipients faced when spending the supplemental ARP funds, and determine whether CDC provided oversight to STLT recipients in developing and implementing a vaccine confidence strategy. For the second audit, we will determine whether select STLT recipients used supplemental ARP funding in accordance with Federal requirements and applicable award terms and conditions, and for underserved communities. COVID-19, Emergency Preparedness and Response, Financial Stewardship, Grants
July 2022 Centers for Medicare and Medicaid Services Medicare Payments for Intermittent Urinary Catheters Office of Audit Services WA-22-0008 (W-00-22-35888) 2023 Medicare covers reasonable and necessary durable medical equipment, prosthetics, and orthotics supplies (DMEPOS), such as intermittent urinary catheters (Social Security Act § 1861 (n) and (s)(8), and 1862(a)(1)(A)). For calendar year 2021, Medicare paid more than $308 million for intermittent urinary catheters. Prior reviews performed by OIG and CMS contractors have identified high improper payment rates for urological supplies (including intermittent urinary catheters) that did not meet Medicare requirements. Upon request, a supplier must provide documentation from the physician or treating practitioner indicating that the urological supplies were reasonable and necessary for the beneficiary's condition (42 CFR § 410.38(d)(3)). We will audit Medicare payments for intermittent urinary catheters to determine whether claims submitted by DMEPOS suppliers complied with Medicare requirements and guidance. Medical Supplies and Equipment, Medicare B
June 2022 Food and Drug Administration Food and Drug Administration's Actions Regarding the Abbott Infant Formula Recall Office of Audit Services WA-22-0006 (W-00-22-59472) 2023 The Federal Food, Drug, and Cosmetic Act requires the Food and Drug Administration (FDA) to safeguard the Nation's food supply, including infant formula, and ensure that all ingredients are safe. As part of its oversight activities, FDA conducts inspections at infant formula manufacturers and can require infant formula manufacturers to recall adulterated infant formula that presents a risk to human health. We will determine whether FDA followed the inspections and recall process for infant formula in accordance with Federal requirements. Specifically, we will review FDA's actions leading up to the infant formula recall at the Abbott facility in February 2022 to determine whether FDA followed applicable policies and procedures to: (1) conduct inspections of the manufacturing facility and (2) oversee Abbott's initiation of the infant formula recall. Food, Drug, and Device Safety, Public Health Issues, Children and Families, Other Funding
June 2022 Centers for Medicare and Medicaid Services Medicare Administrative Contractor Cost Report Settlements with Audit Office of Audit Services W-00-22-35886 2023 HHS contracts with Medicare Administrative Contractors (MACs) to process claims and cost reports and determine payment amounts to providers (Social Security Act, § 1874A(a)). MACs determine the total amount of reimbursement based on providers' cost reports. MACs perform a desk review, and at their discretion, may perform either a field audit or an in-house audit to determine the cost report's adequacy, completeness, and accuracy. Generally, some cost reports that have been audited and settled are later reopened to correct audit adjustments. CMS has stated that it does not maintain data related to the number of cost reports that are reopened, the monetary adjustments to the settlement made as a result of reopenings, or the types and/or causes of adjustments. Our objective will be to: (1) quantify the extent to which the MAC amends audit adjustments after cost reports have been audited and settled, and whether the audit adjustments contain obvious errors or are inconsistent with the law, regulations and rulings, or general instructions; (2) quantify the effect of amended audit adjustments; and (3) gain an understanding of the types and/or causes of amended audit adjustments. Initially, we will audit a single MAC, and based on the results, we may expand this work to others. Departmental Operational Issues, Hospitals, Nursing Homes, Nursing Facilities, and Assisted Living Facilities, Medicare A, Medicare B
June 2022 Centers for Medicare and Medicaid Services States' and MCOs' Compliance With Mental Health Parity Requirements Office of Audit Services WA-22-0003 (W-00-22-31565) 2023 The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) promotes equal access to treatment for mental health and substance use disorder (MH/SUD) by prohibiting coverage limitations that apply more restrictively to MH/SUD benefits than medical or surgical benefits. Such limitations could include higher copayments, separate deductibles, and stricter preauthorization or medical necessity reviews, as compared to other covered medical treatments. Federal regulations require managed care organizations (MCOs) with plans that provide services to Medicaid enrollees to comply with the parity provisions of MHPAEA. Federal regulations require that States or their MCOs, as applicable, conduct analyses to demonstrate compliance with parity requirements. CMS reviews States' parity analyses as part of its review of States' MCO contracts. We will audit CMS's oversight of States' compliance with Federal parity requirements, including whether States and their MCOs conducted the required parity analyses and whether States ensured that their MCOs complied with certain parity requirements for MH/SUD benefits.

Hospitals, Managed Care, Mental Health, Substance Abuse Disorders, Medicaid
June 2022 Administration for Children and Families Audit of the Low Income Home Energy Assistance Program for Fiscal Years 2021 and 2022 Office of Audit Services WA-22-0001 (W-00-22-20036) 2023 The Low Income Home Energy Assistance Program (LIHEAP) assists low income households in meeting their immediate home energy needs. LIHEAP funds can be used to help pay for heating and cooling, crisis assistance, and services (such as counseling) to reduce the need for energy assistance. At the Federal level, LIHEAP is administered by the Administration for Children and Families (ACF). States either administer the LIHEAP program or award LIHEAP funds to subgrantees that administer the program on a State's behalf. Federal requirements allow for 10 percent of total grant funds to be used for planning and administering LIHEAP. Previous OIG and Government Accountability Office audits revealed that ACF oversight of LIHEAP was not adequate to ensure that States and subgrantees consistently administered grant funds in accordance with Federal requirements. Since March 2020, the Federal Government has appropriated $9.3 billion for LIHEAP through the Coronavirus Aid, Relief, and Economic Security Act, the American Rescue Plan Act, the Infrastructure Investment and Jobs Act, and the annual LIHEAP block grant. We plan to conduct a series of audits of LIHEAP in high-risk States to determine whether the selected States monitored subgrantees to ensure compliance with Federal and State LIHEAP requirements. COVID-19, Financial Stewardship, Children and Families, Grants
Revised Centers for Medicare and Medicaid Services Strategies To Improve Access to Maternal Health Care in Medicaid Managed Care Office of Evaluation and Inspections OEI-05-22-00330 2024 Pregnant people in the United States experience the worst pregnancy outcomes in the developed world, and significant disparities exist. Maternal health care can improve pregnant people's pregnancy outcomes; however, many pregnant people in the United States lack access to maternal health care. Medicaid is the Nation's largest maternal health care payor, financing more than 42 percent of all U.S. births, and many pregnant Medicaid beneficiaries are enrolled in managed care plans. This study will identify strategies to increase access overall and reduce disparities in access to maternal health care for Medicaid beneficiaries enrolled in managed care. Managed Care, Mental Health, Substance Abuse Disorders, Children and Families, Native Americans, Other Minorities, Medicaid
May 2022 Administration for Children and Families Audit of the Administration for Children and Families Awarding of an Unaccompanied Children Program Sole Source Contract to Family Endeavors, Inc. Office of Audit Services W-00-22-20035 2023 The Office of Refugee Resettlement (ORR), a program office of HHS's Administration for Children and Families (ACF), manages the Unaccompanied Children Program. In fiscal year 2021, an influx of unaccompanied children began arriving at the U.S. southern border, coinciding with the Nation's ongoing efforts to control the spread of COVID-19. As a result, ACF identified a need to increase the number of shelter beds in its provider network and entered into contracts for shelter and related services for unaccompanied children. These contracts included services for a new type of provider facility known as an emergency intake site (EIS). ACF awarded a sole source contract to Family Endeavors, Inc., a nonprofit social service agency, to operate as an EIS and provide services for unaccompanied children. Congress has expressed concerns about and the media has reported on ACF's awarding of the sole source contract to Family Endeavors, Inc. We will determine whether ACF awarded this sole source contract in accordance with Federal statutes and regulations, as well as HHS policies and procedures. Contracts, Emergency Preparedness and Response, Children and Families, Other Funding
May 2022 Centers for Medicare and Medicaid Services Accuracy of Falls Reporting in Home Health OASIS Assessments Office of Evaluation and Inspections OEI-05-22-00290 2023 In April 2022, CMS will begin publicly reporting on the Care Compare website the percentage of patients in home health care who fell and endured major injuries for each home health agency (HHA). HHAs report falls in patient assessments using the standardized Outcome and Assessment Information Set (OASIS), and CMS reports the agency fall rates calculated from these assessments. In this study, we will assess the accuracy of HHAs' reporting of falls in OASIS. Specifically, we will use Medicare claims to identify hospitalizations due to falls with major injuries among Medicare beneficiaries in home health care. We will then assess the extent to which those falls were reported in OASIS assessments. We will describe the characteristics of beneficiaries who did not have their falls reported. Finally, we will describe the characteristics of HHAs that have particularly low reporting rates. Non-institutional care, Quality of Care, Elderly, Medicare A, Medicare B, Medicare C
May 2022 Centers for Medicare and Medicaid Services Medicare Part B Add-On Payments for COVID-19 Tests Office of Audit Services W-00-22- 35884 2023 Laboratory tests are critical for early detection, diagnosis, monitoring, and treatment of disease. Effective testing for COVID-19 is essential to slow its spread by identifying those with the virus and enabling treatment or isolation. On October 15, 2020, CMS announced actions to incentivize prompt COVID-19 test turnaround times by paying more for expedited results. CMS has identified that timelier test results benefit individual patients, their immediate communities, and the public at large. Starting in 2021, the amended Administrative Ruling (CMS 2020-1-R2) lowered the base payment amount for COVID-19 clinical diagnostic laboratory tests (CDLTs) that use high-throughput technology to $75 in accordance with CMS's assessment of the resources needed for those tests. The amended ruling also established an additional $25 add-on payment for a COVID-19 CDLT that uses high-throughput technology if the laboratory: (1) completed the test in 2 calendar days or less and (2) completed a majority of the CDLTs that use high-throughput technology in 2 calendar days or less for all their patients (not just their Medicare patients) in the previous month. For this audit, we will review providers' supporting documentation for the COVID-19 CDLT add-on payments to determine whether the documentation complied with Medicare requirements.

COVID-19, Laboratories, Medicare B
May 2022 Centers for Medicare and Medicaid Services Followup Review of Inpatient Claims Under the Post-Acute-Care Transfer Policy (PACT) Office of Audit Services W-00-22-35885 2023 Medicare makes the full Medicare Severity Diagnosis-Related Group (MS-DRG) payment to a hospital that discharges an inpatient beneficiary "to home." However, for certain qualifying MS-DRGs under the post-acute-care transfer policy, Medicare pays hospitals a per diem rate when an inpatient beneficiary is transferred to post-acute care. The per diem payment cannot exceed the full payment that would have been made if the beneficiary had been discharged to home. A prior OIG review identified Medicare overpayments to hospitals that did not comply with the post-acute-care transfer policy (42 CFR § 412.4(c)). OIG's review found that the CMS Common Working File (CWF) edits that detected inpatient claims under the post-acute care transfer policy were working appropriately. However, some Medicare contractors did not receive automatic notifications of improperly billed claims or did not act to adjust those claims. As a result, OIG recommended that CMS recover the identified overpayments in line with its policies and procedures and ensure that the Medicare contractors are receiving the notifications and are acting to recover the overpayments. CMS concurred with all OIG recommendations and detailed how they were addressed. This followup audit will determine whether CMS's CWF edits are working properly in detecting inpatient claims under the post-acute-care transfer policy and are automatically recovering overpayments, and whether Medicare contractors are receiving the automatic notifications and acting to recover overpayments. Hospitals, OIG Statutory Authority and Regulatory Matters, Medicare A
Revised Centers for Medicare and Medicaid Services Use of Medications for Opioid Use Disorder (MOUD) in Medicaid Office of Evaluation and Inspections OEI-BL-22-00260 2024 Deaths from opioid overdoses surged to unprecedented levels during the COVID-19 pandemic. As of April 2021, 75,000 people died from opioid overdoses in the preceding 12 months, a 35-percent increase from the same period the year before. Access to medications that treat opioid use disorders (known as MOUD) is essential to address the high rates of opioid addiction and overdose mortality. Medicaid covers almost 40 percent of nonelderly adults with opioid use disorder (OUD), underscoring the key role that the program can play in providing access to MOUD. This study will examine the extent to which beneficiaries diagnosed with OUD receive MOUD in Medicaid. Non-institutional care, Prescription Drug, Substance Abuse Disorders, Medicaid
April 2022 Centers for Medicare and Medicaid Services Medicaid Rehabilitation Services Made by Community Residence Providers Office of Audit Services W-00-22-31563 2023 States can provide optional rehabilitation services under Medicaid programs available to adults with developmental disabilities and children and adolescents with serious emotional issues in certain community residential settings (e.g., group homes or supervised apartments). These residential rehabilitation services may include training and assistance with daily living skills, medication management, socialization, substance use disorder services, and parental training. Services are designed to improve or maintain the beneficiary's ability to remain and function in the community, as well as develop greater independence. Prior OIG audits of these services, over a decade ago, identified significant deficiencies. We will determine whether States claimed Federal Medicaid reimbursement for rehabilitation services provided by community residence providers in accordance with Federal and State requirements. In addition, we will determine whether previously audited States have made improvements to their Medicaid community residence rehabilitation programs based on the prior recommendations. Financial Stewardship, Mental Health, Non-institutional care, Quality of Care, Substance Abuse Disorders, People with Disabilities, Medicaid
April 2022 Centers for Medicare and Medicaid Services Electronic Visit Verification System for Medicaid In-Home Services Office of Audit Services W-00-22-31564 2023 TAll States must implement electronic visit verification (EVV) for personal care services (PCS) by January 1, 2020, and for home health services (HHSC) by January 1, 2023, as required by the 21st Century Cures Act. CMS granted 1-year extensions (to January 1, 2021) for the vast majority of States to meet the EVV requirements for PCS. Once implemented, EVV could increase the risk that Medicaid beneficiaries' needs are not being met, potentially compromising their health and safety. Our objectives will be to determine whether the State: (1) has implemented an EVV system in accordance with Federal and State requirements, and (2) has developed policies and procedures when using EVV to ensure that Medicaid beneficiaries receive their required in-home services.

Information Technology and Cybersecurity, Non-institutional care, Quality of Care

April 2022 Centers for Medicare and Medicaid Services Identifying Gaps in the Receipt of Recommended Care Among Medicaid Beneficiaries with HIV Office of Evaluation and Inspections OEI-05-22-00240 2023 People with HIV can improve their health and prevent HIV transmissions by receiving recommended HIV care. But certain groups with HIV, such as African Americans, are less likely to receive regular HIV care compared to other groups. Medicaid plays an important role in providing care to people with HIV, as it is the single largest source of insurance for people living with HIV. This study will identify the extent to which Medicaid beneficiaries diagnosed with HIV receive care that aligns with the widely used Federal performance measures, both overall and by selected demographic factors that include race/ethnicity, sex, and location. Identification of potential gaps and disparities in care can help CMS, States, and managed care organizations identify areas for improvement to ensure that Medicaid beneficiaries with HIV receive care that improves health outcomes and reduces HIV transmission. Managed Care, Public Health Issues, Quality of Care, Other Minorities, Medicaid
Completed (partial) Centers for Medicare and Medicaid Services COVID-19 Vaccination Status of Nursing Home Staff Office of Audit Services W-00-22-31560;
A-09-22-02003
2023 Residents of long-term care facilities (nursing homes) have been severely impacted by COVID-19 and are disproportionately represented in the number of COVID-19-related deaths in the United States. Data reported by nursing homes to the Centers for Disease Control and Prevention's National Healthcare Safety Network identified that COVID-19 infections among nursing home residents were higher in nursing homes with lower vaccination coverage among staff. The data also indicates that while nursing homes have made significant progress in vaccinating their residents, approximately one in five nursing home staff were not vaccinated as of the end of 2021. CMS amended Federal regulations at 42 CFR § 483.80 to require that nursing home staff be fully vaccinated against COVID-19. The regulations allow nursing homes to grant staff exemptions from the vaccination requirements based on Federal law (e.g., for specific medical and religious reasons). The regulations, among other things, also require nursing homes to track and securely document the vaccination status of staff, exemptions requested, and exemptions granted. The effective date of the regulations varies by State, but all States must be in compliance by March 21, 2022. Through a series of audits, we will determine whether nursing homes nationwide are in compliance with the regulations and identify the COVID-19 vaccination status of their staff members. COVID-19, Emergency Preparedness and Response, Nursing Homes, Nursing Facilities, and Assisted Living Facilities, Elderly, Medicaid, Medicare A
March 2022 Centers for Medicare and Medicaid Services Medicaid Estate Recovery Program Office of Audit Services W-00-22-31561 2023 Several States have not implemented all the requirements of their Medicaid Estate Recovery Programs; therefore, they might be running the programs ineffectively and not recovering certain long-term care costs due from the applicable estates of deceased Medicaid recipients. We will determine whether State agencies, under their Medicaid Estate Recovery Programs: (1) had policies and procedures to comply with Federal and State requirements, (2) attempted to recover the applicable reimbursement costs for certain long-term care, (3) accurately reported Medicaid estate recovery amounts associated with certain long-term care services on the CMS-64, and (4) identified the costs incurred to recover from the estates. Financial Stewardship, Nursing Homes, Nursing Facilities, and Assisted Living Facilities, Medicaid
March 2022 Centers for Medicare and Medicaid Services Achieved Savings Rebate Program-Offset of Rebates on CMS-64 Office of Audit Services W-00-22-31562 2023 The Social Security Act (the Act) Section 1115 gives CMS authority to approve experimental, pilot or demonstration projects that it considers likely to assist in promoting the objectives of the Medicaid program. States may then use CMS-approved waivers to have Managed Care Organizations (MCOs) provide care to Medicaid beneficiaries. Under these arrangements, States make capitation payments to the MCOs in return for the MCOs providing the patient care for the Medicaid beneficiaries. Some States place limitations on MCOs' earnings, for example, limiting the profits they may earn or requiring a certain percentage of their revenues to be spent on medical expenses. States with such limitations may require the MCOs to return a portion of the capitation payments when the MCOs exceed those limitations. According to the Act, § 1903(d)(3)(A) States are required to refund to the Federal Government the Federal share of any amounts recovered during any fiscal quarter. Additionally, 45 CFR § 75.406(a) requires recipients of Federal awards (which includes State Medicaid agencies) to credit to the Federal award the Federal share of reduction-of-expenditure type transactions, such as rebates, purchase discounts, or allowances when those transactions relate to allowable costs. For selected States, we will determine whether the States properly offset against CMS-64 expenditures refunds of capitation payments received from MCOs. Financial Stewardship, Medicaid
Revised Administration for Children and Families Audit of States' Child Support Administrative Costs Office of Audit Services W-00-22-20034;
A-01-18-02501
2023 The Child Support Enforcement Program, established in 1975 under Title IV-D of the Social Security Act, functions as a Federal, State, and local partnership to collect child support payments from noncustodial parents for distribution to custodial parents. Within the Department of Health and Human Services, Administration for Children and Families, the Office of Child Support Enforcement provides Federal oversight of the program. In most States, a single State agency performs the day-to-day operations, but in others counties operate the program, and States administer it. Program responsibilities include locating noncustodial parents—those who are not the primary caregivers or do not have custody or control —, establishing paternity and support orders, and collecting and distributing child support payments. Costs to carry out these responsibilities are administrative and uncapped, so the Federal share of the program increases as States spend more on program administration. Based on a risk assessment, we will select States for review to determine whether program administrative costs claimed were allowable and allocable in accordance with Federal and State requirements. Grants, Children and Families, Financial Stewardship
February 2022 Administration for Children and Families Audit of the Administration for Children and Families Awarding and Monitoring of Unaccompanied Children Program Contracts for Emergency Intake Sites Office of Audit Services W-00-22-20033 2023 The Office of Refugee Resettlement (ORR), a program office of the Administration for Children and Families (ACF) within HHS, manages the Unaccompanied Children Program. In fiscal year 2021, an influx of unaccompanied children began arriving at the U.S. southern border, coinciding with the Nation's ongoing efforts to control the spread of COVID-19. As a result, ACF identified a need to increase the number of shelter beds in its provider network and entered into contracts for shelter and related services for unaccompanied children. In addition, ACF opened a new type of provider facility known as an emergency intake site (EIS). We will determine whether ACF awarded, monitored, and terminated contracts for EISs in accordance with Federal statutes and regulations, as well as HHS policies and procedures. Contracts, Emergency Preparedness and Response, Children and Families, Other Funding
February 2022 Assistant Secretary for Preparedness and Response Audit of ASPR's Actions to Address Previously Identified Deficiencies in HHS's Ability to Coordinate the Federal Government's Response to Emergency Events Office of Audit Services W-00-22-59470 2023 To improve the Nation's public health emergency management and response, the Office of the Assistant Secretary for Preparedness and Response (ASPR) was created in 2006 under the Pandemic and All-Hazards Protection Act. ASPR leads the Nation's medical and public health preparedness for, response to, and recovery from disasters and public health emergencies. The Secretary of HHS designated ASPR as the department's coordinating body to ensure integration of Federal preparedness and response activities for public health emergencies. The National Response Framework is a guide to how the Nation responds to all types of disasters and emergencies and is comprised of Emergency Support Function (ESF) annexes. HHS is the coordinator of ESF #8—Public Health and Medical Services. The Secretary of HHS, through ASPR, coordinates national ESF #8 preparedness, response, and recovery actions. For the last 10 years, OIG and other Federal agencies have conducted reviews of HHS's coordination of response efforts to emergency events such as hurricanes, wildfires, and emerging infectious diseases, e.g., Ebola, Zika, and Covid-19. These reviews identified deficiencies in HHS's ability to coordinate the Federal Government's response to a public health emergency. Our objective will be to determine whether ASPR has implemented controls and mitigating strategies to address identified risks associated with coordinating the Government's response to emergency events. Emergency Preparedness and Response, Financial Stewardship, Grants
Revised CMS, ASPR Nursing Home Capabilities and Collaboration to Ensure Resident Care During Emergencies Office of Evaluation and Inspections OEI-06-22-00100 2023 Nursing homes face a broad range of challenges from public emergencies, such as emerging infectious disease outbreaks and natural disasters. To protect residents and prevent disruption of care during emergencies, nursing homes must develop and maintain an emergency preparedness program that addresses a wide range of issues, from maintaining emergency supplies to collaborating with local emergency responders. Despite these requirements, recent emergencies have exposed weaknesses in nursing home emergency preparedness. This study will survey the challenges nursing homes face in preparing for emergencies, with specific focus on the their capabilities for managing resident care during emergencies, as well as their collaboration with community partners (e.g., other health care providers, emergency management agencies). We will present our findings in a data brief. We will also use a portion of the data collected for this study for a new Key Performance Indicator that will track the prevalence and severity of challenges experienced by nursing homes over time. COVID-19, Emergency Preparedness and Response, Nursing Homes, Nursing Facilities, and Assisted Living Facilities, Elderly, Medicare A, Medicaid
February 2022 Centers for Disease Control and Prevention Audit of CDC's COVID-19 Awards to Selected State Departments of Health Office of Audit Services W-00-22-59469 2023 In response to the COVID-19 pandemic in the United States, the Secretary of HHS declared a public health emergency on January 31, 2020. During 2020, Congress approved five COVID-19 appropriation bills: (a) Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 (P.L. 116-123), (b) Families First Coronavirus Response Act (P.L. 116-127), (c) CARES Act (Coronavirus Aid, Relief, and Economic Security Act) (P.L. 116-136), (d) Paycheck Protection Program and Health Care Enhancement Act (P.L. 116-139), and (e) Coronavirus Response and Relief Supplemental Appropriations Act, 2021 (P.L. 116-260). The CDC distributed funds from these appropriations through existing grants and cooperative agreements to provide support for core public health response activities, such as epidemiology, surveillance, laboratory capacity, infection control, mitigation, and communications. These distributions increased some States’ normal annual award amounts by approximately three to four times. Prior OIG audits have identified potential risk areas related to influxes of appropriations to States. Our objective will be to determine whether selected State Departments of Health used their CDC COVID-19 funding in accordance with award requirements. Emergency Preparedness and Response, Financial Stewardship, Grants, People with Disabilities, Medicare D
Revised Centers for Medicare and Medicaid Services Medicare Beneficiaries Receiving Buprenorphine for the Treatment of Opioid Use Disorder Office of Evaluation and Inspections OEI-02-22-00160 2023 Opioid-related overdose deaths in the United States are at an all-time high, with an estimated 76,000 in the 12-month period ending in June 2021. As they continue to rise, it is essential to ensure access to medication to treat opioid use disorder. Buprenorphine is the most commonly used medication to treat opioid use disorder and has been shown to decrease illicit opioid use and opioid-related overdose deaths. However, it also has a risk of diversion. To address this risk, providers must obtain a waiver through the Substance Abuse and Mental Health Services Administration to prescribe or administer buprenorphine in office-based settings. In April 2021, the Biden-Harris Administration released its drug policy priority areas for its first year, which include removing unnecessary barriers to prescribing buprenorphine and identifying opportunities to expand low-barrier treatment services. As the Department and the Administration consider additional changes to the requirements regarding buprenorphine, it is important to balance the need to increase access while minimizing diversion. This study will provide insight into the use of buprenorphine among Medicare Part D beneficiaries, including the number who are receiving concerning levels of buprenorphine. It will also detail the prescribing patterns of providers who order buprenorphine for these beneficiaries. Substance Abuse Disorders, Children and Families, People with Disabilities, Medicare D
February 2022 Centers for Disease Control and Prevention Audit of the Centers for Disease Control and Prevention Grants to Recipients for COVID-19 Screening Testing at Schools Office of Audit Services W-00-22-59468 2023 The Centers for Disease Control and Prevention's (CDC's) Epidemiology and Laboratory Capacity for Prevention and Control of Emerging Infectious Diseases (ELC) program provides strategic investments aimed at reducing infectious disease-related illnesses and death through its cooperative agreement with health departments throughout the United States. Financial resources and technical assistance are provided each year to 64 jurisdictions to support activities related to surveillance, detection, response, and prevention of infectious diseases. The American Rescue Plan (ARP) Act of 2021, enacted March 11, 2021 (P.L. No. 117-2), provides additional relief to address COVID-19's continued impact on the economy, public health, State and local governments, individuals, and businesses. The CDC, through the ELC program, provided $10 billion in ARP funding to States to support COVID-19 screening testing for teachers, staff, and students to assist schools in reopening safely for in-person instruction. The $10 billion, under the ELC reopening school awards, was awarded to the current 64 ELC jurisdictions according to a population-based formula. Our first audit will determine whether the CDC provided effective oversight to the ELC recipients in implementing the screening testing programs. Our second phase of audits will determine whether select ELC recipients had controls in place to monitor schools in implementing COVID-19 screening testing programs. In addition, we will determine whether select ELC recipients and schools used the ARP funding in accordance with Federal requirements and the applicable grant terms. COVID-19, Emergency Preparedness and Response, Financial Stewardship, Laboratories, Medical Supplies and Equipment, Children and Families, Grants
February 2022 Administration for Community Living Audit of Administration for Community Living's Coronavirus Aid, Relief, and Economic Security Act Funding for the Older American Act Nutrition Services Program Office of Audit Services W-00-22-59467 2023 Through the Older Americans Act (OAA) Nutrition Services Program, the Administration for Community Living provides grants to States and U.S. territories to help support nutrition services nationwide for individuals 60 or older. These services include both home-delivered meals and meals served in group settings (congregate settings), such as senior centers and faith-based locations. In March 2020, many State and local governments across the country instituted stay-at-home orders that confined individuals to their homes except to shop for essentials or seek medical attention. Because seniors were at a higher risk of hospitalization and death due to complications of COVID-19, the Centers for Disease Control and Prevention advised them to have limited interactions with the general public. Consequently, many of the congregate meal locations closed, and those that did not were cautioned to prioritize safety for clients and providers. Thus, COVID-19 increased the need for home-delivered meals. On April 21, 2020, the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) provided approximately $480 million for the OAA Nutrition Services Program to expand “drive-through” or “grab-and-go" meals for older adults who previously would have participated in congregate meal programs. Our audit will determine whether CARES Act OAA Nutrition Services Program funds were used in accordance with Federal and State requirements. COVID-19, Financial Stewardship, Elderly, Grants
February 2022 Centers for Medicare and Medicaid Services Biosimilar Trends in Medicare Part B Office of Evaluation and Inspections OEI-05-22-00140 2023 Biologic drugs—large, complex molecules produced in a living system—are among the most expensive drugs on the U.S. market. Biosimilar drugs are highly similar and have no clinically meaningful difference from their reference biologics and also tend to be less expensive. Medicare Part B and beneficiaries have the potential to spend less on prescription drugs with the increased use of biosimilars rather than their reference biologics, but their use remains low. Limited biosimilar use in Part B may be related to how providers are reimbursed for these drugs—currently, providers do not have strong financial incentives to use less expensive biosimilars. This study will describe use and cost trends of biosimilars and reference biologics covered by Part B over time. It also will determine how much Medicare and beneficiaries paid for biosimilars and reference biologics covered by Part B in 2021, and then compare those costs to determine how much Part B and beneficiaries could have spent with increased use of biosimilars or with different reimbursement policies. Prescription Drug, Medicare B
January 2022 Administration for Children and Families Audit of the Administration for Children and Families Awarding and Monitoring of an Unaccompanied Children Program Sole Source Contract to Deloitte Consulting LLP Office of Audit Services W-00-22-20029 2023 The Office of Refugee Resettlement (ORR), a program office of the Administration for Children and Families (ACF) within the Department of Health and Human Services (HHS), manages the Unaccompanied Children Program. In fiscal year 2021, an influx of unaccompanied children began arriving at the U.S. southern border, coinciding with the Nation's ongoing efforts to control the spread of COVID-19. As a result, ACF identified a need to increase the number of shelter beds in its provider network and entered into contracts for shelter and related services for unaccompanied children. ACF awarded a sole source contract to Deloitte Consulting LLP to provide professional support services to address the influx of children at the southern border. We will determine whether ACF awarded and monitored this sole source contract in accordance with Federal statutes, Federal regulations, and HHS policies and procedures. Contracts, Emergency Preparedness and Response, Children and Families, Other Funding
January 2022 Health Resources and Services Administration Hospital's Compliance With the Provider Relief Fund Balance Billing Requirement for Out - of - Network Patients Office of Audit Services W-00-22-35878 2023 The Coronavirus Aid, Relief, and Economic Security (CARES) Act, Paycheck Protection and Health Care Enhancement Act, and Consolidated Appropriations Act, 2021, appropriated a combined $178 billion in relief funds to hospitals and other health care providers. This funding, known as the Provider Relief Fund (PRF), is administered by the Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) and is intended to reimburse eligible health care providers for health care-related expenses or lost revenue attributable to COVID-19 and to ensure that Americans could get testing and treatment for COVID-19. Under the PRF terms and conditions, hospitals are eligible for PRF distribution payments if they attest to specific requirements, including a requirement that providers, such as hospitals, must not pursue the collection of out-of-pocket payments from presumptive or actual COVID-19 patients in excess of what the patients otherwise would have been required to pay if the care had been provided by in-network providers. We refer to this limitation on balance billing, commonly referred to as "surprise billing," as the "balance billing requirement." We will perform a nationwide audit to determine whether hospitals that received PRF payments and attested to the associated terms and conditions complied with the balance billing requirement for COVID‑19 inpatients. We will assess how bills were calculated for out‑of-network patients admitted for COVID-19 treatment, review supporting documentation for compliance, and assess procedural controls and monitoring to ensure compliance with the balance billing requirement. COVID-19, Financial Stewardship, Hospitals, Public Health Issues, Medicare C, Private Insurance, Other Funding
January 2022 Centers for Medicare and Medicaid Services Nationwide Review of Hospice Beneficiary Eligibility Office of Audit Services W-00-22-35883 2023 Hospice care can provide comfort to beneficiaries, families, and caregivers at the end of beneficiarie's lives. To be eligible for hospice care, they must be entitled to Medicare Part A and be certified as being terminally ill. The certification of terminal illness for hospice benefits shall be based on the clinical judgment of the hospice medical director or physician member of the interdisciplinary group, and the beneficiarie's attending physician, if they have one, regarding the normal course of their illness. OAS has performed several compliance audits of individual hospice providers in recent years, and each of those audit reports identified findings related to beneficiary eligibility. We will perform a nationwide review of hospice eligibility, focusing on those hospice beneficiaries that haven't had an inpatient hospital stay or an emergency room visit in certain periods prior to their start of hospice care. Departmental Operational Issues, Financial Stewardship, Non-institutional care, Elderly, Medicare A
January 2022 Centers for Medicare and Medicaid Services Followup Audit on CMS's Use of Medicare Data To Identify Instances of Potential Abuse or Neglect Office of Audit Services W-00-22-35882 2023 A prior audit (A-01-17-00513) identified 34,664 Medicare claims containing diagnosis codes that indicated Medicare beneficiaries were treated for injuries possibly caused by abuse or neglect from January 1, 2015, through June 30, 2017. It estimated that 30,754 of these Medicare claims were supported by medical records that contained evidence of potential abuse or neglect. CMS did not identify the Medicare claims that indicate potential abuse or neglect because, according to CMS officials, it did not extract data consisting of Medicare claims with diagnosis codes related to abuse or neglect. The lack of a data extract impeded the ability of CMS and public and patient safety organizations to pursue legal, administrative, and other appropriate remedies to ensure the safety, health, and rights of Medicare beneficiaries. This audit is a followup to determine whether CMS improved its use of Medicare data to identify incidents of potential abuse and neglect since we issued our previous report. We will also determine: (1) the prevalence of incidents of potential abuse or neglect of Medicare beneficiaries in 2019 and 2020, (2) who may have perpetrated those incidents and where they occurred, (3) and whether the incidents were reported to law enforcement. Departmental Operational Issues, Hospitals, Nursing Homes, Nursing Facilities, and Assisted Living Facilities, Quality of Care, Children and Families,People with Disabilities, Elderly, Native Americans, Other Minorities, Medicare A, Medicare B
January 2022 Centers for Medicare and Medicaid Services Medicare Administrative Contractor Cost Report Oversight - Contract Review Office of Audit Services W-00-22-35881 2023 In accordance with their CMS contracts, Medicare administrative contractors (MACs) are responsible for accepting, auditing, and settling provider Medicare cost reports. The MAC performs desk reviews of all cost reports and audits as warranted prior to settlement of the cost report to determine adequacy, completeness, and accuracy and reasonableness of the data in the cost report. We will review the MACs cost report oversight by verifying the number of desk reviews and the number of audits performed in accordance with the CMS contract and identify non-compliance issues. Following this review, we will conduct additional reviews that will include MAC audit findings and recommendations to determine whether the provider implemented the recommendations and took corrective action. Finally, we will examine CMS's oversight of the MAC cost report desk reviews/audits. Our audit's objective is to determine whether the individual MACs met requirements stated in the MAC contracts. Contracts, Financial Stewardship, Medicare A
January 2022 OS OIG DATA Act Audit and Data Completeness & Accuracy (2022) Office of Audit Services W-00-22-41021 2023 On May 9, 2014, the President signed the DATA Act of 2014, which mandated the establishment of Government-wide data standards for financial and payment data by May 2015, and agency reporting of consistent, reliable, and searchable financial and payment data by May 2017, to be displayed for taxpayers and policymakers on USASpending.gov. The DATA Act also requires OIG to review a statistically valid sampling of the spending data submitted under this Act by HHS and submit to Congress and make publicly available a report assessing the completeness, timeliness, quality, and accuracy of the data sampled and the implementation and use of data standards by HHS. We will use the independent external auditor contracted to audit the annual CMS and HHS Financial Statement Audits to perform this work. Financial Stewardship; Other Funding
December 2021 Centers for Medicare and Medicaid Services Telehealth Services in Select Federal Health Care Programs Office of Evaluation and Inspections OEI-02-22-00150 2023 Throughout the COVID-19 pandemic, the use of telehealth has been critically important. Telehealth has helped ensure access to care while reducing the risk of community spread of the virus. As the effects of the pandemic are still being felt throughout the Nation, there are questions about how telehealth can best be used to meet the needs of beneficiaries in the future. HHS-OIG will work with the other OIG members in and leadership of the Pandemic Response Accountability Committee (PRAC) to produce a report describing the types of telehealth services that are available, including those that were expanded during the pandemic, and key program integrity risks associated with the use of telehealth across six selected Federal health care programs. Medicare is the HHS program included in this evaluation. HHS-OIG will conduct this evaluation with OIGs from the departments of Defense, Justice, Labor, and Veterans Affairs, and the Office of Personnel Management. PRAC will issue the resulting report. It will provide policymakers and stakeholders with foundational information about the nature of telehealth across select Federal health care programs and related program integrity risks in order to inform the use of telehealth in the future. COVID-19, Other Funding
Completed (partial) Centers for Disease Control and Prevention Grantees' Use of President's Emergency Plan for AIDS Relief Funds Office of Audit Services W-00-22-57300;
W-00-20-57300;
W-00-21-57300;
A-04-20-01017
2023 In more than 60 countries, Centers for Disease Control and Prevention (CDC) grantees such as ministries of health and other partners work to control the HIV/AIDS epidemic. CDC awarded more than $5.5 billion in President's Emergency Plan for AIDS Relief (PEPFAR) funds to grantees during FYs 2018 through 2020 (about 96 percent of PEPFAR funds received by HHS during the three FYs) to accelerate HIV treatment and prevention worldwide by using public health, innovation, and data-driven approaches to achieve the global goal of HIV/AIDS epidemic control. To date, HHS-OIG has conducted 21 audits of grantees in 8 countries on 2 continents (Africa and Asia). OIG's PEPFAR oversight has helped grant recipients learn important grant and program integrity lessons that apply to ongoing and future responses to infectious diseases. In previous audits of foreign PEPFAR grantees, OIG identified unallowable expenditures, inadequate accounting systems, and internal control weaknesses. We will determine whether selected foreign or domestic grantees: (1) managed and expended PEPFAR funds in accordance with award requirements, and (2) have controls to mitigate potential risk to the PEPFAR program. Public Health Issues, Grants
December 2021 Centers for Disease Control and Prevention Audit of Centers for Disease Control and Prevention's Vaccines for Children Program Requirement for Provider Site Visits Office of Audit Services W-00-22-59464 2023 The Vaccines for Children (VFC) program is a federally funded program that provides vaccines at no cost to eligible children through health care providers enrolled in the program. The Centers for Disease Control and Prevention (CDC) has the lead responsibility for policy development and implementation of the VFC program. CDC buys vaccines at a discount and distributes them to grantees-i.e., State health departments and certain local and territorial public health agencies-which in turn distribute them at no charge to those private physicians' offices and public health clinics registered as VFC providers. To ensure the quality of VFC vaccines and the integrity of the VFC program, CDC requires grantees to conduct: (1) an enrollment site visit for all new and re-enrolling VFC providers before they receive VFC vaccines; (2) compliance site visits for all enrolled and active VFC providers every 24 months; and (3) unannounced storage and handling site visits at a minimum of 5 percent of VFC providers during the cooperative agreement budget period. Site visits help determine provider compliance with VFC Program requirements, including adherence to vaccine eligibility screening and documentation, accountability, and management. We will conduct an audit to determine whether CDC VFC grantees conducted site visits at enrolled and active VFC program providers that provide routine childhood vaccines (not COVID-19 vaccines) according to program requirements. Due to the COVID-19 pandemic, we will identify alternative procedures or approaches that grantees may have taken to complete site visits. Food, Drug, and Device Safety, Public Health Issues, Quality of Care, Grants
Revised Centers for Medicare and Medicaid Services Race and Ethnicity Data for Medicaid Beneficiaries Office of Evaluation and Inspections OEI-02-22-00130 2023 Complete and consistent race and ethnicity data for Medicaid beneficiaries are critical to identifying and addressing health disparities. As the COVID-19 pandemic has highlighted disparities among racial and ethnic groups, the availability and quality of data on race and ethnicity warrants a closer look in order to accurately and appropriately mitigate health disparities within the Medicaid population. This study will evaluate the extent to which Medicaid's race and ethnicity data for beneficiaries as reported to T-MSIS are complete and consistent across States. We will also determine the extent to which the data align with Federal data collection standards for race and ethnicity. Other: Health Disparities, Native Americans, Other Minorities, Medicaid
Revised Centers for Medicare and Medicaid Services Survey of Potential Drug Rebates Associated With Drugs Administered to Enrollees in Separate Children's Health Insurance Programs Office of Audit Services W-00-22-35880 2023 Under current Federal requirements, States are required to obtain drug rebates from manufacturers for Medicaid-covered outpatient prescription drugs that are provided through Medicaid expansion-under either: (1) Medicaid expansion only or (2) the Medicaid expansion portion if the State chooses a combination of Medicaid expansion and a separate Children's Health Insurance Program (CHIP). However, for prescription drugs that are funded through a separate CHIP, the Federal Medicaid Drug Rebate Program (MDRP) requirements currently do not apply. We will determine the total drug rebates that States could potentially have collected under separate CHIPs if those rebates had been part of the MDRP requirements and we will identify State policy differences. OIG Statutory Authority and Regulatory Matters, Children and Families, Medicaid
December 2021 Centers for Medicare and Medicaid Services Medicaid Partial Care Program Office of Audit Services W-00-22-31559 2023 Prior audit work identified a State agency's Medicaid adult partial care program as at high risk for improper payments. The purpose of the adult partial care program is to provide Medicaid beneficiaries with serious mental illnesses individualized outpatient clinic services to reduce unnecessary hospitalizations. Our prior audit made a financial recommendation and procedural recommendations to the State agency to improve its guidance and monitoring. This audit work will determine whether the State agency adequately implemented our prior recommendations. We will also review claims for compliance with Federal and State requirements, including the State agency's implementation of telehealth services due to the COVID-19 pandemic. COVID-19, Mental Health, Medicaid
Revised Centers for Medicare and Medicaid Services Availability of Behavioral Health in Medicare Fee-For-Service, Medicare Advantage, and Medicaid Managed Care Office of Evaluation and Inspections OEI-02-22-00050;
OEI-09-21-00410
2024 More than half of all Americans will be diagnosed with a behavioral health condition in their lifetime, estimates indicate, and many experts say that the need for behavioral health services has grown dramatically during the COVID-19 pandemic. Medicare and Medicaid beneficiaries often have unmet behavioral health needs and face difficulty accessing appropriate services. To address these concerns, OIG will conduct a three-part study to examine access to behavioral health care in Medicare fee-for-service, Medicare Advantage, and Medicaid managed care. For selected localities, this study will determine: (1) the ratio of behavioral health providers to beneficiaries within each of these three programs; (2) the extent to which behavioral health providers have availability to accept new patients and schedule appointments within each of the three programs; and (3) the extent to which behavioral health providers listed in networks of managed care plans provided services to the plans' beneficiaries. Combined, these studies will provide significant insight into the accessibility of behavioral health providers within each of these three programs. Managed Care, Mental Health, Physician and Healthcare Practitioners, Quality of Care, Substance Abuse Disorders, Medicaid, Medicare B, Medicare C
December 2021 OS, ACF, CMS, CDC, FDA HHS Cloud Infrastructure as a Service Security Audits Office of Audit Services W-00-22-42041 2024 Federal agencies are increasingly adopting cloud computing services to address information technology needs. During FY 2020, HHS reported that more than 21 percent of its systems were in the cloud. In view of the increase in cloud adoption across HHS, we are concerned that HHS may not be aware of all cybersecurity risks associated with its Infrastructure as a Service (IaaS) cloud environments. The Federal Risk and Authorization Management Program and National Institute of Standards and Technology requirements establish that agencies protect any Federal information that is collected, maintained, and processed by cloud service platforms. We will perform a series of audits to assess the security of the HHS OpDivs' cloud IaaS configurations and test whether attack vectors exist that adversaries could leverage to access HHS data. We will determine whether HHS OpDivs have properly identified and inventoried their IaaS cloud assets. In addition, we will determine whether HHS and OpDivs have implemented effective cybersecurity controls for their cloud IaaS environments in accordance with Federal and HHS security requirements and guidelines. Departmental Operational Issues, Other Funding
Revised Centers for Medicare and Medicaid Services Identifying Denied Claims in Medicare Advantage Encounter Data Office of Evaluation and Inspections OEI-03-21-00380 2023 CMS requires Medicare Advantage organizations (MAOs) to submit records of all services provided to beneficiaries to CMS's Medicare Advantage (MA) Encounter Data System. These records often (although not always) begin as claims for payments that health care providers submit to MAOs. MAOs must submit all records of services to CMS, including records of denied claims-i.e., claims for which an MAO determines it had no responsibility to pay the health care provider.CMS does not require MAOs to differentiate between paid and denied claims when submitting encounter records.In the absence of requiring a denied claims indicator, CMS requires each MAO to submit claim adjustment reason codes that contain information about how the MAO processed the claim and may be a helpful, but not definitive, method for identifying denied claims. The lack of a definitive method to identify denied claims in the MA encounter data may limit the use of these data to ensure MA program integrity and quality of care. This work will: (1) determine the extent to which the MA encounter data contained potentially denied claims and (2) identify any challenges to MA program oversight that result from the lack of a denied claim indicator on services in the MA encounter data. Managed Care, Elderly, Medicare C
November 2021 Centers for Medicare and Medicaid Services States' Use of Local Provider Participation Funds as the State Share of Medicaid Payments Office of Audit Services W-00-22-31557 2023 Local units or jurisdictions of government have the option to use Local Provider Participation Funds (LPPFs) to generate and collect local funding to finance the State share of Medicaid supplemental and directed payment programs. In the past several years, some States and local units of governments have increasingly used LPPFs to fund the State share of Medicaid payments. As such, we will determine whether the LPPFs the State agency used as the State share of Medicaid payments were permissible and in accordance with applicable Federal and State requirements. Hospitals, Medicare C
November 2021 Centers for Medicare and Medicaid Services CMS Oversight of Manufacturer-Reported Average Sales Price Data Office of Evaluation and Inspections OEI-03-21-00390 2023 CMS's review of manufacturer-reported average sales price (ASP) data is a vital component of its oversight of Medicare reimbursement for Part B drugs. CMS uses ASPs reported by manufacturers to calculate Medicare Part B drug reimbursement amounts paid to health care providers. Congress has directed the HHS Office of Inspector General to submit a report to Congress-no later than January 1, 2023-that includes an assessment of the accuracy of ASP data submitted by prescription drug manufacturers and recommendations for how to improve the accuracy of that data. This report will identify any potential gaps in CMS oversight and potentially make recommendations to improve the accuracy of: (1) ASP data reporting and (2) Medicare payment amounts calculated from that data. Departmental Operational Issues, Financial Stewardship, Prescription Drug, Medicare B, Elderly
November 2021 Centers for Medicare and Medicaid Services Medicaid Inpatient Hospital Claims With Severe Malnutrition Office of Audit Services W-00-22-31558 2023 Malnutrition can result from treatment of another condition, inadequate treatment or neglect, or general deterioration of a patient's health. Hospitals are allowed to bill for treatment of malnutrition on the basis of the severity of the condition (mild, moderate, or severe) and whether it affects patient care. Severe malnutrition is classified as a major complication or comorbidity (MCC). Adding an MCC to a claim can result in an increased payment by causing the claim to be coded in a higher diagnosis-related group. We will conduct statewide reviews to determine whether hospitals complied with Medicaid billing requirements when assigning severe malnutrition diagnosis codes to inpatient hospital claims. Hospitals, Medicaid
November 2021 Centers for Medicare and Medicaid Services Medicare Payments for Inpatient Claims With Mechanical Ventilation Office of Audit Services W-00-22-35879 2023 We will review Medicare payments for inpatient hospital claims with certain Medicare Severity Diagnosis Related Group (MS-DRG) assignments that require mechanical ventilation to determine whether hospitals' DRG assignments and resultant Medicare payments were appropriate. Mechanical ventilation is the use of a ventilator to take over active breathing for a patient. For certain MS-DRGs to qualify for Medicare coverage, a beneficiary must have received more than 96 hours of mechanical ventilation. Our review will include claims for beneficiaries who received more than 96 hours of mechanical ventilation. Previous OIG reviews identified improper payments made because hospitals inappropriately billed for beneficiaries who did not receive at least 96 hours of mechanical ventilation. Financial Stewardship, Hospitals, Medicare A
November 2021 Administration for Children and Families Audit of Unaccompanied Children Data Cybersecurity Controls Office of Audit Services W-00-22-42038 2023 The Unaccompanied Children (UC) Program, operated by the Office of Refugee Resettlement (ORR) within the Administration for Children and Families (ACF), provides temporary shelter, care, and other related services to UC in its custody. ORR uses the Unaccompanied Children Portal (UC Portal) and other data sources to maintain information on over 100,000 UC. We will determine whether ACF has sufficiently addressed findings identified during a previous UC Portal audit, implemented controls to ensure the cybersecurity of sensitive UC data in accordance with Federal requirements, and incorporated adequate system development life-cycle planning to ensure that the UC Portal aligns with business and performance objectives. Information Technology and Cybersecurity, Children and Families, Other Funding
November 2021 Food and Drug Administration Audit of the Food and Drug Administration's Premarket Tobacco Product Application Process for Electronic Nicotine Delivery System Products Office of Audit Services W-00-22-59465 2023 The Food and Drug Administration (FDA) is responsible for regulating tobacco products. Under section 910 of the Federal Food, Drug, and Cosmetic Act (FD&C Act), manufacturers wanting to market a new tobacco product must first obtain a marketing order. Those seeking a marketing order for a new tobacco product may submit a Premarket Tobacco Product Application (PMTA) to the FDA. FDA has received PMTA submissions from manufacturers of electronic nicotine delivery system (ENDS) products.Section 910(b)(1) of the FD&C Act contains the requirements for a PMTA submission.In FDA's assessment of PMTAs, FDA must determine whether the new tobacco product is appropriate for the protection of public health. Our objectives are to determine: (1) FDA's progress on reviewing applications for ENDS products; (2) whether FDA's policies and procedures ensured that marketing orders were granted or denied for ENDS products in accordance with Federal statutes, regulations, and guidance; and (3) what actions FDA has taken to ensure that ENDS products that are not appropriate for the protection of public health are not marketed. Food, Drug, and Device Safety, Public Health Issues, Children and Families, Other Funding
November 2021 OS, OIG, CMS, FDA, CDC Network Cyber Threat Hunting Audit of the HHS Trusted Internet Connection and Select Operating Division Networks Office of Audit Services W-00-22-42039 2023 In recent years, HHS has been the target of numerous cyberattacks, which has affected HHS operations and demanded additional resources to combat the growing cyber threats. The cyberattacks have increased in complexity and frequency and at times evade cybersecurity defense tools. In accordance with the Federal Information Security Modernization Act and the Executive Order on Improving the Nation's Cybersecurity of May 12, 2021, the Federal Government must detect and respond to threats that can potentially affect the confidentiality, availability, and integrity of its services and data. Failure to do so may result in service disruptions and breaches that could potentially affect the security and privacy of public health data or U.S citizens' personally identifiable information. We will perform a series of information technology audits at HHS and selected Operating Divisions to determine whether their network cybersecurity defenses are effective. Information Technology and Cybersecurity, Other Funding
Revised Health Resources and Services Administration COVID-19 Pandemic Relief Funding and Its Effects on Nursing Homes in Select Locations: Pandemic Response Accountability Committee Impact Study Office of Evaluation and Inspections OEI-06-22-00040;
OEI-06-22-00440;
OEI-06-22-00450:
OEI-06-22-00460;
OEI-06-22-00470;
OEI-06-22-00480
2023 The Pandemic Response Accountability Committee (PRAC) is producing a report about COVID-19 pandemic relief funding in six communities selected by PRAC for review. As part of PRAC's efforts, OIG will review Provider Relief Fund (PRF) payments and their effects on nursing homes in the selected locations. Congress and HHS have used the PRF to support nursing homes and other health care providers during the pandemic. HHS allocated $9.5 billion from the PRF directly to nursing homes through two channels: (1) a distribution to skilled nursing facilities for lost revenue and expenses related to preventing, preparing for, and responding to COVID-19; and (2) the Nursing Home Infection Control Distribution for improving infection control practices and reducing rates of COVID-19 infection. In addition to contributing to PRAC's report for the five locations with nursing homes that received PRF payments, OIG will use interviews and other data collected as part of those efforts to produce its own evaluation of nursing home use of PRF payments and Health Resources and Services Administration oversight. COVID-19, Emergency Preparedness and Response, Nursing Homes, Nursing Facilities, and Assisted Living Facilities, Public Health Issues, Quality of Care, Elderly, Other Funding
Revised CDC, NIH, AHRQ Cybersecurity Testing of HHS and Consumer Mobile Applications Office of Audit Services W-00-22-42040 2024 Various HHS OpDivs use mobile applications as alternative ways to reach mobile device users.Cybersecurity researchers have indicated that a large majority of Android and iOS apps across every industry lack the most basic security protections.HHS-OIG will perform a series of penetration test audits of certain mobile applications to determine whether security controls protecting HHS and its OpDivs' mobile applications are effective in preventing certain cyberattacks.Also, as part of this work, we will determine whether HHS and its OpDivs are following required security standards and policies for the development and vetting of mobile apps.HHS-OIG will perform this work because of the steady increase in the use of mobile apps by HHS and its OpDivs to provide access to health services. Departmental Operational Issues, Information Technology and Cybersecurity
Revised Centers for Disease Control and Prevention Nursing Home Reporting of COVID-19 Data to the National Healthcare Safety Network Office of Evaluation and Inspections OEI-06-22-00030 2023 Since May 2020, nursing homes nationwide have been required to report COVID-19 data to the National Healthcare Safety Network (NHSN), an infection surveillance system managed by the Centers for Disease Control and Prevention (CDC).This requirement significantly increased nursing home enrollment and reporting, which was formerly voluntary, to NHSN.This study will evaluate CDC processes for nursing home reporting of COVID-19 data to NHSN.We will assess CDC oversight and support of nursing home reporting and identify challenges reporting to NHSN that nursing homes have faced.Our work will inform the Departments ongoing efforts to support infection surveillance, including the collection of routine infection data and data related to public health emergencies such as COVID-19. COVID-19; Departmental Operational Issues; Nursing Homes; Nursing Facilities, and Assisted Living Facilities; Public Health Issues; Elderly; Other Funding
Revised CMS, AHRQ Toolkit for Identifying Adverse Events Through Medical Record Review Office of Evaluation and Inspections OEI-06-21-00030 2023 OIG has found that patient harm is common among Medicare beneficiaries in a range of inpatient health care settings.Federal regulations require that hospitals and other health care facilities identify harm, such as adverse events, and work to reduce these events.We will use guidance materials and tools created for our prior studies of adverse events to develop a web-based toolkit for identifying and measuring adverse events to assist health care facilities, government agencies, and researchers in their efforts to improve care.We will share the resources that we developed and used in our adverse event studies to aid hospitals and other researchers in their own efforts to identify and monitor the incidence of adverse events.The toolkit will provide standard definitions for most event types, lists of triggers to flag patient harm, suggested guidance for reviewers, and considerations for clinical decision making. Hospitals; Quality of Care; Medicare A
Revised CMS, AHRQ, OMHA Adverse Events: Disparities Among Hospitalized Medicare Patients Office of Evaluation and Inspections OEI-06-21-00040 2023 Disparities in the delivery of health care and patient outcomes are a significant U.S. public health concern, with communities of color and other disadvantaged groups experiencing poorer health outcomes compared to the U.S. population as a whole.Research on disparities in patient safety and adverse events is limited and this study intends to add to the body of information specific to health outcome disparities.We will identify the extent to which disparities in adverse event rates exist and which patient and hospital characteristics are associated with higher adverse event rates (e.g., race/ethnicity, hospital type, and geographic location).We will use data collected for an ongoing OIG study of adverse events (OEI-06-18-00400), which includes detailed information about adverse events experienced by a random sample of 770 hospitalized Medicare patients.We will analyze these adverse event data in conjunction with demographic information available in the medical record and other information contained in CMS claims data or in publicly available datasets, such as U.S. Census Bureau data. An increased understanding of disparities in patient safety will help medical providers and researchers identify and address the underlying issues that contribute to inequities in the delivery of health care. Hospitals; Quality of Care; Medicare A; Other Minorities
Revised Centers for Medicare and Medicaid Services Accuracy of Manufacturer-Reported Average Sales Pricing Office of Evaluation and Inspections OEI-BL-21-00330 2023 Effective January 1, 2005, the Medicare Modernization Act of 2003 revised how Medicare Part B reimburses health care providers for physician-administered infused and injected drugs, moving from the average wholesale price to the average sales price (ASP).Congress has directed OIG to assess and submit to Congress a report—no later than January 1, 2023—on the accuracy of ASP information submitted by manufacturers and to include any recommendations on how to improve the accuracy of that information.This study will compare the ASPs for the top 25 highest-expenditure drugs in Medicare Part B to other benchmark prices and explore possible reasons for any potential pricing anomalies we identify. Prescription Drug; Medicare B
Revised Centers for Medicare and Medicaid Services COVID-19 Increased FMAP State Eligibility Audit Office of Audit Services W-00-21-31556 2023 The Federal Government pays its share of a State's Medicaid expenditures based on the Federal Medical Assistance Percentages (FMAPs), which vary depending on the State's per capita income.Although FMAPs are adjusted annually for economic changes in the States, Congress may increase FMAPs at any time.On March 18, 2020, the then President signed into law the Families First Coronavirus Response Act (FFCRA), which provided a temporary 6.2-percentage-point increase to each qualifying State's and territory's FMAP under section 1905(b) of the Act effective January 1, 2020.States must meet the requirements of section 6008(b) and (c) of the FFCRA to qualify to receive the temporary 6.2-percentage-point increase.We plan to perform audit work at selected States to determine whether those States met the requirements to receive the temporary COVID-19 FMAP increase. COVID-19; Medicaid
August 2021 Centers for Medicare and Medicaid Services Audit of Medicare Part B Opioid-Use-Disorder Treatment Services Provided by Opioid Treatment Programs Office of Audit Services W-00-21-35876 2023 Substance use disorders involving drugs or alcohol can cause serious health problems and even death.Medication-assisted treatment is used to treat substance use disorders, including opioid use disorders (OUDs); sustain recovery; and prevent overdoses.There are three medications to treat OUDs: buprenorphine, methadone, and naltrexone, which are approved by the Food and Drug Administration (FDA).Treatment for OUDs is provided in several settings, including freestanding opioid treatment programs (OTPs). Historically, OTPs could not enroll as providers in Medicare or be paid for services provided to Medicare beneficiaries.Section 2005 of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act) established a new Medicare Part B benefit for OUD treatment services furnished by OTPs.CMS implemented this benefit beginning January 1, 2020, as required by the SUPPORT Act.OUD treatment services include FDA-approved treatment medication, dispensing and administration of treatment medication, substance use counseling, individual and group therapy, and toxicology testing. In this audit, we will focus on claims for OUD treatment services provided by nonresidential (i.e., freestanding) OTPs, which are identified with the place-of-service code 58.We will review OUD treatment services for Medicare beneficiaries in nonresidential OTPs to determine whether the services were allowable in accordance with Medicare requirements. Financial Stewardship; Non-institutional care; Physician and Healthcare Practitioners; Public Health Issues; Quality of Care; Substance Abuse Disorders; Medicare B
August 2021 Substance Abuse and Mental Health Services Administration Audits of SAMHSA's Certified Community Behavioral Health Clinic Expansion Grants Office of Audit Services W-00-21-59463 2023 Certified Community Behavioral Health Clinics (CCBHCs) are designed to provide comprehensive 24/7 access to:­­ (1) community-based mental health and substance use disorder services, (2) treatment of co-occurring disorders, and (3) physical health care in one location.In Federal fiscal year 2020, the Substance Abuse and Mental Health Services Administration (SAMHSA) awarded CCBHC expansion grants totaling approximately $450 million to increase access to and improve the quality of community mental health and substance use disorder treatment services through direct services.This included $250 million appropriated by the Coronavirus Aid, Relief and Economic Security Act.We will determine whether SAMHSA followed its policies and procedures for awarding and monitoring CCBHC expansion grants.In a separate audit, we will determine whether CCBHCs used expansion grant funds in accordance with Federal requirements and applicable grant terms. Contracts; COVID-19; Departmental Operational Issues; Financial Stewardship; Mental Health; Non-institutional care; Public Health Issues; Quality of Care; Substance Abuse Disorders; Grants
Revised Centers for Medicare and Medicaid Services Intimate Partner Violence Screening and Referral by Primary Care Providers for Patients Enrolled in Medicaid Office of Evaluation and Inspections OEI-03-21-00310 2024 Intimate partner violence—which includes physical, sexual, and psychological abuse—is a serious, preventable public health problem that affects millions of Americans.Primary care providers play a critical role in screening patients for intimate partner violence and referring patients who screen positive to support services.The U.S. Preventive Services Task Force (USPSTF) has a recommendation that clinicians screen for intimate partner violence in women of reproductive age and provide or refer women who screen positive to ongoing support services.Despite this recommendation, primary care providers may encounter barriers to screening—including lack of knowledge, time constraints, and lack of adequate compensation.Medicaid expansion programs must provide coverage of certain preventive services recommended by USPSTF including screening for intimate partner violence, and States may opt to cover this preventive service in their traditional Medicaid programs.However, there are no specific procedure codes for providers to bill for time spent screening for intimate partner violence and making referrals to support services.This evaluation will determine whether and how primary care providers who serve Medicaid enrollees screen for intimate partner violence and make referrals to support services.We also expect this work to identify opportunities to improve these screening and referral practices. Non-institutional care; Physician and Healthcare Practitioners; Public Health Issues; Quality of Care; Children and Families; Other Minorities; Medicaid
Revised Centers for Medicare and Medicaid Services Audit of Medicare Emergency Department Evaluation and Management Services Office of Audit Services W-00-21-35877; W-00-22-35877 2023 An emergency department is defined as an organized, hospital-based facility for providing unscheduled or episodic services to patients who present for immediate medical attention.Certain Current Procedural Terminology (CPT) codes should only be used when a beneficiary is seen in an emergency department and the services described by the health care CPT coding system code definition are provided.Medicare reimburses physicians based on a patient's documented needs at the time of a visit.All evaluation and management (E/M) services reported to Medicare must be adequately documented so that medical necessity is clearly evident.This review will determine whether Medicare payments to providers for emergency department E/M services were appropriate, medically necessary, and paid in accordance with Medicare requirements. Departmental Operational Issues; Emergency Preparedness and Response; Hospitals; Physician and Healthcare Practitioners; Public Health Issues; Quality of Care; Medicare B
Completed (partial) Food and Drug Administration Review of the FDA's Accelerated Approval Pathway Office of Evaluation and Inspections OEI-01-21-00400;
OEI-01-21-00401
2023 The FDA recently approved Aduhelm (aducanumab) to treat patients with Alzheimer's disease using the accelerated approval pathway.The accelerated approval pathway allows the FDA to approve drugs that treat serious conditions and that fill an unmet medical need based on a surrogate endpoint, which is a marker that is thought to predict a clinical benefit.The FDA's approval of Aduhelm raised concerns due to alleged scientific disputes within the FDA, the advisory committee's vote against approval, allegations of an inappropriately close relationship between the FDA and the industry, and the FDA's use of the accelerated approval pathway.In response to these concerns, we will assess how the FDA implements the accelerated approval pathway.This will include reviewing interactions between the FDA and outside parties as well as other aspects of the process, such as deciding on this pathway and scientific disputes.We will review the FDA's relevant policies and procedures, determine compliance with them, and make appropriate findings and recommendations based on a sample of drugs approved using the accelerated approval pathway, which will include Aduhelm.We will not assess the scientific appropriateness of the FDA's approval of any of the drugs under review.This work may result in multiple reports. Food, Drug, and Device Safety; Prescription Drug; Other Funding
Revised Substance Abuse and Mental Health Services Administration Audit of States' Administration of SAMHSA's Substance Abuse Prevention and Treatment Block Grant Funding Office of Audit Services W-00-21-59462 2023 The Substance Abuse and Mental Health Services Administration's (SAMHSA's) Substance Abuse Prevention and Treatment Block Grant (SABG) program is the largest Federal program dedicated to improving publicly funded substance abuse prevention and treatment systems. The program provides funds to all 50 States, the District of Columbia, and U.S. Territories to prevent and treat substance abuse. Federal requirements for the SABG program state that fiscal control and accounting procedures must permit the tracing of funds to a level of expenditure adequate to establish that such funds were not used in violation of block-grant restrictions and statutory prohibitions (45 CFR § 96.30). We will determine whether the States' SABG expenditures for subrecipients, including expenditures for contracted transitional housing providers, complied with Federal and State requirements. Financial Stewardship; Physician and Healthcare Practitioners; Public Health Issues; Substance Abuse Disorders; Grants
July 2021 Centers for Disease Control and Prevention Audit of Centers for Disease Control and Prevention Racial and Ethnic Approaches to Community Health (REACH) Program Office of Audit Services W-00-21-59460 2023 The Racial and Ethnic Approaches to Community Health (REACH) program, administered by the Centers for Disease Control and Prevention (CDC), awards funds to State and local health departments, tribes, universities, and community-based organizations to improve health, prevent chronic diseases, and reduce health disparities among racial and ethnic populations with the highest risk of chronic disease.In FY 2018, CDC awarded $125.5 million in REACH funds to 31 recipients for a 5-year project period beginning September 30, 2018, with 1-year awards averaging $780,000 per recipient.Grant recipients work with communities to reduce health disparities among racial and ethnic populations with the highest burden of chronic disease (e.g., heart disease, type 2 diabetes, and obesity).The program provides culturally tailored interventions to address preventable risk behaviors, including tobacco use, poor nutrition, and physical inactivity.REACH grant recipients are required to work with one or two of the following priority populations: African Americans, Hispanic Americans, Asian Americans, Native Hawaiians/Other Pacific Islanders, and American Indians/Alaska Natives.Recipients are also required to work in three of the following four strategy areas-tobacco, nutrition, physical activity, and community-clinical linkages-and their accompanying activities to improve social and environmental conditions for better health in the community.We will determine whether selected REACH grant recipients used their funding in accordance with Federal requirements and grant terms.Specifically, OIG plans to audit REACH program funds awarded to the selected recipients to ensure that REACH program funds were used for their intended purposes and met the needs of priority populations. Financial stewardship; Public Health Issues; Quality of Care; Native Americans; Other Minorities; Grants
Revised National Institutes of Health NIH's Oversight Processes To Ensure Diversity Among Human Subjects Enrolled in Clinical Trials Office of Evaluation and Inspections OEI-01-21-00320 2023 Underrepresentation of racial and ethnic minorities, women, and individuals of all ages in clinical trials has been a longstanding concern and has garnered increased attention due to the COVID-19 pandemic's disproportionate impact on minority populations.The National Institutes of Health (NIH) is the largest funder of biomedical and public health research, supporting over $31 billion of research across the agency.NIH's responsibilities include reviewing annual progress reports that document grantees' progress toward NIH-approved enrollment plans, which may include a diversity and inclusion component.This study will assess and describe how NIH monitors and ensures enrollment of racial and ethnic minorities, women, and individuals of all ages within the clinical trials it funds and the actions it takes in response to clinical trials that are not meeting approved enrollment plans.This study will also identify NIH's challenges and the steps it takes to address these challenges while monitoring and ensuring that its grantees meet their commitments to inclusive enrollment in their clinical trials. Financial Stewardship; Public Health Issues; Elderly; Other Minorities; Grants
July 2021 Centers for Medicare and Medicaid Services Home Health Agencies' Emergency Communication Plans: Strengths and Challenges Ensuring Continuity of Care During Disasters Office of Evaluation and Inspections OEI-04-21-00280 2023 The COVID-19 pandemic highlighted the importance of emerging infectious disease (EID) preparedness in health care facilities, including home health agencies (HHAs).OIG has ongoing work reviewing HHA preparedness for EIDs.However, HHAs also must prepare for other types of emergencies.Natural disasters such as hurricanes, floods, and fires continue to threaten operations, even as HHAs continue to address the impact of COVID-19.In 2020, the United States experienced a record number of natural disasters, and Federal scientists predict a greater number of hurricanes and storms in 2021.Previous natural disasters highlighted vulnerabilities in HHAs' preparedness for disasters, specifically with regards to communication and continuity of care.Since November 2017, HHAs have had to comply with CMS Emergency Preparedness Conditions of Participation (EP CoPs).As part of these EP CoPs, CMS requires HHAs to develop communication plans that must include information necessary to ensure continuity of care during any emergency.This evaluation will determine selected HHAs' compliance with EP CoPs and will report factors these HHAs identify as hindering and/or supporting continuity of care during a disaster. Emergency Preparedness and Response; Medicare A
Revised National Institutes of Health National Institutes of Health and Grantee Compliance With Federal Requirements To Ensure Proper Monitoring and Use of Grant Funds by Selected Grantees and Subgrantees Office of Audit Services W-00-21-59461 2023 The National Institutes of Health (NIH) is the primary Federal agency that conducts and supports medical research.NIH funds grants, cooperative agreements, and contracts that support the advancement of fundamental knowledge about the nature and behavior of living systems.Approximately 80 percent of NIH funding goes to support research grants, including grants and subawards to support research conducted outside the United States.OIG has previously identified NIH's oversight of grants to foreign applicants as a potential risk to the Department meeting program goals and the appropriate use of Federal funds.NIH must manage and administer Federal awards to ensure that Federal funding is expended and associated programs are implemented in full accordance with statutory and public policy requirements.To do so, NIH must monitor grantee performance and grantee use of NIH funds.Grantees are responsible for complying with all requirements of the Federal award, including maintaining effective internal controls over the Federal award (45 CFR § 75.300 and § 75.305).Grantees that function as pass-through entities must monitor the activities of subrecipients, including foreign subrecipients, to ensure that subawards are used for authorized purposes in compliance with relevant laws and the terms and conditions of the subaward (45 CFR § 75.352). We will review NIH's monitoring of selected grants, and grantee use and management of NIH grant funds in accordance with Federal requirements. COVID-19; Departmental OperationalIssues; Financial Stewardship; Grants
Revised Centers for Medicare and Medicaid Services Audit of CMS Clinical Laboratory Fee Schedule Rate-Setting Process for Public Health Emergencies Office of Audit Services W-00-21-35875; W-00-22-35875 2023 Medicare Part B pays for most clinical diagnostic laboratory tests (CDLTs) under the Clinical Laboratory Fee Schedule (CLFS).As a result of the Protecting Access to Medicare Act of 2014 (PAMA), beginning in 2018, CMS sets CLFS reimbursement rates based on the weighted median of private payer rates reported to CMS.A rate is set for each CDLT's Healthcare Common Procedure Coding System (HCPCS) code.The data are reported every 3 years, beginning January 1, 2017.(Reporting was postponed from January 1, 2020, to January 1, 2022, because of the pandemic.) For new CDLTs, CMS or its Medicare administrative contractors set reimbursement rates using "cross-walking" or "gap-filling" methodologies.CMS determines the basis (i.e., cross-walking or gap-filling) after it solicits and receives public comments, announces and holds its CLFS annual public meeting regarding new CDLTs, and considers comments and recommendations (and accompanying data) received, including recommendations from an outside advisory panel.The objective of this audit is to determine whether CMS's procedures for clinical diagnostic laboratory test rate-setting could be improved for future public health emergencies. Departmental Operational Issues; Emergency Preparedness and Response; Quality of Care; Public Health Issues; Laboratories; Medicare B
Revised Centers for Medicare and Medicaid Services Audit of Independent Organ Procurement Organizations' Organ Acquisition Overhead Costs Office of Audit Services W-00-21-35874 2023 We will review Medicare payments made to independent organ procurement organizations (OPOs).An OPO is an organization that performs or coordinates the procurement, preservation, and transport of organs and maintains a system for locating prospective beneficiaries for available organs.Medicare reimburses OPOs under 42 CFR § 413.200 according to a cost basis method set out at 42 CFR § 413.24.Prior OIG audits determined that OPOs did not comply with Medicare requirements for reporting overhead costs and administrative and general costs and for reporting organ statistics.We will determine whether payments to OPOs for selected overhead costs complied with Medicare requirements and guidance. Financial Stewardship; Medicare A
Revised National Institutes of Health National Institutes of Health's Use of Single Audit Requirements To Enhance Program Integrity Office of Evaluation and Inspections OEI-04-21-00160 2024 HHS is the largest grant-making agency in the United States.As part of HHS, the National Institutes of Health (NIH) awarded $33.4 billion in grants to over 2,500 external organizations (i.e., universities, medical schools, hospitals, and other research facilities) in FY 2020.External NIH grantees expending $750,000 or more in Federal funds per year must conduct an annual audit in accordance with the Single Audit Act and 45 CFR part 75.These audits provide assurances to NIH that its grantees have adequate internal controls and comply with certain program requirements.NIH must use its grantees' audits to follow up on findings and improve Federal program outcomes.Such action will work to protect the integrity of its awards from fraud, waste, and abuse.We will determine the extent to which NIH monitors and uses grantees' audit findings to improve program integrity at both the individual grantee level and across grantees. Financial Stewardship; Grants
Revised Centers for Medicare and Medicaid Services Accuracy of Place-of-Service Codes on Claims for Medicare Part B Physician Services When Beneficiaries Are Inpatients Under Part A Office of Audit Services W-00-21-35872;
W-00-22-35872
2023 Generally, Medicare makes payments under Part B for physician services and payments under Part A for the costs of inpatient stays at inpatient facilities such as skilled nursing facilities (SNFs) and hospitals.While Medicare pays both SNFs and hospitals through prospective payment systems for the costs of inpatient stays, physician services provided to SNF and hospital inpatients are paid according to the Medicare Physician Fee Schedule.The amount Medicare pays physician service providers (such as physicians, podiatrists, and nurse practitioners, referred to collectively as "physicians") can vary based on where the service is provided (such as a SNF, hospital, or physician's office).Physician services can include medical and surgical procedures, office visits, and medical consultations.Fee schedule payments for physician services are based on three major categories of physician costs: practice expense, physician work, and malpractice insurance.The practice expense is intended to cover overhead costs involved in providing a service.To account for different practice expenses that physicians incur at different settings, Medicare designates a nonfacility rate and a facility rate for each service within the fee schedule.Because physicians generally incur higher practice expenses by performing services in their offices and other nonfacility settings such as independent clinics and urgent care facilities, Medicare generally reimburses physicians at a higher nonfacility rate for services performed in these settings.For services performed at a facility setting such as a SNF or hospital, Medicare generally reimburses physicians for services at a lower facility rate, and the prospective payment system payment to the facility covers the overhead expense.Physicians indicate the applicable place of service on a Medicare claim using a two-digit place-of-service code to ensure that Medicare properly reimburses the physician at either the nonfacility rate or the facility rate.The physical setting where a physician performs a service does not always determine the appropriate place-of-service code.For example, when a beneficiary is a registered inpatient at a hospital or SNF, physician services should always be coded with a facility place-of-service code and paid at the facility rate.This is irrespective of the setting where the patient actually receives the facetoface encounter.Our preliminary data analysis indicates that during 2018 and 2019, Medicare may have paid a significant number of Part B physician service claim lines at the nonfacility rate when the beneficiary was a Part A inpatient at either a hospital or SNF.We will determine whether Medicare appropriately paid claims for Part B physician services based on the correct place-of-service code when a beneficiary was an inpatient at a SNF or hospital. Financial Stewardship; Hospitals; Nursing Homes, Nursing Facilities, and Assisted Living Facilities; Physician and Healthcare Practitioners; Elderly; Medicare B
Revised Centers for Medicare and Medicaid Services Audit of Medicaid Applied Behavior Analysis for Children Diagnosed With Autism Office of Audit Services W-00-21-31555 2023 Autism spectrum disorder (autism) is a developmental disability that can cause significant social, communication, and behavioral challenges for children.According to the Centers for Disease Control and Prevention, there is currently no cure for autism; however, research has shown that early intervention and treatment can improve a child's development.A common treatment for autism is Applied Behavior Analysis (ABA).ABA can help an autistic child improve social interaction, learn new skills, maintain positive behaviors, and minimize negative behaviors.In the past few years, some Federal and State agencies have identified questionable billing patterns by some ABA providers as well as Federal and State payments to providers for unallowable services.We will audit Medicaid claims for ABA services provided to children diagnosed with autism to determine whether a State Medicaid agency's ABA payments complied with Federal and State requirements. Financial Stewardship; Non-institutional care; Children and Families; People with Disabilities; Medicaid
Revised Administration for Children and Families Safe and Efficient Release of Unaccompanied Children to Sponsors Office of Evaluation and Inspections OEI-07-21-00250 2023 The Office of Refugee Resettlement (ORR), a program office of HHS's Administration for Children and Families, experienced a surge of unaccompanied children in spring 2021.As a result of this surge, ORR experienced difficulties in increasing its capacity to care for unaccompanied children; ORR-funded facilities also faced challenges in recruiting and retaining staff.The need to release unaccompanied children to fully vetted sponsors during a surge may have created vulnerabilities that could have put the children's safety at risk.To address this concern, we will conduct an evaluation of the implementation and efficiency of ORR's sponsor screening and followup processes at facilities during this surge, including the newly established intake and influx centers.This evaluation will determine to what extent: (1) proper steps were taken to safely release unaccompanied children to sponsors and (2) these processes were completed in an efficient manner.
Revised Administration for Children and Families Office of Refugee Resettlement Influx Care Facilities and Emergency Intake Sites: Employee/Staff Background Screening Office of Audit Services W-00-21-59459 2023 To address the number of unaccompanied children arriving at the southern border and being referred into the Administration for Children and Families, Office of Refugee Resettlement's (ORR) custody and care, ORR has opened temporary Influx Care Facilities (ICF) and Emergency Intake Sites (EIS) that are not State-licensed.In March 2021, ORR issued waivers for certain background checks for employees, staff, and volunteers at some of its ICF and EIS due to the impossibility or impracticability of obtaining the background check results in a timely manner.Our audit will determine whether these facilities are conducting the background checks that are still required before employees are hired and are implementing mitigation strategies to ensure the safety and well-being of children if ORR permitted employees to have direct access to children before background checks were completed. COVID-19; Public Health Issues; Quality of Care; Children and Families; Grants
Revised HHS, OCR, CMS Audit of the Effectiveness of HHS's Governance To Ensure Hospitals Implement Measures To Prevent, Detect, and Recover From Cyberattacks Office of Audit Services W-00-21-42035 2025 Ransomware, destructive malware, insider threats, and even honest mistakes present an ongoing threat to U.S. hospital operations and the security of electronic protected health information (ePHI).The more quickly and effectively hospitals detect and respond to attacks that may affect the availability and integrity of their data, the more likely they may avoid service disruptions that could potentially affect patient data or lives and save time and money that would be required to recover from such attacks.In recent years, multiple hospitals have fallen prey to significant cyberattacks, including ransomware attacks during the COVID-19 pandemic that have impacted hospital operations and patient care.In October 2020, the Cybersecurity and Infrastructure Security Agency, Federal Bureau of Investigation, and Department of Health and Human Services (HHS) issued a joint cybersecurity advisory regarding ransomware activity targeting the health care and public health sector.The advisory stated that threat actors have continued to develop new functionality and tools, thereby increasing the ease, speed, and profitability of ransomware attacks.HHS-OIG will audit HHS's governance over its programs to determine whether HHS's Office of Civil Rights (OCR) has performed periodic audits of hospitals to assess compliance with Health Insurance Portability and Accountability Act (HIPAA) Security, Privacy, and Breach Notification rules and determine whether these audits effectively assessed ePHI protections.In addition, we will determine whether CMS's certification process for participation in the Medicare program requires hospitals participating in the Medicare program to implement minimum security safeguards to prevent and detect cyberattacks, ensure continuity of patient care, and protect beneficiary data.We will also conduct security assessments at 10 U.S. hospitals to determine whether they have adequately implemented HIPAA security requirements or effective cybersecurity measures to prevent, detect, and recover from cyberattacks. Departmental Operational Issues; Emergency Preparedness and Response; Hospitals; Information Technology and Cybersecurity; Medicare A
Completed (partial) Centers for Medicare and Medicaid Services Audits of Medicare Payments for Spinal Pain Management Services Office of Audit Services W-00-21-35825;
W-00-22-35825;
A-09-21-03002;
W-00-20-35825;
A-09-20-03003;
A-09-20-03010
2023 Medicare Part B covers various spinal pain management services including facet joint injections, facet joint denervation sessions, lumbar epidural injections, and trigger point injections.Medicare Part B also covers sedation administered during these pain management services.We will audit whether Medicare payments for spinal pain management services billed by physicians complied with Federal requirements. Medical Supplies and Equipment;Physician and Healthcare Practitioners; Elderly; Medicare B
Revised Centers for Medicare and Medicaid Services Impact of Expanding the Hospital Transfer Payment Policy for Early Discharges to Postacute Care Office of Audit Services W-00-21-35871 2023 We will determine how the hospital transfer policy for early discharges to postacute care (PAC) would financially affect Medicare and hospitals if it were expanded to include all Medicare Severity Diagnosis-Related Groups (MS-DRGs).The transfer payment policy for discharges from hospitals to PAC facilities, such as a skilled nursing facility, applies to certain specified MS-DRGs.Analysis of Medicare claims data demonstrates significant occurrences of early discharges from hospitals to PAC facilities for MS-DRGs that are not currently subject to the PAC transfer payment policy.Medicare pays a full prospective payment system (PPS) rate to hospitals for these early discharges.In contrast, Medicare pays hospitals a reduced payment for shorter lengths of stay for certain MS-DRGs when beneficiaries are transferred to PAC settings (42 CFR § 412.4(f)).Our proposed audit would provide CMS with a more updated analysis of the financial impact that an expanded hospital-to-PAC transfer payment policy (i.e., all MS-DRGs) would have on Medicare and hospitals. Financial Stewardship; Hospitals; Medicare A
Revised Administration for Children and Families Impact of the COVID-19 Pandemic on State Child Support Enforcement Programs Office of Evaluation and Inspections OEI-06-21-00150 2023 The Office of Child Support Enforcement (OCSE) within the Administration for Children and Families funds and oversees State child support enforcement (CSE) agencies, which establish child support orders and collect support.CSE agencies have faced challenges in maintaining their operations and providing essential services during the COVID-19 pandemic.Such challenges include limited access to State courts for child support hearings.Nationally, child support programs are an important source of funds for families, and high unemployment resulting from the COVID-19 pandemic makes these services even more critical.Using a survey of State CSE agencies, interviews, and document reviews, our study will assess the impact of the COVID-19 pandemic on State CSE operations.In addition, we will evaluate the support and oversight of States by the Federal OCSE.We will also identify strategies and promising approaches used by State CSE agencies in managing these critical services during a national emergency. Covid-19; Emergency Preparedness and Response; Children and Families; Other Funding
Revised Health Resources and Services Administration Audit of CARES Act Provider Relief Funds—Payments to Health Care Providers That Applied for General Distribution Under Phases 1, 2, and 3 Office of Audit Services W-00-21-35873; W-00-22-35873 2023 The Provider Relief Fund (PRF), a $178 billion program, provides relief funds to hospitals and other health care providers for health-care-related expenses or lost revenue attributable to COVID-19 and to ensure that uninsured Americans can get testing and treatment for COVID-19.For the General Distribution of the PRF, HHS allocated funds in three phases: $50 billion during Phase 1 for Medicare providers; $18 billion during Phase 2 for Medicaid and Children's Health Insurance Program providers, dental providers, certain Medicare providers, and assisted living facilities; and $24 billion during Phase 3 for certain behavioral health providers and newly practicing providers, as well as providers that received a payment under a previous phase. Providers applying for General Distribution funds must meet certain requirements, such as submitting revenue information and supporting documentation to the Health Resources and Services Administration, which uses this information to determine eligibility and payments.We will perform a series of audits of funds related to the three phases of the General Distribution to determine whether payments were: (1) correctly calculated for providers that applied for these payments, (2) supported by appropriate and reasonable documentation, and (3) made to eligible providers. COVID-19; Financial Stewardship; Other Funding
Revised National Institutes of Health NIH Oversight of Foreign Grant Recipients' Compliance With Audit Requirements Office of Audit Services W-00-21-59457 2023 The National Institutes of Health (NIH) is the primary Federal agency for conducting and supporting medical research.To realize its mission of extending healthy lifespans and reducing the burdens of illness and disability, NIH funds grants, cooperative agreements, and contracts that support the advancement of fundamental knowledge about the nature and behavior of living systems.The 27 Institutes and Centers of NIH provide leadership and financial support to researchers both inside and outside the United States.Approximately 80 percent of NIH funding goes to support research grants, including grants to foreign organizations.Foreign grant recipients that spend $750,000 or more in HHS funds within one year are subject to certain audit requirements intended to provide assurance to the Federal Government that the recipient has in place adequate internal controls and is generally in compliance with program requirements.We will review NIH funding to foreign grant recipients to determine whether: (1) NIH foreign grant recipients submit required audit reports and (2) NIH appropriately maintains and uses the audit reports. Departmental Operational Issues; Financial Stewardship; Grants
Completed (partial) Centers for Medicare and Medicaid Services Meeting the Challenges Presented by COVID-19: Nursing Homes Office of Evaluation and Inspections OEI-02-20-00490;
OEI-02-20-00491;
OEI-02-20-00492
2023 Nursing homes have been at the epicenter of the COVID-19 pandemic.Residents in these homes have been particularly affected by the disease, as they are predominantly elderly individuals who have underlying medical conditions and live in close quarters.To prevent and mitigate future outbreaks, it is important that we understand how nursing homes experienced the COVID-19 pandemic.This nationwide, three-part study will examine how the pandemic affected nursing homes.The first part will analyze the extent to which Medicare beneficiaries residing in nursing homes were diagnosed with COVID-19 and describe the characteristics of those who were at greater risk.The second part will describe the characteristics of the nursing homes that were hardest hit by the pandemic (i.e., homes with high numbers of beneficiaries who had COVID-19).The third part will describe the strategies nursing homes used to mitigate the unprecedented challenges of COVID-19.These challenges include procuring critical supplies, testing residents and staff, isolating high numbers of contagious residents, caring for those afflicted, and protecting residents and staff on a scale never before experienced in this country. COVID-19; Emergency Preparedness and Response; Nursing Homes, Nursing Facilities, and Assisted Living Facilities; Quality of Care; Elderly; Medicare A; Medicare B; Medicare C; Other Funding
Revised Centers for Disease Control and Prevention Use of States' Immunization Information Systems To Monitor COVID-19 Vaccinations Office of Evaluation and Inspections OEI-05-22-00010 2023 Immunization Information Systems (IISs) play an integral role in monitoring vaccine uptake in the population and meeting vaccination goals.While the Centers for Disease Control and Prevention (CDC) and other stakeholders have long invested significant efforts to establish plans and standards to guide improvements in IISs, State, and local jurisdictions have often struggled to make these improvements.CDC's work to collect and share data on COVID-19 vaccinations relies heavily on State and local IISs working with Federal systems, but the preexisting limitations of these systems pose challenges for CDC's goal of comprehensive immunization data being made available for clinical and public health uses.This study will examine State and Federal experiences using these systems to collect, share, and monitor data on COVID-19 vaccinations, and identify lessons learned that can improve vaccination data and monitoring for future mass vaccination campaigns as well as routine vaccination programs. COVID-19; Emergency Preparedness and Response; Information Technology and Cybersecurity; Public Health Issues; Other Funding
Revised Indian Health Service Audit of Background Verification Process at IHS-Operated Health Facilities Office of Audit Services W-00-21-59454 2023 The Indian Child Protection and Family Violence Prevention Act (P.L. No. 101-630) requires background checks, including Federal Bureau of Investigation fingerprinting, for individuals whose duties involve contact with children.Furthermore, Indian Health Service (IHS) appropriated funds may not be used to pay for services provided by individuals excluded from federally funded health care programs.Prior OIG audit work identified IHS and Tribal health facilities that did not meet Federal requirements for background verifications of employees in contact with children.We will determine whether IHS-operated health facilities met Federal requirements for background verifications of employees, contractors, and volunteers in contact with Indian children served by the facilities, and whether health care providers treating these children were appropriately licensed. Departmental Operational Issues; Hospitals; Quality of Care; Children and Families; Native Americans; Grants; Medicaid; Medicare A; Medicare B
Revised Centers for Medicare & Medicaid Services Skilled Nursing Facility Reimbursement Office of Audit Services W-00-21-35784 2023 A skilled nursing facility (SNF) is a nursing home that provides skilled nursing care and rehabilitation services such as physical, speech, and occupational therapy to beneficiaries who need assistance after hospitalization. In October 2019, the Centers for Medicare & Medicaid Services (CMS) implemented a new payment system for determining Medicare Part A payments to SNFs.  Specifically, CMS implemented the Patient Driven Payment Model (PDPM), a new case-mix classification system for classifying SNF patients in a Medicare Part A covered stay into payments groups under the SNF Prospective Payment System.  Under PDPM, payment is determined by factoring in a combination of six payment components.  Five of the components are case-mix adjusted and include a physical therapy component, an occupational therapy component, a speech-language pathology component, a nontherapy ancillary services component, and a nursing component.  Additionally, there is a non-case-mix adjusted component to cover utilization of SNF resources that do not vary according to patient characteristics.  We will determine whether Medicare payments to SNFs under PDPM complied with Medicare requirements. Nursing Homes, Nursing Facilities, and Assisted Living Facilities; Elderly; Medicare A
Revised Health Resources and Services Administration Audit of Health Resources and Services Administration's COVID-19 Supplemental Grant Funding for Health Centers Office of Audit Services W-00-21-59456 2023 The Health Resources and Services Administration (HRSA) awarded nearly $2 billion in supplemental grant funding to 1,387 health centers nationwide in fiscal year (FY) 2020 to respond to the COVID-19 public health emergency. The funding was intended to support the health centers' activities related to the detection, prevention, diagnosis, and treatment of COVID-19, including maintaining or increasing health center capacity and staffing levels during the pandemic, and expanding COVID-19 testing. The performance period for each of these one-time supplemental grant awards, which HRSA began awarding in March 2020, is 12 months. Health centers were permitted to charge to their awards pre-award costs in order to support expenses related to the COVID-19 public health emergency dating back to January 20, 2020. We will determine whether health centers used their HRSA COVID-19 supplemental grant funding in accordance with Federal requirements and grant terms. COVID-19; Emergency Preparedness and Response; Financial Stewardship; Public Health Issues; Grants
Revised Centers for Medicare & Medicaid Services Dermatologist Claims for Evaluation and Management Services on the Same Day as Minor Surgical Procedures Office of Audit Services W-00-21-35868 2023 Medicare covers an Evaluation and Management (E/M) service when the service is reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body member.Generally, Medicare payments for global surgery procedures include payments for necessary preoperative and postoperative services related to surgery when furnished by a surgeon.Medicare global surgery rules define the rules for reporting E/M services with minor surgery and other procedures covered by these rules.In general, E/M services provided on the same day of service as a minor surgical procedure are included in the payment for the procedure.The decision to perform a minor surgical procedure is included in the payment for a minor surgical procedure and must not be reported separately as an E/M service.An E/M service should be billed only on the same day if a surgeon performs a significant and separately identifiable E/M service that is unrelated to the decision to perform a minor surgical procedure.In this instance, the provider should append a modifier 25 to the appropriate E/M code.In 2019, about 56 percent of dermatologists' claims with an E/M service also included minor surgical procedures (such as lesion removals, destructions, and biopsies) on the same day.This may indicate abuse whereby the provider used modifier 25 to bill Medicare for a significant and separately identifiable E/M service when only a minor surgical procedure and related preoperative and postoperative services are supported by the beneficiary's medical record.We will determine whether dermatologists' claims for E/M services on the same day of service as a minor surgical procedure complied with Medicare requirements. Physician and Healthcare Practitioners; Elderly; Medicare B
Completed Indian Health Service Audit of Indian Health Service's COVID-19 Vaccine Policies and Procedures for COVID-19 Vaccines Distributed to Tribal Health Programs Office of Audit Services W-00-21-59455;
A-07-21-04125
2023 The COVID-19 pandemic has disproportionately affected American Indian and Alaska Native (AI/AN) populations nationwide.The Centers for Disease Control and Prevention (CDC) reported that the age-adjusted AI/AN population's mortality rate from COVID-19 was 1.8 times higher than that among non-Hispanic whites as of December 2020.The Indian Health Service (IHS) has issued its COVID-19 Pandemic Vaccine Plan detailing how the IHS health care system will distribute, allocate, and administer the COVID-19 vaccine.The CDC recommended that all jurisdictions be prepared to immediately vaccinate identified critical populations as the earliest COVID-19 vaccine doses became available and were granted emergency use authorization.IHS is recognized as a "coordinator," similar to a State or other jurisdiction, for vaccine distribution.Tribal Health Programs and Urban Indian Organizations had the option to receive vaccines through either the IHS or their State.IHS direct facilities receive the vaccine through IHS.Approximately 338 facilities elected to receive vaccines through the IHS (including IHS direct facilities, Tribal Health Programs, and Urban Indian Organizations).We will focus on IHS's coordination of the distribution, allocation, and administration of the vaccine to Tribal Health Programs.The objective of this audit is to determine whether IHS followed the Memorandum of Agreement for the CDC COVID-19 Federal Agency Vaccination Program and the IHS COVID-19 Pandemic Vaccine Plan to coordinate the distribution, allocation, and administration of the vaccines to Tribal Health Programs to protect AI/AN beneficiaries.This objective will allow us to review the OIG priority area of promoting public health and safety with respect to services provided to the vulnerable population served by IHS.It will also allow us to address particularly critical goals that bear directly upon OIG's mission and that are identified in the OIG Strategic Plan: Oversight of COVID-19 Response and Recovery.These goals include protecting the health and safety of the AI/AN population that receives health care services through IHS programs and identifying opportunities to increase the effectiveness of IHS's COVID-19 response.We will review the policies and procedures that IHS had in place during our audit period and evaluate the measures implemented by Tribal Health Programs during Phases 1a and 1b of their vaccination programs—specifically, the measures to distribute, allocate, and administer the COVID-19 vaccines developed by Pfizer-BioNTech and the Moderna—for the period of December 11, 2020, through February 28, 2021.We will select a sample of Tribal Health Programs to review and will identify best practices as well as challenges that Tribal Health Programs have faced when coordinating the distribution, allocation, and administration of COVID-19 vaccinations.
Revised OS Audit of FY 2022 HHS Consolidated Financial Statements Office of Audit Services W-00-21-40009 2023 The HHS financial statement audit determines whether the financial statements present fairly, in all material respects, the financial position of the audited entity for the specified time period. We will retain an independent external auditor and review the independent auditor's work papers to determine whether financial statement audits of HHS and its components were conducted in accordance with Federal requirements. The financial statement audit is required by Chief Financial Officers Act of 1990, as amended by the Government Management Reform Act of 1994, and performed in accordance with Generally Accepted Government Auditing Standards and Office of Management and Budget (OMB) Bulletin 21-04, "Audit Requirements for Federal Financial Statements." The audited consolidated FYs 2021 and 2022 financial statements for HHS are due to OMB by November 15, 2021 and 2022, respectively. We plan to perform a number of ancillary financial-related reviews pertaining to the audits of the FYs 2021 and 2022 financial statements. The purpose of the ancillary financial-related reviews is to fulfill requirements in OMB Bulletin 21-04, §§ 6.1 through 12. Financial Stewardship; Other Funding
Revised OS Audit of FY 2022 CMS Financial Statements Office of Audit Services W-00-21-40008 2023 The CMS financial statement audit determines whether the financial statements present fairly, in all material respects, the financial position of the audited entity for the specified time period (Chief Financial Officers Act of 1990, as amended; Government Management Reform Act of 1994; Federal Financial Management Improvement Act of 1996; Generally Accepted Government Auditing Standards; and Office of Management and Budget Bulletin 21-04, "Audit Requirements for Federal Financial Statements"). We will retain an independent external auditor and review the independent auditor's work papers to determine whether the financial statement audit of CMS was conducted in accordance with Federal requirements. Financial Stewardship; Other Funding
Revised OS, CDC, ASPR Awardee Challenges in Implementing COVID-19 Vaccination Program Office of Evaluation and Inspections OEI-04-21-00190 2023 Dispensing vaccines effectively and efficiently is a critical step in fighting the COVID‑19 pandemic.CDC Immunization and Vaccines for Children Cooperative Agreement awardees, which are typically State and large metropolitan area public health departments, plan for and oversee the vaccine distribution and administration process.Stakeholders have acknowledged challenges early in Phase 1 distribution and dispensing, and note that these challenges will likely span all three phases identified in the CDC's COVID-19 Vaccine Playbook.We will interview all awardees to identify the reported challenges they are facing while distributing and dispensing vaccines.We will also ask awardees about effective strategies to mitigate those challenges, new challenges they anticipate, and how HHS can best support them in distributing and dispensing COVID-19 vaccines.In doing so, this review will provide HHS with timely and actionable information to address challenges associated with the COVID-19 vaccination efforts. Covid-19; Emergency Preparedness and Response; Other Funding
Revised FDA, NIH, CMS Audit of HHS's Contracting Compliance for the Acquisition of Information Technology Office of Audit Services W-00-21-42033; W-00-21-42034 2023 HHS is one of the largest contracting agencies in the Federal Government.In FY 2020, HHS obligated $3.4 billion to the acquisition of information technology (IT).HHS has one of the largest dollar investments in major IT systems and the second-largest number of IT investments in the Federal Government.The Federal Acquisition Regulation guides the acquisition process by which executive agencies of the Federal Government acquire goods and services by contract.We will perform a series of audits (three OpDivs).At each OpDiv, we will examine one vendor with contracts awarded for the acquisition of IT exceeding $10 million during FYs 2018 through 2020.We will determine whether HHS OpDivs are administering certain IT contracts in accordance with Federal statutes, regulations, and HHS policies and procedures. Contracts; Information Technology and cybersecurity; Other Funding
Revised Centers for Medicare and Medicaid Services Audits of Medicare Part B Laboratory Services During the COVID-19 Pandemic Office of Audit Services W-00-21-35867 2023 Laboratory tests are critically important because they are used for early detection, diagnosis, monitoring, and treatment of disease.COVID-19, the disease caused by a new strain of coronavirus that had not been previously identified in humans, first emerged in China in December 2019, and the first reported U.S. case occurred in January 2020.Because of the rapid worldwide spread of the virus, the World Health Organization declared COVID‑19 a global pandemic in March 2020.To protect the health and safety of the American people and to assist the Department of Health and Human Services and its Federal partners, laboratories began to provide COVID-19 testing to identify individuals who had contracted the coronavirus that causes COVID-19.Laboratory testing for both COVID-19 tests and non‑COVID‑19 tests (i.e., laboratory tests that are not for COVID-19) is important for all Medicare beneficiaries, but may be especially important for beneficiaries with certain medical conditions who are identified to be at increased risk for severe illness from COVID-19.Ensuring individuals receive necessary laboratory tests is critical to improving health care quality and containing long-term health costs. Our preliminary analysis has shown that the number of non-COVID-19 tests billed for Medicare Part B beneficiaries during the COVID-19 pandemic has decreased compared with the 6-month period before the pandemic, and many independent laboratories have encountered challenges in providing COVID‑19 testing.We will conduct a series of audits on Medicare Part B laboratory services during the pandemic that will initially focus on the effect of the pandemic on non-COVID-19 testing.The series of audits will also focus on aberrant billing of COVID-19 testing during the pandemic. COVID-19; Laboratories; Medicare B
Revised Centers for Medicare and Medicaid Services Audit of Home Health Services Provided as Telehealth During the COVID-19 Public Health Emergency Office of Audit Services W-00-21-35864 2023 On March 13, 2020, President Trump declared a national emergency in response to the COVID-19 pandemic, which allowed the Centers for Medicare & Medicaid Services (CMS) to take proactive steps to support the response to COVID-19 through the use of section 1135 waivers.By means of this authority, CMS waived certain requirements in order to expand Medicare telehealth benefits to health care professionals who were previously ineligible, including physical therapists, occupational therapists, speech language pathologists, and others.However, the waiver does not allow for payment of telehealth services on home health claims.In the COVID‑19 Public Health Emergency Interim Final Rule With Comment, CMS amended regulations on an interim basis to allow home health agencies to use telecommunications systems in conjunction with in-person visits.In the CY 2021 Home Health PPS Final Rule, CMS permanently finalized these changes.The final amended regulations state that the plan of care must include any provision of remote patient monitoring or other services furnished via telecommunications technology or audio-only technology, and that such services must be tied to patient-specific needs as identified in the comprehensive assessment.They further state that telehealth services cannot substitute for a home visit ordered as part of the plan of care, and cannot be considered a home visit for the purposes of patient eligibility or payment.We will evaluate home health services provided by agencies during the COVID-19 public health emergency to determine which types of skilled services were furnished via telehealth, and whether those services were administered and billed in accordance with Medicare requirements.We will report as overpayments any services that were improperly billed.We will make appropriate recommendations to CMS based on the results of our review. Covid-19; Non-institutional care; OIG Statutory Authority; Elderly; Medicare A
January 2021 Health Resources and Services Administration Health Resources and Services Administration's Monitoring of High-Risk COVID-19 Grantees Office of Audit Services W-00-21-59452 2023 The Health Resources and Services Administration (HRSA) is the primary Federal agency for improving health care to people who are geographically isolated and economically or medically vulnerable.HRSA funds nearly 1,400 health centers that deliver care to the most vulnerable individuals and families, regardless of ability to pay.HRSA should identify and mitigate risks related to awarding grants to health centers in order to minimize the potential misuse or loss of Federal funds, as required by the HHS Grants Policy Administration Manual, Part F, Chapter 4.a.1.In spring 2020, HRSA awarded through three programs nearly $2 billion to approximately 1,380 health centers in response to the COVID-19 pandemic.To expedite distribution of this funding, HRSA did not require that health centers apply for grants.Instead, it made funds immediately available to health centers.Health centers had 30 days from the award release date to submit the information that is usually submitted, reviewed, and approved during the grant application process prior to a grantee receiving funding.The information that each of the health centers provided included a program narrative, a budget and budget narrative, and a list of equipment to be purchased, if applicable.We will determine whether HRSA had an effective process for identifying and monitoring high-risk health centers that received COVID-19 grant funds. COVID-19; Financial Stewardship; Grants
Revised Centers for Medicare and Medicaid Services Medicare Needs Better Controls To Prevent Fraud, Waste, and Abuse Related to Orthotic Braces Office of Audit Services W-00-21-35863 2023 Prior OIG work identified inappropriate payments for orthotic braces that were not medically necessary, not documented in accordance with Medicare requirements, or fraudulent.We will compile the results of prior OIG audits, evaluations, and investigations of orthotic braces that were paid for by Medicare.We will also analyze data to identify trends in payment, compliance, and fraud vulnerabilities, and offer recommendations for improving detected vulnerabilities. Medical Supplies and equipment; Elderly; Medicare B
Revised Centers for Medicare and Medicaid Services Medicare Part D Payments During Covered Part A SNF Stay Office of Audit Services W-00-21-35866 2023 Medicare Part A prospective payments to skilled nursing facilities (SNFs) cover most services, including drugs and biologicals furnished by the SNF for use in the facility for the care and treatment of beneficiaries.Accordingly, Medicare Part D drug plans should not pay for prescription drugs related to posthospital SNF care because these drugs are already included in the consolidated payment for Part A SNF stays.We will determine whether Medicare Part D paid for drugs that should have been paid under Part A SNF stays. Nursing Homes, Nursing Facilities, and Assisted Living Facilities; Prescription Drug; Elderly Medicare D
Revised Centers for Medicare and Medicaid Services Background Checks for Nursing Home Employees Office of Audit Services W-00-21-31553 2023 Federal regulation 42 CFR 483.12(a)(3) provides beneficiaries who rely on long-term care services with protection from abuse, neglect, and theft by preventing prospective employees with disqualifying offenses from being employed by these care providers and facilities.The National Background Check Program was enacted by legislation in 2010 to assist States in developing and improving systems for conducting Federal and State background checks.Prior OIG work has shown that not all States complied with the National Background Check Program for Long-Term Care Providers.We will determine whether Medicaid beneficiaries in nursing homes in selected States were adequately safeguarded from caregivers with a criminal history of abuse, neglect, exploitation, mistreatment of residents, or misappropriation of resident property, according to Federal requirements. Nursing Homes, Nursing Facilities, and Assisted Living Facilities; Elderly; Medicaid
Revised Centers for Medicare and Medicaid Services Duplicate Payments Made by Medicare and the Department of Veterans Affairs' Veterans Community Care Program Office of Audit Services W-00-21-35865 2023 The Veterans Community Care Program (VCCP) authorizes the Department of Veterans Affairs (VA) to furnish hospital care and medical services to eligible veterans through agreements with non-VA providers.Duplicate claims may be improperly paid by both Medicare and the VCCP if claims for services are billed to both programs.Because Medicare regulations prohibit payment for services that are paid for either directly or indirectly by another Government entity, subject to a few exceptions, Medicare is not responsible for payment of claims for services in which the VCCP has paid for those services.The payments associated with these claims are considered overpayments.This audit is a collaborative effort with VA-OIG to determine whether the VCCP and Medicare paid duplicate claims for the same medical services. Hospitals; Laboratories; Medical Supplies and Equipment; OIG Statutory Authority; Physician and Healthcare Practitioners; Medicare A; Medicare B
Revised Centers for Medicare and Medicaid Services Medicaid Claims for Federal Reimbursement Using Managed-Care Proxy Methodology Office of Audit Services W-00-21-31554 2023 Federal health care benefits are generally allowable when provided to a beneficiary who is a U.S. citizen, U.S. national, or qualified alien.Generally, a qualified alien is ineligible for full-scope Medicaid services before 5 years have passed from the date he or she enters the United States with qualifying status (5-year bar).Medicaid eligibility for most qualified aliens who are subject to the 5-year bar is generally limited to emergency services (restricted-scope services).States may choose to provide full-scope services to qualified aliens who are subject to the 5-year bar using their own State funds.Furthermore, States may choose to cover full-scope services to aliens permanently residing in the United States under color of law and to children under the age of 19 regardless of immigration status.However, the costs related to nonemergency services provided to non-citizens in these groups without satisfactory immigration status are not eligible for Federal reimbursement.We will review whether States properly claimed Federal Medicaid reimbursement related to services provided to non-citizens who lacked satisfactory immigration status. Managed care; Medicaid
Revised Centers for Medicare and Medicaid Services Audits of Medicare Part B Telehealth Services During the COVID-19 Public Health Emergency Office of Audit Services W-00-21-35862 2023 Telehealth is playing an important role during the public health emergency (PHE), and CMS is exploring how telehealth services can be expanded beyond the PHE to provide care for Medicare beneficiaries.Because of telehealth's changing role, we will conduct a series of audits of Medicare Part B telehealth services in two phases.Phase one audits will focus on making an early assessment of whether services such as evaluation and management, opioid use disorder, end-stage renal disease, and psychotherapy (Work Plan number W-00-21-35801) meet Medicare requirements.Phase two audits will include additional audits of Medicare Part B telehealth services related to distant and originating site locations, virtual check-in services, electronic visits, remote patient monitoring, use of telehealth technology, and annual wellness visits to determine whether Medicare requirements are met. COVID-19; Elderly; Medicare B
Completed Centers for Medicare and Medicaid Services Home Health Agencies' Challenges and Strategies in Responding to the COVID-19 Pandemic Office of Evaluation and Inspections OEI-01-21-00110 2022 Home health agencies (HHAs) have faced unprecedented challenges to providing care during the COVID-19 pandemic.Reported challenges include, but are not limited to, procuring necessary equipment and supplies, implementing telehealth to treat patients remotely, and addressing staffing shortages.However, the full spectrum of these challenges, including how challenges have evolved over time, is unknown.HHAs have used strategies to address these challenges, but the array of strategies and the extent to which HHAs found them helpful are also unknown.This nationwide study will provide insights into the strategies HHAs have used to address the challenges presented by COVID-19, including how well their emergency preparedness plans served them during the COVID-19 pandemic. Covid-19; Non-institutional care; Physicians and Healthcare providers; Public health issues; Medicare A
Completed (partial) Administration for Children and Families States' Use of the Child Welfare Information Systems To Monitor Medication Prescribed to Children in Foster Care Office of Audit Services A-05-18-00007;
W-00-18-59434;
W-00-21-59434;
A-05-21-00020
2023 Psychotropic and opioid drugs are among those that may be prescribed to children in foster care.Psychotropic medications treat mental health disorders such as schizophrenia, depression, bipolar disorder, anxiety disorders, and attention deficit/hyperactivity disorder.Prescription opioids include narcotics to manage pain from surgery, injury, or illness, and have a high risk for abuse and misuse.To receive certain Federal funding for child welfare services, States are required to have a plan for overseeing and coordinating health care services for any child in foster care placement, including protocols for the appropriate use and monitoring of medications (the Social Security Act § 422(b)(15)(A)).The Comprehensive Child Welfare Information System (CCWIS) is a federally funded information system for State child welfare agencies to support case management for children and families receiving child welfare services.We will review States' use of the CCWIS for monitoring psychotropic and opioid medications prescribed to children in foster care.Because the Administration for Children and Families (ACF) oversees States' foster care programs, we will also determine the extent to which ACF ensures that children in foster care receive medications in accordance with State requirements.
Revised Centers for Medicare and Medicaid Services Risk Assessment at a State Medicaid Agency Office of Audit Services W-00-21-31552 2023 One goal of the President's Management Agenda is to maximize grant funding by applying a risk-based, data-driven framework that balances compliance requirements with demonstrating successful results to the American taxpayer.Enterprise Risk Management-based risk assessments can help organizations quickly understand and prioritize critical, enterprisewide risks, and develop plans to maximize as well as mitigate and manage risk.We will perform an Enterprise Risk Management-based risk assessment at one State Medicaid agency to identify internal control weaknesses and process risks. Departmental Operational Issues; Medicaid
Completed (partial) Centers for Medicare and Medicaid Services Followup Review on Medicare Claims for Outpatient Services Provided During Inpatient Stays Office of Audit Services W-00-21-35861;
A-09-22-03007
2023 A prior OIG review (A-09-16-02026) identified that Medicare inappropriately paid acute-care hospitals for outpatient services they provided to beneficiaries who were inpatients of other facilities (i.e., long-term care hospitals (LTCHs), inpatient rehabilitation facilities (IRFs), inpatient psychiatric facilities (IPFs), and critical-access hospitals).It was found that none of the $51.6 million we reviewed, representing 129,792 claims, should have been paid because the inpatient facilities were responsible for payments.In addition, beneficiaries were held responsible for unnecessary deductibles and coinsurance totaling $14.3 million paid to acute-care hospitals for those outpatient services.In addition, it was found that Medicare overpaid acute-care hospitals because the common working file (CWF) edits that should have prevented or detected the overpayments were not working properly. Federal regulations state that the inpatient hospital services provided to Medicare beneficiaries are paid under Medicare Part A.These include inpatient stays at LTCHs, IRFs, and IPFs.Federal regulations also state that Medicare does not pay any provider other than the inpatient hospital for services provided to the beneficiary while the beneficiary is an inpatient of the hospital.The hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements.This provision also applies to LTCHs, IRFs, and IPFs.This audit is a followup to determine whether CMS corrected the CWF edits and ensured that the edits were working properly. OIG Statutory Authority; Medicare A; Medicare B
Revised Centers for Medicare and Medicaid Services Comparison of T-MSIS Prescription Drug Payment Data to Actual Pharmacy Reimbursements for Medicaid Managed Care Office of Evaluation and Inspections OEI-03-20-00560 2023 Effective oversight of growing prescription drug costs in Medicaid requires accurate and consistent data.Managed-care organizations (MCOs) are responsible for the majority of Medicaid enrollment and prescription drug reimbursements.The Centers for Medicare and Medicaid Services (CMS) established the Transformed Medicaid Statistical Information System (T-MSIS) to provide CMS, States, and other stakeholders with accurate and reliable Medicaid claims and encounter data to safeguard the Medicaid program.However, States' managed‑care drug claims data reported in T-MSIS may not uniformly represent drug payments across the Medicaid program.The data may contain the amounts MCOs or their pharmacy benefit managers (PBMs) paid to pharmacies or the amounts MCOs paid to their PBMs, which could include certain PBM fees known as "spread." CMS and States have expressed concerns that the use of spread pricing by PBMs lacks transparency and may inflate Medicaid drug costs.This evaluation will identify how States report managed-care drug payment data to T‑MSIS and determine the extent to which these data represent pharmacy reimbursements.Furthermore, we will identify how States ensure the accuracy of their T-MSIS managed-care drug claims data and use these data to oversee managed-care prescription drug expenditures and the PBMs' spread‑pricing practices. Financial Stewardship; Managed Care; Prescription Drug; Medicaid
December 2020 Centers for Medicare and Medicaid Services Supplier Acquisition Costs for Urinary Supplies Office of Evaluation and Inspections OEI-04-20-00620 2022 We will compare current Medicare reimbursement rates to supplier acquisition costs for selected urinary supplies to determine whether Medicare may be paying too much for these items.Medicare Part B payments for urinary supplies, including intermittent urinary catheter tips and intermittent urinary catheters with insertion supplies, has increased from $125 million in 2010 to $298 million in 2019.CMS could reduce payment rates for urinary supplies through two methods: CMS can adjust the fee schedule price, or it may introduce an item into the Competitive Bidding Program (CBP).To facilitate CMS decision making, we will provide cost information and additional context regarding the extent that urinary supplies are a good fit for potential introduction into the CBP. Financial Stewardship; Medical Supplies and Equipment; Elderly; Medicare B
Revised Assistant Secretary for Preparedness and Response Audit of the Assistant Secretary for Preparedness and Response Oversight of the Hospital Preparedness Program With Respect to Crisis Standards of Care Office of Audit Services W-00-21-59451 2023 The HHS Assistant Secretary for Preparedness and Response (ASPR) administers the Hospital Preparedness Program (HPP), which awards grants to State, territorial, and major metropolitan public health agencies to advance preparedness in health care systems for emergencies and disasters.Crisis standards of care are guidelines for how providers ration resources, such as ventilators, during mass casualty events, such as pandemics.State public health agencies receiving HPP funds must issue these guidelines, and providers can choose to adopt them.An HHS awarding agency must administer Federal awards in a manner that ensures that programs are implemented in full accordance with U.S. statutory and public policy requirements, including the prohibition of discrimination.Recipients of Federal funds are required to comply with an award's terms and conditions as well as Federal civil rights laws.The objective of our audit is to conduct a grant performance review of ASPR's oversight of the HPP program with respect to awardees' adopting crisis standards of care that comply with Federal nondiscrimination laws. COVID-19; Emergency Preparedness and Response; Public Health Issues; Quality of Care; People with Disabilities; Other minorities; Native Americans; Elderly; Grants
Revised Centers for Medicare & Medicaid Services Medicare Part B Payments for Psychotherapy Services Office of Audit Services W-00-17-35801; A-09-17-xxxxx 2023 Medicare Part B covers psychotherapy services. Psychotherapy is the treatment of mental illness and behavioral disturbances in which a physician or other qualified health care professional establishes professional contact with a patient and, through therapeutic communication and techniques, attempts to alleviate emotional disturbances, reverse or change maladaptive patterns of behavior, and encourage personality growth and development. In calendar year 2016, Part B allowed approximately $1.2 billion for psychotherapy services, including individual and group therapy. A prior OIG review found that Medicare allowed $185 million in inappropriate outpatient mental health services, including psychotherapy services. The review found that psychotherapy services were particularly problematic, noting that almost half of the psychotherapy services reviewed were inappropriate. Specifically, Medicare paid for services that were not covered, inadequately documented, or medically unnecessary. We will review Part B payments for psychotherapy services to determine whether they were allowable in accord with Medicare documentation requirements. COVID-19; Physician and Health Care Providers; Elderly; Medicare B
Revised Centers for Medicare and Medicaid Services CMS Oversight of the Two-Midnight Rule for Inpatient Admissions Office of Audit Services W-00-20-35857 2023 Prior OIG audits identified millions of dollars in overpayments for inpatient claims with short lengths of stay.Instead of billing the stays as inpatient claims, they should have been billed as outpatient claims, which usually results in a lower payment.To reduce inpatient admission errors, CMS implemented the Two-Midnight Rule in fiscal year 2014.Under the Two-Midnight Rule, CMS generally considered it inappropriate to receive payment under the inpatient prospective payment system for stays not expected to span at least two midnights.The only procedures excluded from the rule were newly initiated mechanical ventilation and any procedures appearing on the Inpatient Only List.Revisions were made to the Two-Midnight Rule after its implementation.We plan to audit hospital inpatient claims after the implementation of and revisions to the Two-Midnight Rule to determine whether inpatient claims with short lengths of stay were incorrectly billed as inpatient and should have been billed as outpatient or outpatient with observation.We also plan to review policies and procedures for enforcing the Two-Midnight Rule at the administrative level and contractor level.While OIG previously stated that it would not audit short stays after October 1, 2013, this serves as notification that the OIG will begin auditing short stay claims again, and when appropriate, recommend overpayment collections. tags
Revised Centers for Medicare and Medicaid Services Medicare Part D Compounded Drugs Office of Audit Services W-00-21-35415 2023 In 2016, OIG called attention to significant growth in spending for compounded drugs.Specifically, OIG found that Medicare Part D spending for compounded topical drugs grew by 625 percent during 2006—2015.OIG has been involved in an increasing number of fraud investigations related to compounded drugs.We will conduct a risk assessment of CMS's oversight of pharmacies compounding drugs for beneficiaries to determine whether systemic vulnerabilities affecting the integrity of Medicare Part D; specifically, we will assess the risk that pharmacies did not meet Federal and State requirements. Prescription Drug; Elderly; Medicare D
Revised Centers for Medicare and Medicaid Services Medicaid and ACA Enrollment Processes During the COVID-19 Pandemic Office of Evaluation and Inspections OEI-09-20-00590 2023 Economic and health impacts caused by the COVID-19 pandemic have left States facing increases in new applications for health insurance through the Medicaid and ACA Marketplace programs.Responding to the pandemic, including meeting the new enrollment and oversight demands, has taxed State health care systems.This evaluation will assess efforts by the States and CMS to effectively enroll residents impacted by the COVID-19 pandemic in Medicaid and ACA Marketplace plans.By identifying effective practices or any breakdowns in enrollment and oversight systems, this review would help improve the efficiency of State health insurance enrollment processes under both emergency and more typical conditions. tags
Revised Centers for Medicare and Medicaid Services Nursing Homes' Compliance With Facility-Initiated Discharge Requirements Office of Evaluation and Inspections OEI-01-18-00251 2023 A facility-initiated transfer or discharge of a resident from a nursing home can be an unsafe and traumatic experience for the resident and his or her family.To address these concerns, Congress passed the Nursing Home Reform Act of 1987 to protect residents against inappropriate facility-initiated transfer and discharge.However, data from the National Ombudsman Reporting System show that from 2011 through 2016, the Long-Term Care Ombudsman Program, established to advocate for older Americans by the Older Americans Act of 1965, cited complaints related to "discharge/eviction" more frequently than any other concern.In addition, the media has highlighted the rise in nursing home evictions.We have ongoing work determining the extent to which State long-term care ombudsmen, State survey agencies, and CMS address facility-initiated discharges from nursing homes.To complement this ongoing work, we will examine the extent to which nursing homes meet CMS requirements for facility-initiated discharges. tags
Completed Centers for Medicare & Medicaid Services Audit of Medicaid Components for States in Cycle 1 of CMS's PERM Review Office of Audit Services W-00-20-31540;
A-02-20-01006
2022 The Improper Payments Information Act of 2002 requires the heads of Federal agencies to annually review programs they administer in order to identify programs that may be susceptible to significant improper payments and estimate the amount of improper payments.The Medicaid program has been identified as a program at risk for significant improper payments.CMS developed the Payment Error Rate Measurement (PERM) program to measure improper payments in the Medicaid program.PERM produces an improper payment rate based on reviews of the fee-for-service, managed care, and eligibility components of Medicaid.In 2017, CMS published a new, final rule implementing substantive changes to the PERM program that, among other things, were aimed at improving program integrity and promoting State accountability through policy and operational improvements.We will assess the adequacy of the PERM program by determining the accuracy of determinations for the eligibility, fee-for-service, and managed care components of the PERM error rate. Departmental Operational Issues; Medicaid
Completed (partial) Health Resources and Services Administration Audit of HRSA's Controls Over Medicare Providers' Compliance with the Attestation, Submitted-Revenue-Information, and Quarterly Use-of-Funds Reporting Requirements Related to the $50 Billion General Distribution of the Provider Relief Fund Office of Audit Services W-00-21-59060;
A-09-21-06001
2023 A combined $178 billion in funding from the Coronavirus Aid, Relief, and Economic Security (CARES) Act and the Paycheck Protection Program and Health Care Enhancement Act constitutes the Provider Relief Fund (PRF), which provides relief funds to hospitals and other health care providers for health-care-related expenses or lost revenue attributable to COVID-19 and to ensure that uninsured Americans can get testing and treatment for COVID-19.HHS allocated $50 billion for a General Distribution to Medicare providers.
Providers that receive PRF funds are subject to certain requirements for attestation, submission of revenue information, and reporting of quarterly use-of-funds to HHS.A provider that received a PRF payment and retained it for at least 90 days without contacting HHS regarding the payment is deemed to have accepted its terms and conditions.Further, a provider must submit general revenue data after receiving or when applying to receive a payment.Finally, according to the CARES Act, Division B, Title V, Section 15011(b)(2), no later than 10 days after the end of each calendar quarter, a provider that received more than $150,000 in total funds for the coronavirus response and related activities shall submit a report to HHS regarding the use of those funds.
As part of the OIG's oversight of the $50 billion General Distribution of the PRF, we will provide a snapshot of the effectiveness of the Health Resources and Services Administration's (HRSA's) controls over Medicare providers' compliance with the attestation, submitted-revenue-information, and quarterly use-of-funds reporting requirements.Specifically, we will review HRSA's internal controls and assess its policies and procedures related to these areas.
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Revised Centers for Medicare and Medicaid Services Ineligible Providers in Medicare Part C and Part D Office of Audit Services W-00-20-35859 2023 CMS contracts with Medicare Advantage plans and private prescription drug plans (collectively known as "sponsors") to offer Part C and Part D managed care benefits to eligible beneficiaries.Federal law prohibits Medicare payments for services provided or prescriptions written by individuals or entities who are excluded from Federal health care programs (excluded providers) when the sponsor knows or has reason to know of the exclusion.Federal regulations also prohibit Medicare payments to ineligible providers whose billing privileges have been deactivated, denied, or revoked.We will conduct a nationwide audit of Medicare Part C and Part D managed care data for calendar years 2018 and 2019 to identify ineligible providers that had been excluded, precluded, or deactivated as Medicare providers but provided services through Part C and D sponsors.Our audit will determine whether Part C and Part D sponsors complied with Federal requirements on preventing ineligible providers from rendering services to Medicare beneficiaries. tags
Revised Centers for Medicare and Medicaid Services Nationwide Review of the Administration and Oversight of Physician-Administered Drugs Office of Audit Services W-00-20-35860 2023 States are required to collect rebates on covered outpatient drugs administered by physicians in order to be eligible for Federal matching funds (SSA § 1927(a)).Previous OIG work identified significant concerns with States' efforts in obtaining rebates for these physician-administered drugs.We will summarize the results and issues identified in these audits and examine CMS's policies and procedures to ensure States appropriately collect Medicaid rebates on physician-administered drugs. tags
Revised Centers for Medicare and Medicaid Services Joint Work With State Agencies Office of Audit Services W-00-21-40002 2023 To strengthen program integrity and efficiently use audit resources, we will enhance our efforts to provide broader oversight of the Medicaid program by partnering with State auditors, State comptrollers general, and State inspectors general.Federal-State partnerships will provide effective methods that address improper payments in fee-for-service programs such as home health, hospice, and durable medical equipment, and in managed care.OIG will partner with States to: (1) address known vulnerabilities that it has identified in both Medicare and Medicaid to curb such vulnerabilities in Medicaid nationwide; and (2) identify new areas that put the integrity of the Medicaid program at risk. tags
Revised Centers for Medicare and Medicaid Services Risk Assessment of Puerto Rico Medicaid Program Office of Audit Services W-00-20-31544 2023 The Puerto Rico Medicaid program is a 100-percent managed care program that provides health services to more than 1 million beneficiaries.In December 2019, Congress provided Puerto Rico additional funding under the Further Consolidated Appropriations Act of 2020 (P.L. 116-94).P.L. 116-94 also contains anticorruption measures including requirements for OIG to develop and submit to Congress a report identifying payments made under Puerto Rico's Medicaid program to managed care organizations that are at high risk for waste, fraud, or abuse, and a plan for auditing such payments. tags
Completed (partial) Administration for Children and Families Audit of States' Efforts To Locate IV-E Eligible Children Missing From Foster Care Office of Audit Services W-00-20-20027;
W-00-21-20027;
W-00-22-20027;
A-07-20-06095
2023 Title IV-E of the Social Security Act established the Federal Foster Care Program, which helps States provide safe and stable out-of-home care for children who meet certain eligibility requirements until they are safely returned home, placed permanently with adoptive families, or placed in other planned arrangements. We will conduct a survey examining the policies and procedures that State agencies adopted pertaining to reporting and locating children missing from foster care placements during the period July 1,2019, through September 30, 2020. We will use the responses obtained from State agencies to provide Federal, State and local decisionmakers insight into the issues surrounding children missing from foster care and share approaches for addressing those issues in order to reduce the number of and improve outcomes for children missing from foster care. We will also examine whether State agencies are reporting children missing from foster care to the National Center for Missing and Exploited Children and to the National Crime Information Center as required by Federal law. Public Health Issues, Children and Families, Grants
Revised Health Resources and Services Administration Audit of Health Resources and Services Administration's COVID-19 Uninsured Program Office of Audit Services W-00-20-30053 2023 To address the COVID-19 pandemic, the Families First Coronavirus Response Act (FFCRA) and the Paycheck Protection Program and Health Care Enhancement Act (PPP) together appropriated $2 billion to reimburse providers for costs associated with conducting COVID-19 testing and testing-related items and services for the uninsured.Additionally, a portion of the $178 billion appropriated to the Provider Relief Fund by the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) and PPP will be used for treating uninsured individuals with a confirmed COVID-19 diagnosis.HHS, through the Health Resources and Services Administration (HRSA), launched the COVID-19 Uninsured Program Portal, a single electronic claims processing system for health care providers for submitting claims for reimbursements for diagnostic testing and treating uninsured individuals.We will determine whether claims for COVID-19 diagnostic testing and treatment services reimbursed by HHS through HRSA's COVID-19 Uninsured Program complied with Federal requirements. tags
Completed Centers for Medicare and Medicaid Services Use of Medicare Telehealth Services During the COVID-19 Pandemic Office of Evaluation and Inspections OEI-02-20-00520;
OEI-02-20-00522
2022 In response to the coronavirus disease 2019 (COVID-19) pandemic, CMS made a number of changes that allowed Medicare beneficiaries to access a wider range of telehealth services without having to travel to a health care facility.Although these changes are currently temporary, CMS is exploring whether telehealth flexibilities should be extended.These two concurrent reviews will be based on Medicare Parts B and C data and will examine the use of telehealth services in Medicare during the COVID-19 pandemic.The first review will examine the extent to which telehealth services are being used by Medicare beneficiaries, how the use of these services compares to the use of the same services delivered face-to-face, and the different types of providers and beneficiaries using telehealth services.The second review will identify program integrity risks with Medicare telehealth services to ensure their appropriate use and reimbursement during the COVID-19 pandemic. tags
Revised ASPR, CDC, FDA, NIH, CMS HHS and ASPR Actions Related to Resources, Supplies, and Treatments Needed to Address COVID-19 Office of Evaluation and Inspections OEI-09-20-00570 2023 HHS may take a variety of actions in response to an emerging infectious disease, including, but not limited to, actions related to resources, supplies, and treatments needed to address COVID-19.This study will examine actions taken by HHS, including the Office of Assistant Secretary for Preparedness and Response, to protect public health in response to the COVID-19 pandemic. tags
Revised Centers for Medicare and Medicaid Services Audit of Medicare Payments for Inpatient Discharges Billed by Hospitals for Beneficiaries Diagnosed With COVID-19 Office of Audit Services W-00-20-35856 2023 Section 3710 of the Coronavirus Aid, Relief, and Economic Security Act directs the Secretary to increase the weighting factor that would otherwise apply to the assigned diagnosis-related group by 20 percent for an individual who is diagnosed with COVID-19 and discharged during the COVID-19 public health emergency period.We will audit whether payments made by Medicare for COVID-19 inpatient discharges billed by hospitals complied with Federal requirements. tags
Revised Centers for Medicare and Medicaid Services Audit of CARES Act Provider Relief Funds: General and Targeted Distributions to Providers Office of Audit Services W-00-20-35855 2023 The Coronavirus Aid, Relief, and Economic Security (CARES) Act and the Paycheck Protection Program and Health Care Enhancement Act appropriated $178 billion for the Provider Relief Fund (PRF) to support health care providers affected by the COVID-19 pandemic. In April 2020, the Health Resources and Services Administration began distributing the funds through general distributions to Medicare providers based on 2018 net patient revenue and targeted distributions for certain provider types (e.g., providers in areas particularly impacted by COVID-19, skilled nursing providers, and providers in rural areas). Providers such as hospitals may be eligible for PRF payments from the general and targeted distributions. We will select for audit a judgemental sample of providers that received general and/or targeted distributions. Our objective is to determine whether providers that received PRF payments complied with certain Federal requirements, and the terms and conditions for reporting and expending PRF funds. tags
Revised HHS Audit of Foundational Cybersecurity Controls for the U.S. Healthcare COVID-19 Portal and Protect.HHS.gov Office of Audit Services W-00-20-42031R 2023 The Protect.HHS.gov ecosystem and the U.S. Healthcare COVID-19 portal are both critically important systems contributing to the Federal pandemic response.The data collected by these systems are utilized in the response to COVID-19 by, for example, tracking the movement of the virus, identifying potential stresses in the health care delivery system, and provide information about the distribution of supplies.Without proper cybersecurity, the integrity and availability of the data are at risk and the impact to public health efforts could be significant if decisionmakers cannot rely on COVID-19 data from States, communities, and hospitals.We will determine whether HHS has implemented foundational cybersecurity controls to ensure the integrity and availability of Protect.HHS.gov and the U.S. Healthcare COVID-19 portal. tags
Revised Centers for Medicare and Medicaid Services Accuracy of Nursing Home Compare Website's Reported Health, Fire Safety, and Emergency Preparedness Deficiencies Office of Audit Services W-00-20-31551 2023 CMS's Nursing Home Compare website provides information on nursing homes that participate in the Medicare or Medicaid programs.CMS reports the information for consumers to research and make decisions when selecting a nursing home.Included in the information are a nursing home's quality ratings; the results of recent health, fire safety, and emergency preparedness inspections; staffing levels; quality-of-care measures; and penalties assessed by CMS.We will review the information reported on Nursing Home Compare and determine whether the information is accurate and can be relied upon by consumers to compare and select nursing homes. tags
Revised Assistant Secretary for Preparedness and Response Audit of the Assistant Secretary for Preparedness and Response Biomedical Advanced Research and Development Authority's Awarding of Research and Development Contracts for FY 2017 through FY 2020 Office of Audit Services W-00-20-59448 2023 The Office of the Assistant Secretary for Preparedness and Response (ASPR) leads the Nation's medical and public health preparedness for, response to, and recovery from disasters and public health emergencies.The Biomedical Advanced Research and Development Authority (BARDA), a part of ASPR, aids in safeguarding our Nation from pandemic influenza and emerging infectious diseases, and supports the transition of medical countermeasures, such as vaccines, from research through advanced development.Congressional FY appropriations for BARDA are made available to support advanced research and development pursuant to section 319L of the Public Health Service Act and other administrative expenses.We will review contracts awarded through the ASPR Next and BARDA Division of Research, Innovation, and Ventures (DRIVe) programs which were created by ASPR to spur innovation in either the development of certain new lifesaving technologies and products or medical countermeasure efforts.We will determine whether ASPR complied with Federal requirements when awarding contracts with BARDA FY 2017 through FY 2020 appropriations.Furthermore, we will determine whether ASPR appropriately used the ASPR Next and DRIVe programs when awarding contracts. tags
Revised Centers for Medicare and Medicaid Services Swing-Bed Services at Nationwide Critical Access Hospitals Office of Audit Services W-00-20-35853 2023 In 2015, the Office of Inspector General reported that swing-bed usage at Critical Access Hospitals (CAHs) significantly increased from CY 2005 through CY 2010.Medicare spending for swing-bed services at CAHs steadily increased to, on average, almost four times the cost of similar services at alternative facilities.We estimated that Medicare could have saved $4.1 billion over the CY 2005 through CY 2010 period if payments for swing-bed services at CAHs had been made using Skilled Nursing Facility Prospective Payment System rates.We will review swing-bed data for CY 2015 through CY 2019 to determine whether: (1) any actions were taken to reduce swing-bed usage at CAHs; (2) Medicare payment amounts were updated for swing-bed services to CAHs; and (3) alternative care was available to Medicare beneficiaries at a potentially lower rate. tags
Revised Assistant Secretary for Preparedness and Response Audit of Obligations and Expenditures Made From Biomedical Advanced Research and Development Authority FY 2018 and FY 2019 Appropriations Office of Audit Services W-00-20-59449 2023 The Office of the Assistant Secretary for Preparedness and Response (ASPR) leads the Nation's medical and public health preparedness for, response to, and recovery from disasters and public health emergencies.The Biomedical Advanced Research and Development Authority (BARDA), part of ASPR, aids in safeguarding our nation from pandemic influenza and emerging infectious diseases, and supports the transition of medical countermeasures, such as vaccines, from research through advanced development.Congressional FY 2018 and FY 2019 appropriations for BARDA were made available to support advanced research and development pursuant to section 319L of the Public Health Service Act and other administrative expenses of BARDA.We intend to audit the obligations and expenditures made from these appropriations to determine whether they were used for their intended purpose in accordance with Federal requirements. tags
Revised Indian Health Service Audit of Indian Health Service's Coverage of COVID-19 Testing Office of Audit Services W-00-20-20025 2023 The Families First Coronavirus Response Act provided $64 million in additional resources for COVID-19 response activities through the Indian Health Service (IHS) and requires coverage, without cost-sharing, for COVID-19 testing for American Indians/Alaska Natives, who receive health services.The Paycheck Protection Program and Health Care Enhancement Act provided $750 million for COVID-19 testing and testing-related services through IHS.From these two Acts, funding for COVID-19 testing to urban Indian organizations total $53 million and funding to IHS Federal health programs and Tribal health programs total $611 million.We will audit IHS's allocation and utilization of funding to urban Indian organizations, IHS Federal health programs and Tribal health programs.Specifically, our objectives will be to determine whether: (1) IHS allocated the COVID-19 funds to ensure that testing supplies were available to meet community needs, and (2) COVID-19 funds were used by IHS and grantees for testing, including other testing-related services, in accordance with Federal requirements. tags
Revised OS, HRSA, CDC Geographic Distribution of Provider Relief Funds to Communities Disproportionately Impacted by Adverse COVID-19 Outcomes Office of Evaluation and Inspections OEI-05-20-00580 2023 As information on rates of infection and outcomes for the ongoing COVID-19 pandemic emerges, numerous reports document racial, ethnic, and socioeconomic disparities in rates of adverse outcomes from COVID-19, including death.This study will review the locations of hospitals that received Provider Relief Funds, with particular attention to hospitals located in communities of color and economically disadvantaged communities that were disproportionately impacted by adverse COVID-19 outcomes (i.e., hospitalization or death). tags
Revised Centers for Medicare and Medicaid Services Audit of CMS's Controls Over the Expanded Accelerated and Advance Payment Program Payments and Recovery Office of Audit Services W-00-20-35854 2023 This work will provide details of the effectiveness of CMS controls over its Accelerated and Advance Payment Program (AAP) payments to providers and payment recovery.We will obtain data and meet with program officials to understand CMS's eligibility determination process for AAP payments and the steps CMS will have taken to recover such funds in compliance with the CARES Act and other Federal requirements.The objectives of our work will be to determine whether CMS made AAP payments to eligible providers and implemented controls to recover the AAP payments in compliance with the CARES Act and other Federal requirements.We will also evaluate a select group of providers to determine whether they were eligible for AAP payments, and their efforts to repay CMS in compliance with the CARES Act and other Federal requirements. tags
Revised Centers for Medicare and Medicaid Services Assessing Trends Related to the Use of Psychotropic Drugs in Nursing Homes Office of Evaluation and Inspections OEI-07-20-00500 2023 Previous OIG work found that elderly nursing home residents who were prescribed antipsychotic drugs—a type of psychotropic drug—were at risk for harm.CMS concurred with some OIG recommendations and developed new initiatives.However, policymakers continue to raise concerns about whether CMS has made sufficient progress in reducing the use of antipsychotic drugs to care for the elderly.We will report the changes over time for the following: (1) the use of psychotropic drugs for elderly nursing home residents; (2) citations and civil monetary penalties assessed to nursing homes regarding psychotropic drugs; and (3) the presence of diagnoses that exclude nursing home residents from CMS's measure of the use of antipsychotic drugs. tags
Revised Centers for Medicare and Medicaid Services Hospital Collection Effort for Medicare Bad Debt Basic Health Program Eligibility Determinations Office of Audit Services W-00-20-35849 2023 Medicare allows providers to claim reimbursement for a portion of these uncollectible deductibles and coinsurance (known as “bad debt”) once the provider establishes that reasonable collection efforts were made, that the debt was uncollectible, and that there was no likelihood of future recovery based on sound business judgment.Reasonable collection efforts can include billings, followup letters, phone calls, and personal contact.We plan to select a random sample of hospitals and review the policies and procedures in place related to collecting deductibles and coinsurance, offering financial assistance, identifying bad debt, and accounting for the receipt of previously reimbursed bad debt.In addition, we will select a judgmental sample of claims with high-dollar bad-debt amounts (coinsurance or deductible) and determine how the hospitals adhered to Federal criteria in treating these bad debts.Our audit will determine whether hospitals' policies and procedures for collecting Medicare deductible and coinsurance amounts from beneficiaries are in compliance with Federal regulations for the reimbursement of bad debt. tags
Revised Centers for Medicare and Medicaid Services Analysis of New Rural Add-On Payment Methodology Office of Audit Services W-00-20-35850 2023 Section 50208 of the Bipartisan Budget Act of 2018 (the BBA) extended rural add-on payments for home health episodes and visits ending during calendar years (CYs) 2019 through 2022, and mandated implementation of a new methodology for applying those payments.Beginning in CY 2019, rural add-on payments were provided in varying amounts according to classification in one of three rural categories: (1) high utilization, (2) low population density, and (3) all other.The BBA requires home health claims to indicate the code for the county in which the home health service is provided.CMS has instructed providers to use value code 85 to report the county code and will return claims for correction when the code is missing or invalid.The BBA also mandated that, no later than January 1, 2023, HHS-OIG submit to Congress an analysis of Medicare home health claims and utilization of home health services by county (or equivalent area) and recommendations, as appropriate, based on such analysis.To meet that mandate, we will perform an analysis of Medicare home health claims for CYs 2019 through 2021.We will trend the claim data and cost reports to determine what impact, if any, the new rural add-on methodology has had on home health agency providers and the utilization of home health services in rural areas. tags
Revised Centers for Medicare and Medicaid Services Trend Analysis of Medicare Laboratory Billing for Potential Fraud and Abuse With COVID-19 Add-on Testing Office of Evaluation and Inspections OEI-09-20-00510 2023 The coronavirus disease 2019 (COVID-19) pandemic has led to an unprecedented demand for diagnostic laboratory testing to determine whether an individual has the virus. Beyond the COVID-19 tests, laboratories can also perform add-on tests, for example to confirm or rule out diagnosis other than COVID-19. However, OIG has program integrity concerns related to add-on tests in conjuction with COVID-19 testing, particularly related to potentially fraudulent billing for associated respiratory pathogen panel (RPP) tests, allergy tests, or genetic tests. The Centers for Medicare & Medicaid Services has relaxed rules related to COVID-19 testing and other associated diagnostic laboratory testing to no longer require an order from the treating physician or nonphysician practitioner (NPP) during the COVID-19 public health emergency. Relaxation of the physician ordering/NPP rules could allow unscrupulous actors more leeway for fraudulent billing of unnecessary add-on testing. This study will examine Medicare claims data for laboratory testing to identify trends in the use of RPP, allergy, and genetic testing and identify patterns of billing by laboratories that may indicate fraud and abuse. tags
Revised Centers for Medicare and Medicaid Services Medicaid—Telehealth Expansion During COVID-19 Emergency Office of Audit Services W-00-20-31548 2023 As a result of the coronavirus disease 2019 (COVID-19) pandemic, State Medicaid programs have expanded options for telehealth services.Rapid expansion of telehealth may pose challenges for State agencies and providers, including State oversight of these services.Our objective is to determine whether State agencies and providers complied with Federal and State requirements for telehealth services under the national emergency declaration, and whether the States gave providers adequate guidance on telehealth requirements. tags
Revised Administration for Children and Families Audit of Foster Care Services During Coronavirus Disease 2019 (COVID-19) Office of Audit Services W-00-21-20024 2023 Title IV-E of the Social Security Act (the Act), as amended, authorizes the Federal Foster Care Program, which helps provide safe and stable out-of-home care for children until the children are safely returned home, placed permanently with adoptive families, or placed in other planned arrangements for permanency.Title IV-B of the Act authorizes Federal funding to States to promote flexibility in the development and expansion of coordinated child and family services programs.In response to COVID-19, on April 15, 2020, the Children's Bureau—the operating division of the Administration for Children and Families (ACF) that administers the Title IV-B and Title IV-E programs at the Federal level—provided flexibility to State Title IV-E agencies related to (1) fingerprint-based criminal record checks requirements for prospective foster parents (allowing for name-based checks until fingerprint-based checks can safely be done), and (2) caseworker visit requirements (allowing videoconferencing visits to count toward the requirement that 50 percent of visits must occur in the child's home).On April 27, 2020, the Children's Bureau reminded States of additional flexibilities afforded by the Statute, including the authority to modify foster family licensing standards as long as the standards are applied to all of these placements in accordance with the requirements of the Statute.Additionally, States have the authority to set their own foster care maintenance payment rates including, at their own discretion, enhancing those rates for children who test positive for COVID-19.
We intend to survey all States and identify the States that adopted any new licensing regulations or policies and procedures as a result of the existing flexibilities in the Statute and the waivers provided by ACF.Based on the information gathered, we plan to identify three States and conduct separate audits to ensure foster care providers are safeguarding the health and safety of children during the COVID-19 pandemic and identify any vulnerabilities or gaps in policies or procedures that could place these children at risk.As part of these audits, we would ensure that criminal record checks for foster parents conducted via name-based checks were ultimately conducted through fingerprints whenever determined safe to do so.
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Revised Centers for Medicare and Medicaid Services Advanced Care Planning Services: Compliance With Medicare Requirements Office of Audit Services W-00-20-35848 2023 In 2016, Medicare began paying for Advanced Care Planning (ACP), which is a face-to-face service through which a Medicare physician (or other qualified health care professional) and a patient discuss the patient's wishes for health care if he or she becomes unable to make decisions about care.It allows Medicare beneficiaries to make important decisions, giving them control over the type of care they receive and when they receive it.Previous reviews have shown improper payments due to a lack of clinical documentation to support face-to-face services, clinical documentation of the time spent discussing ACP, or both.We plan to perform a nationwide audit to determine whether Medicare providers for ACP services complied with Federal regulations. tags
Completed (partial) Administration for Children and Families Audit of Grantee's Expenditures Under the Additional Supplemental Appropriations for Disaster Relief Requirement Act, 2018 Office of Audit Services W-00-20-20023;
A-02-20-02003
2023 On February 9, 2018, the Bipartisan Budget Act of 2018 (P.L. 115-123) included division B, subdivision 1, the Further Additional Supplemental Appropriations for Disaster Relief Requirement Act, 2018, which provided disaster relief totaling approximately $89.3 billion.Of this, HHS was allocated $5.97 billion ($1.07 billion for discretionary programs and $4.9 billion for Medicaid).OIG received $2 million to provide oversight of HHS's activities and to ensure that program activities and funds expended for recovery and response efforts related to hurricanes Harvey, Irma, and Maria achieved their intended purposes to help individuals and communities in need.For this series of reviews, we will determine whether Further Additional Supplemental Appropriations for Disaster Relief Requirement Act, 2018, recipients claimed allowable costs in accordance with Federal requirements. tags
Revised Centers for Medicare and Medicaid Services Penetration Tests of State Medicaid Management Information Systems and Eligibility & Enrollment Systems Office of Audit Services W-00-20-42028; W-00-21-42028 2023 State Medicaid agencies use the Medicaid Management Information System (MMIS) for administrating the Medicaid program; processing beneficiary and provider inquiries and services; operating claims control and computer capabilities; and managing reporting for planning and control.State Medicaid Eligibility & Enrollment (E&E) systems support processes related to a determination of Medicaid coverage and required procedures necessary for registration.State agencies are responsible for the security of MMIS and E&E systems.HHS OIG will perform a series of penetration tests in select State MMIS or Medicaid E&E environments to identify cybersecurity vulnerabilities on high-risk information systems and networks. tags
Completed (partial) Centers for Medicare and Medicaid Services Audit of Nursing Home Infection Prevention and Control Program Deficiencies Office of Audit Services W-00-20-31545;
A-01-20-00005;
A-01-20-00004
2023 The Centers for Disease Control and Prevention has indicated that individuals at high risk for severe illness from coronavirus disease 2019 (COVID-19) are people aged 65 years and older and those who live in a nursing home.Currently, more than 1.3 million residents live in approximately 15,450 Medicare- and Medicaid-certified nursing homes in the United States.As of February 2020, State Survey Agencies have cited more than 6,600 of these nursing homes (nearly 43 percent) for infection prevention and control program deficiencies, including lack of a correction plan in place for these deficiencies.To reduce the likelihood of contracting and spreading COVID-19 at these nursing homes, effective internal controls must be in place.Our objective is to determine whether selected nursing homes have programs for infection prevention and control and emergency preparedness in accordance with Federal requirements. tags
Revised OS Audit of CARES Act Provider Relief Funds—Distribution of $50 Billion to Health Care Providers Office of Audit Services W-00-20-35847; W-00-22-35847 2023 This work will examine the effectiveness of HHS controls over the awarding and disbursement of $50 billion in Provider Relief Fund (PRF) payments to hospitals and other providers.We will obtain data and interview program officials to gain an understanding of how PRF payments were calculated and review PRF payments for compliance with Coronavirus Aid, Relief, and Economic Security (CARES) Act requirements.Among other things, we will seek to determine whether HHS controls over PRF payments ensured that payments were correctly calculated and disbursed to eligible providers. tags
Revised National Institutes of Health Review of Institutions of Higher Education Grantees Receiving National Institutes of Health Awards Office of Audit Services W-00-20-59445 2023 More than 80 percent of National Institutes of Health (NIH) funding is awarded through almost 50,000 competitive grants to more than 300,000 researchers at more than 2,500 universities, medical schools, and other research institutions located in every State and around the world.OIG has identified areas of potential risk at institutions of higher education receiving NIH awards such as inappropriate or unsupported charges to Federal awards, lack of financial conflict-of-interest polices, and deficiencies in internal control related to the financial management system.In addition, Congress, NIH, and Federal intelligence agencies have raised concerns about foreign threats to the integrity of U.S. medical research and intellectual property at institutions of higher education.Our objective will be to determine whether institutions of higher education (1) managed NIH awards to ensure allowability of costs in accordance with Federal and award requirements, and (2) met Federal conflict-of-interest requirements. tags
Revised Centers for Medicare and Medicaid Services Medicare Part D Payments for Transmucosal Immediate-Release Fentanyl Drugs Office of Audit Services W-00-20-35846 2023 Transmucosal Immediate-Release Fentanyl (TIRF) drugs are a Schedule II controlled substance.Medicare Part D covers TIRF drugs only for managing breakthrough pain in adult cancer patients who are already receiving and are tolerant to around-the-clock opioid therapy for their underlying persistent cancer pain.We will determine whether TIRF drugs were appropriately dispensed in Medicare Part D in accordance with Medicare requirements. tags
Revised Centers for Medicare & Medicaid Services Blood Lead Screening Tests, Followup Services, and Treatment for Medicaid-Enrolled Children Office of Evaluation and Inspections OEI-07-18-00370 2023 There is no safe level of lead exposure for children. In the absence of timely screening, followup services, and treatment, children remain vulnerable to cognitive deficiencies associated with lead exposure. Medicaid-enrolled children are required to receive blood lead screenings. Under the Early and Periodic Screening, Diagnostic, and Treatment program, children are also entitled to receive followup services and treatment for conditions identified through screenings (e.g., elevated blood lead levels (EBLLs). Although previous OIG reports identified low rates of lead screenings, an evaluation of followup services for Medicaid-enrolled children with EBLLs has not been done. We will identify the percentage of children under 26 months of age who (1) received required blood lead screenings, (2) had EBLLs, and (3) received needed followup services and treatment. Additionally, we will determine why children with EBLLs did not receive screening, followup services, and treatment and the extent to which the Centers for Medicare & Medicaid Services provided guidance and technical assistance to States. tags
Revised Centers for Medicare & Medicaid Services Medicare Payments for Stelara Office of Evaluation and Inspections OEI-BL-19-00500 2024 Since 2016, total Medicare Part B payments to physicians for Stelara-an expensive drug used to treat certain autoimmune diseases that is often self-injected by patients in their home-have increased substantially. Such a large increase in payments for a drug that would not typically be covered under Part B raises questions about what is driving the growth, including the possibility of improper billing. In this study, OIG will (1) determine whether versions of Stelara that are typically self-injected meet the criteria for Medicare Part B coverage, (2) identify factors that may be causing the substantial growth in payments, and (3) determine whether claims for Stelara show evidence of improper billing by physicians. tags
Revised Food and Drug Administration FDA's Tobacco Retailer Compliance Check Inspection Program Office of Evaluation and Inspections OEI-01-20-00240; OEI-01-20-00241 2023 Youth tobacco use, specifically e-cigarette use, continues to grow at an alarming rate. The Centers for Disease Control and Prevention (CDC) found that e-cigarette use among youth increased by more than 1.5 million users (38 percent) between 2017 and 2018. FDA's Retailer Compliance Check Inspection program plays a key role in its Youth Tobacco Prevention Plan. Under the program, FDA contractors, generally States, carry out undercover buy inspections of tobacco retailers to ensure that they comply with restrictions on sales to minors. They also conduct advertising and labeling inspections to ensure that retailers comply with limitations on marketing of tobacco products. Since the program began in 2010, contractors have carried out over 1 million inspections. The first time FDA finds violations during a tobacco retailer inspection, FDA generally issues a warning letter. When followup inspections reveal subsequent violations, FDA may seek to impose civil monetary penalties and no-tobacco-sale orders that prevent retailers with repeated violations from selling tobacco products indefinitely or for a specified period of time. We will determine the extent and nature of inspections, violations, and enforcement actions by inspection type, on a State-by-State basis, and over time. We will also assess FDA's direction and oversight of the program, including how it targets inspection priorities and holds contractors responsible for their performance. tags
Completed HHS Assessing HHS Agencies' Adherence to Health, Safety, and Operational Protocols During Repatriation and Quarantine Efforts for the COVID-19 Outbreak Office of Evaluation and Inspections OEI-04-20-00360 2023 The U.S. Department of Health and Human Services (HHS) plays a lead role in preparing for and responding to public health emergencies. The current novel coronavirus (COVID-19) pandemic highlights the need for HHS to efficiently and effectively respond to protect the nation. OIG will evaluate how HHS staff were deployed, trained, and protected when assigned tasks that could entail potential exposure to COVID-19, such as work at quarantine sites and at ports of entry. We will analyze steps taken to protect HHS staff and, in turn, the public, during pre-deployment, deployment, and post-deployment. We will also review the extent to which HHS has established mechanisms to identify and correct any vulnerabilities in deployment protocols. We plan to issue multiple work products reporting findings for the Administration for Children and Families (ACF), Centers for Disease Control and Prevention (CDC), and the Department overall. tags
Revised Assistant Secretary for Preparedness and Response Audit of ASPR's Operation of the Strategic National Stockpile in Response to the COVID-19 Disease Pandemic Office of Audit Services W-00-20-59446 2023 The Strategic National Stockpile (Stockpile) is a repository of supplies for use in the event of a national emergency in the United States or its territories. Originally funded by Congress in Fiscal Year 1999 and operated by the Centers for Disease Control and Prevention, the Assistant Secretary for Preparedness and Response (ASPR) at the Department of Health and Human Services has been responsible since 2018 for the operation of the Stockpile. OIG has historically reviewed various aspects of the Department's emergency preparedness and response. We plan to determine whether the Stockpile, under the direction of ASPR, was effective in response to the coronavirus disease 2019 (COVID-19) pandemic. tags
Revised Centers for Disease Control and Prevention Audit of HHS's Production and Distribution of COVID-19 Lab Test Kits Office of Audit Services W-00-20-57303 2023 When a new viral disease emerges, CDC uses its expertise and biosafety laboratories to develop and distribute tests to state public health laboratories.CDC uses confirmed viral samples from initial patients to develop these tests.To ensure that it has a functioning test, CDC conducts quality assurance reviews.After validating that it has a functioning test, CDC sends the tests to state public health labs for their use.During the early phases of identification and spread of the novel coronavirus in the United States in 2020, CDC developed testing kits, called the CDC 2019-Novel Coronavirus Real-Time Reverse Transcriptase-PCR Diagnostic Panel (CDC 2019-nCoV Real Time RT-PCR), and sent the kits to qualified laboratories to identify COVID-19 cases.We plan to review the controls that HHS has in place to produce and distribute the COVID-19 test kits and whether CDC has designed and implemented controls to mitigate any potential risks.The objective of our audit will be to review CDC's process of producing and distributing the COVID-19 test kits. tags
Completed (partial) Centers for Medicare and Medicaid Services CMS's Internal Controls Over Hospital Preparedness for Emerging Infectious Disease Epidemics Such as Coronavirus Disease 2019 Office of Audit Services A-02-21-01003;
W-00-20-35845;
W-00-21-35845
2023 Hospitals that participate in the Medicare program must comply with Federal participation requirements, including requirements that hospitals engage in all-hazards emergency preparedness planning. On February 1, 2019, CMS added planning for emerging infectious diseases to its emergency preparedness guidance. We will audit CMS's internal controls over hospital preparedness for an emerging infectious disease epidemic, such as coronavirus disease 2019 (COVID-19). We will also audit hospital compliance with CMS's emergency preparedness requirements. tags
Revised Centers for Medicare & Medicaid Services Medicaid—Audit of Health and Safety Standards at Individual Supported Living Facilities Office of Audit Services W-00-20-31543 2023 State agencies operate home and community-based services programs under a 1915(c) waiver to their respective Medicaid State plans. Some of these waivers allow for providing services to individuals with developmental disabilities. Such waivers include individualized supported living habilitation services, which provide assistance and necessary support to achieve personal outcomes that enhance individuals' ability to live in and participate in their communities. To receive approval for a waiver, State agencies must ensure the health and welfare of the beneficiaries of the service. Recent media coverage throughout the United States of deaths of people with developmental disabilities involving abuse, neglect, or medical errors has led to OIG audits in several States. Our objective is to determine whether State agencies and providers complied with Federal and State health and safety requirements involving Medicaid beneficiaries with developmental disabilities residing in individualized supported living settings, including infection control for conditions such as coronavirus disease 2019 (COVID-19) and other infectious diseases. tags
Completed (partial) Centers for Medicare & Medicaid Services Health and Safety Standards in Social Services for Adults Office of Audit Services A-05-16-00044;
A-05-17-00030;
A-05-17-00009;
A-05-17-00028;
W-00-20-31503
2023 State agencies operate elderly waiver programs under a 1915(c) waiver to their Medicaid State plan. Adult day centers are center-based facilities directly licensed by the State agency. They provide adult day services to functionally impaired adults on a regular basis for periods of fewer than 24 hours during the day in a nonresidential setting. As the licensing agency for adult day care centers, the State agency must ensure that adult day centers follow applicable licensing standards to protect the health and safety of adults receiving services at these facilities. Recent OIG reports have identified numerous instances of noncompliance in regulated child care facilities and family adult foster care homes. We will determine whether regulated adult day centers comply with applicable Federal, State, and local regulations and standards on ensuring the health and safety of adults in their care, including infection control for conditions such as coronavirus disease 2019 (COVID-19) and other coronaviruses. tags
Completed (partial) Centers for Medicare and Medicaid Services Medicaid Nursing Home Life Safety and Emergency Preparedness Reviews Office of Audit Services W-00-20-31525;
A-02-21-01010
2023 Previous OIG audits on Medicaid nursing home life safety and emergency preparedness have identified multiple issues that put vulnerable populations at risk and indicated that nursing homes in various States are not complying with these requirements. In 2016, CMS updated its health care facilities' life safety and emergency preparedness requirements to improve protections for all Medicare and Medicaid beneficiaries, including those residing in long-term-care (LTC) facilities. In addition, in 2019 CMS also issued expanded guidance on emerging infectious disease control to ensure that health care facilities are prepared to respond to threats from infectious diseases. OIG is reviewing this area because residents of LTC facilities are particularly vulnerable to risks such as fires, natural disasters, or disease outbreak (such as COVID-19 and other coronaviruses). Our objective is to determine whether LTC facilities that received Medicare or Medicaid funds complied with new Federal requirements for life safety and emergency and infectious disease control preparedness. tags
Revised Centers for Medicare and Medicaid Services Medicare Part B Payments to Physicians for Co-Surgery Procedures Office of Audit Services W-00-20-35844; W-00-22-35844 2023 Under Medicare Part B, when the individual skills of two surgeons are necessary to perform a specific surgical procedure or distinct parts of a surgical procedure (or procedures) simultaneously on the same patient during the same operative session (co-surgery), each surgeon should report the specific procedure(s) by billing the same procedure code(s) with a modifier "62." By appending modifier "62" to the procedure code(s), the fee schedule amount applicable to the payment for each co-surgeon is 62.5 percent of the global surgery fee schedule amount. We plan to audit a sample of claim line items-specifically where different physicians billed for the same co-surgery procedure code, for the same beneficiary, on the same date of service. Our objective is to determine whether Medicare Part B payments to physicians for co-surgery procedures were properly made. tags
Revised Centers for Medicare and Medicaid Services Medicare Hospital Payments for Claims Involving the Acute- and Post-Acute-Care Transfer Policies Office of Audit Services W-00-20-35832 2023 Medicare's acute- and post-acute-care transfer policies designate some discharges as transfers when beneficiaries receive care from certain post-acute-care facilities. The diagnosis-related group (DRG) payment provides payment in full to hospitals for all inpatient services associated with a particular diagnosis. Because of its transfer payment policies, Medicare pays hospitals a per diem rate for early discharges when beneficiaries are transferred to another prospective payment system hospital or to post-acute-care settings, including skilled nursing facilities, inpatient rehabilitation facilities, home health agencies, long-term-care hospitals, psychiatric hospitals, and hospice. This is based on the presumption that hospitals should not receive full payments for beneficiaries discharged early and then admitted for additional care in other clinical settings. Previous Office of Inspector General reviews identified Medicare overpayments to hospitals that did not comply with Medicare's post-acute-care transfer policy. We will review Medicare hospital discharges that were paid a full DRG payment when the patient was transferred to a facility covered by the acute and post-acute transfer policies where Medicaid paid for the service. Under the acute- and post-acute transfer policies, these hospital inpatient stays should have been paid a reduced amount. Additionally, we will assess the transfer policies to determine if they are adequately preventing cost shifting across healthcare settings. tags
Revised Centers for Medicare & Medicaid Services Nationwide Audit of Medicare Part D Eligibility Verification Transactions Office of Audit Services W-00-20-35751 2023 An E1 transaction is a Medicare Part D eligibility verification transaction that the pharmacy submits to the Part D transaction facilitator to bill for a prescription or determine drug coverage billing order. The Part D transaction facilitator returns information to the pharmacy that is needed to submit the prescription drug event. E1 transactions are part of the real-time process of the Coordination of Benefits and calculating the true out-of-pocket costs (CMS, Medicare Prescription Drug Benefit Manual, Pub. No. 100-18, chapter 14, 30.4). We will review CMS's oversight of E1 transactions processed by contractors and determine whether the E1 transactions were created and used for intended purposes. tags
Revised Centers for Medicare & Medicaid Services Medicaid MCO PBM Pricing Office of Audit Services W-00-20-31542 2023 The State Medicaid agency and the Federal Government are responsible for financial risk for the costs of Medicaid services. Managed care organizations (MCOs) contract with State Medicaid agencies to ensure that beneficiaries receive covered Medicaid services including prescription drugs. MCOs may contract with pharmacy benefit managers (PBMs) to manage or administer the prescription drug benefits on their behalf. Spread pricing is a practice where a PBM charges an MCO more for a drug than the amount a PBM pays a pharmacy. Our audit will determine whether States provide adequate oversight of Medicaid MCOs to ensure accountability over amounts paid for prescription drug benefits to its PBMs. tags
Revised Administration for Children and Families Audit of Office of Refugee Resettlement's Placement and Transfer of Children in the Unaccompanied Alien Children Program Office of Audit Services W-00-20-20002 2023 The Unaccompanied Alien Children Program, managed by the Office of Refugee Resettlement (ORR), Administration for Children and Families (ACF), provides temporary shelter, care, and other related services to unaccompanied children. ORR funds a network of approximately 170 state-licensed care provider facilities for children in its custody. The ORR Guide: Children Entering the United States Unaccompanied details the policies for initial placement of children in and transfer between ORR care provider facilities. ORR must make every effort to place and keep each child in the least restrictive setting available that is in the child's best interest. Our objective will be to determine whether ORR followed its policies, procedures, and guidance both when making initial placements in care provider facilities funded by ORR and when transferring children between those facilities. We will also determine how frequently children are transferred between care provider facilities, the reason for transfers and denials of transfers, and any challenges that care provider facilities face when children are identified as requiring a transfer. Departmental Operational Issues; Emergency Preparedness and Response; Hospitals; Information Technology and Cybersecurity; Medicare A
Completed (partial) Centers for Medicare & Medicaid Services Medicare Part B Payments for Laboratory Services Office of Audit Services A-06-16-02002;
A-09-16-02034;
A-06-17-04002;
A-04-18-08063;
A-09-19-03027;
A-06-20-04000;
A-09-20-03027;
W-00-17-35726;
W-00-20-35726;
W-00-22-35726;
various reviews
2023 Medicare covers diagnostic clinical laboratory services that are ordered by a physician who is treating a beneficiary and who uses the results in the management of the beneficiary's specific medical problem (42 CFR 410.32(a)). These covered services can be furnished in hospital laboratories (for outpatient or nonhospital patients), physician office laboratories, independent laboratories, dialysis facility laboratories, nursing facility laboratories, and other institutions. Previous OIG audits, investigations, and inspections have identified areas of billing for clinical laboratory services that are at risk for noncompliance with Medicare billing requirements. Payments to service providers are precluded unless the provider furnishes on request the information necessary to determine the amounts due (the Social Security Act § 1833(e)). We will review Medicare payments for clinical laboratory services to determine laboratories' compliance with selected billing requirements. We will focus on claims for clinical laboratory services that may be at risk for overpayments. For example, our reviews will focus on the improper use of claim line modifiers for a code pair, genetic testing, and urine drug testing services. We may use the results of these reviews to identify laboratories or other institutions that routinely submit improper claims. tags
Completed (partial) Substance Abuse and Mental Health Services Administration Post-Award State or Tribal Audits of Substance Abuse and Mental Health Services Administration's Opioid Response Grants Office of Audit Services W-00-20-59441;
A-07-20-04121;
W-00-21-59441;
W-00-22-59441;
A-06-20-07003
2023 The Substance Abuse and Mental Health Services Administration (SAMHSA) has awarded a series of grants to combat opioid use disorder. These grants include State Targeted Response to the Opioid Crisis grants (Opioid STR) with approximately half of $970 million awarded in fiscal year (FY) 2017 and the other half awarded in FY 2018. In FY 2018, SAMHSA also awarded more than $930 million in the State Opioid Response grants (SOR) and approximately $50 million in Tribal Opioid Response grants (TOR). The purpose of the Opioid STR, SOR, and TOR grants are to increase access to treatment, reduce unmet treatment need, and reduce opioid overdose related deaths. This post-award audit will determine how select States or Tribal agencies implemented programs under the Opioid STR, SOR, or TOR grants. We will also determine whether the activities of these agencies and subrecipients responsible for implementing the programs complied with Federal regulations and met grant program goals. tags
Completed (partial) Centers for Medicare & Medicaid Services Medicaid Concurrent Eligibility Office of Audit Services A-05-19-00023;
A-05-19-00031;
A-05-19-00032;
W-00-19-31539;
A-05-20-00025
2023 State Medicaid agencies contract with managed care organizations (MCOs) to make services available to enrolled Medicaid beneficiaries. The contractual arrangement shifts financial risk for the cost of care to the MCO. State Medicaid agencies pay MCOs on a per-beneficiary per-month basis, and MCOs are at financial risk if the costs of care exceed those payments. If a beneficiary who resides in one State subsequently establishes residency in another State, the beneficiary's Medicaid eligibility in the previous State should end and the MCO should not receive payments for that beneficiary. Our review will determine whether States made capitation payments on behalf of beneficiaries who established residency in another State. tags
Completed (partial) Indian Health Service Review of Background Verification Process at Tribally Operated Health Facilities Office of Audit Services A-01-20-01500; W-00-20-51001 2023 The Indian Health Service's (IHS's) mission is to partner with American Indians and Alaska Natives to elevate their physical, mental, social, and spiritual health to the highest level. The goal of IHS is to ensure that comprehensive, culturally acceptable personal and public health services are available and accessible to all of the approximately 2.6 million members of the 573 federally recognized Tribes. In 1975, Congress recognized the importance of Tribal decision making in Tribal affairs and the nation-to-nation relationship between the United States and Tribes through the passage of the Indian Self-Determination and Education Assistance Act (ISDEAA) (P.L. No. 93-638). Under ISDEAA, federally recognized Tribes administer their own healthcare programs and services that IHS would otherwise provide through P.L. No. 93-638 funding agreements with IHS. In 2019, a pediatrician who worked at several IHS health facilities during a 21-year period was convicted of sexually abusing children served at these facilities. Congressional officials have expressed concerns about safeguards for Indian children and specifically about IHS failing to address this pediatrician's history of offenses at the various IHS health facilities where he was employed. The Indian Child Protection and Family Violence Prevention Act (P. L. No. 101-630), requires background checks, including Federal Bureau of Investigation fingerprinting, for employees whose job duties involve contact with children. Prior OIG audit work identified two Tribal health facilities that did not meet Federal requirements for background verifications for employees in contact with children. We will determine whether the tribally operated health facilities met Federal and Tribal requirements for background verification of employees, contractors, and volunteers in contact with children served by the facilities. tags
Completed (partial) Centers for Medicare & Medicaid Services Medicare Advantage Risk-Adjustment Data - Targeted Review of Documentation Supporting Specific Diagnosis Codes Office of Audit Services A-07-19-01187;
A-07-19-01188;
A-07-17-01173;
W-00-20-35079;
W-00-19-35079;
W-00-17-35079;
A-01-19-00500;
A-02-18-01029;
A-06-18-05002;
A-03-18-00002;
A-04-19-07084;
A-03-19-00001;
A-05-19-00039;
A-07-19-01195;
A-02-20-01009;
A-09-20-03009
2023 Payments to Medicare Advantage (MA) organizations are risk-adjusted on the basis of the health status of each beneficiary. MA organizations are required to submit risk-adjustment data to CMS in accordance with CMS instructions (42 CFR § 422.310(b)), and inaccurate diagnoses may cause CMS to pay MA organizations improper amounts (SSA §§ 1853(a)(1)(C) and (a)(3)). In general, MA organizations receive higher payments for sicker patients. CMS estimates that 9.5 percent of payments to MA organizations are improper, mainly due to unsupported diagnoses submitted by MA organizations. Prior OIG reviews have shown that some diagnoses are more at risk than others to be unsupported by medical record documentation. We will perform a targeted review of these diagnoses and will review the medical record documentation to ensure that it supports the diagnoses that MA organizations submitted to CMS for use in CMS's risk score calculations and determine whether the diagnoses submitted complied with Federal requirements. tags
Completed (partial) Centers for Medicare & Medicaid Services Review of Hospice Inpatient and Aggregate Cap Calculations Office of Audit Services W-00-19-35826;
W-00-21-35826
2023 Hospice care can provide great comfort to beneficiaries, families, and caregivers at the end of a beneficiary's life. To ensure that hospice care does not exceed the cost of conventional medical care at the end of life, Medicare imposes two annual limits to payments made to hospice providers: the inpatient cap and the aggregate cap. The inpatient cap limits the number of days of inpatient care for which Medicare will pay to 20 percent of a hospice's total Medicare patient care days, and a hospice must refund to Medicare any payment amounts in excess of the inpatient cap. The aggregate cap limits the total aggregate payments that any individual hospice can receive in a cap year to an allowable amount based on an annual per-beneficiary cap amount and the number of beneficiaries served. Any amount paid to a hospice for its claims in excess of the aggregate cap is considered an overpayment and must be repaid to Medicare. Medicare administrative contractors (MACs) oversee the cap process and hospices must file their self-determined aggregate cap determination notice with their MAC no later than 5 months after the end of the cap year and remit any overpayment due at that time. tags
Revised Centers for Medicare & Medicaid Services Medicare Part B Payments for Speech-Language Pathology Office of Audit Services W-00-19-35827; W-00-21-35827 2023 Outpatient speech therapy services are provided by speech-language pathologists and are necessary for the diagnosis and treatment of speech and language disorders that result in communication disabilities and swallowing disorders (dysphagia). When Medicare payments for a beneficiary's combined physical therapy and speech therapy exceed an annual therapy spending threshold (e.g., $2,010 in 2018), the provider must append the KX modifier to the appropriate Healthcare Common Procedure Coding System reported on the claim. The KX modifier denotes that outpatient physical therapy and speech therapy services combined have exceeded the annual spending threshold per beneficiary, and that the services being provided are reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. We will determine whether the claims using the KX modifier adhere to Federal requirements. In addition, we will evaluate payment trends to identify Medicare payments for outpatient speech therapy services billed using the KX modifier that are potentially unallowable. tags
Completed (partial) Centers for Medicare & Medicaid Services Review of Medicare Payments for Power Mobility Device Repairs Office of Audit Services W-00-19-35828;
W-00-22-35828;
A-09-20-03016
2023 Medicare Part B covers medically necessary power mobility devices (PMDs), such as power wheelchairs, and PMD repairs that are reasonable and necessary to make the equipment serviceable. For calendar year 2018, Medicare Part B paid approximately $46.7 million for PMD repairs, including replacement parts needed to repair PMDs. Durable medical equipment (DME) suppliers must maintain documentation from the physician or treating practitioner indicating that the PMD being repaired continued to be medically necessary and that the repairs were reasonable and necessary. DME suppliers must also maintain detailed records describing the need for and nature of all repairs, which includes a justification for the replaced parts and the labor time. In addition, if the expense for repairs exceeds the estimated expense of purchasing or renting another PMD for the remaining period of medical need, no payment can be made for the amount of the excess. We will audit Medicare payments for PMD repairs to determine whether suppliers complied with Medicare requirements. tags
Completed (partial) Centers for Medicare & Medicaid Services Review of Medicare Part B Urine Drug Testing Services Office of Audit Services A-09-20-03017;
W-00-20-35829
2023 Medicare covers treatment services for substance use disorders (SUDs), such as inpatient and outpatient services when they are reasonable and necessary. SUDs occur when the recurrent use of alcohol or other drugs causes clinically significant impairment, including health problems, disability, and failure to meet major responsibilities at work, school, or home. Medicare also covers clinical laboratory services, including urine drug testing (UDT), under Part B. Physicians use UDT to detect the presence or absence of drugs or to identify specific drugs in urine samples. A patient in active treatment for an SUD or being monitored during different phases of recovery from an SUD may undergo medical management for a variety of medical conditions. UDT results influence treatment and level-of-care decisions for individuals with SUDs. The 2018 Medicare fee-for-service improper payment data showed that laboratory testing, including UDT, had an improper payment rate of almost 30 percent, and that the overpayment rate for definitive drug testing for 22 or more drug classes was 71.7 percent. We will review UDT services for Medicare beneficiaries with SUD-related diagnoses to determine whether those services were allowable in accordance with Medicare requirements. tags
Revised Centers for Medicare & Medicaid Services Supplier Compliance with Medicare Requirements for Replacement of Positive Airway Pressure Device Supplies Office of Audit Services W-00-20-35830; W-00-22-35830 2023 Beneficiaries receiving continuous positive airway pressure or respiratory assist device (collectively known as positive airway pressure (PAP) devices) therapy require replacement of supplies (e.g., mask, tubing, headgear, and filters) when they wear out or are exhausted. Medicare payments for these replacement supplies in 2017 and 2018 were approximately $945.8 million. Prior OIG work found that most Medicare claims that suppliers submitted for replacement PAP device supplies did not comply with Medicare requirements. For supplies and accessories used periodically, orders must specify the type of supplies needed, the frequency of use, if applicable, and the quantity to be dispensed, and suppliers must not automatically ship refills on a predetermined basis (Centers for Medicare & Medicaid Services Medicare Program Integrity Manual, Pub. 100-08, Ch. 5, §§ 5.2.3 and 5.2.8). We will review claims for frequently replaced PAP device supplies at selected suppliers to determine whether documentation requirements for medical necessity, frequency of replacement and other Medicare requirements are met. tags
Revised Centers for Medicare & Medicaid Services Medicare Payments of Positive Airway Pressure Devices for Obstructive Sleep Apnea Without Conducting a Prior Sleep Study Office of Audit Services W-00-19-35823; W-00-22-35823 2023 An OIG analysis of the 2017 Comprehensive Error Rate Testing (CERT) program for positive airway pressure (PAP) device payments shows potential overpayments of $566 million. Claims for PAP devices used to treat obstructive sleep apnea (OSA) for beneficiaries who have not had a positive diagnosis of OSA based on an appropriate sleep study are not reasonable and necessary (Medicare National Coverage Determination Manual, Chapter 1, Part 4, § 240.4 and Local Coverage Determination (LCD) L33718). Medicare will not pay for items or services that are not "reasonable and necessary" (Social Security Act § 1862(a)(1)(A)). We will examine Medicare payments to durable medical equipment providers for PAP devices used to treat OSA to determine whether an appropriate sleep study was conducted. tags
Completed (partial) Centers for Medicare & Medicaid Services States' Medicaid Agency Claims for Indian Health Service Expenditures Office of Audit Services W-00-19-31538;
A-06-19-09005
2023 The Federal government pays its share of a State's Medicaid expenditures based on the Federal Medical Assistance Percentage (FMAP), which varies depending on the State's relative per capita income. States' regular FMAPs range from a low of 50 percent to a high of 83 percent; however, States receive a 100-percent FMAP for expenditures related to services received through Indian Health Service (IHS) facilities. In Federal fiscal years 2016 through 2018, States claimed $6.6 billion in expenditures at the IHS services FMAP, all of which was federally funded. We will analyze selected States' methodologies for identifying expenditures claimed at the IHS services FMAP and determine whether the States claimed these expenditures in accordance with Federal requirements. tags
Revised Centers for Medicare & Medicaid Services Medicare Part B Services to Medicare Beneficiaries Residing in Nursing Homes During Non-Part A Stays Office of Audit Services W-00-19-35824; W-00-22-35824 2023 Medicare pays physicians, non-physician practitioners, and other providers for services rendered to Medicare beneficiaries, including those residing in nursing homes (NHs). Most of these Part B services are not subject to consolidated billing; therefore, each provider submits a claim to Medicare. Since the 1990s, OIG has identified problems with Part B payments for services provided to NH residents. An opportunity for fraudulent, excessive, or unnecessary Part B billing exists because NHs may not be aware of the services that the providers bill directly to Medicare, and because NHs provide access to many beneficiaries and their records. We will determine whether Part B payments to Medicare beneficiaries in NHs are appropriate and whether NHs have effective compliance programs and adequate controls over the care provided to their residents. tags
Revised Centers for Medicare & Medicaid Services Overturned Denials in Medicaid Managed Care Office of Evaluation and Inspections OEI-09-19-00350 2023 Managed care organizations (MCOs) contract with State Medicaid agencies to provide beneficiaries with Medicaid services. MCOs must cover services in at least the same amount, duration, and scope that would be covered under Medicaid fee-for-service. However, capitated payment models in managed care may create an incentive for MCOs to inappropriately limit or deny access to covered services to increase profits. We will review the extent to which selected MCOs' denied services and payments were overturned upon appeal. We will also review any concerns about the selected MCOs' performance related to denials and appeals that were identified through State oversight and monitoring efforts. tags
Completed (partial) Centers for Medicare & Medicaid Services Review of Medicare Part B Claims for Intravitreal Injections of Eylea and Lucentis Office of Audit Services A-09-19-03022;
A-09-19-03025;
W-00-19-30100;
W-00-22-30100
2023 Medicare Part B covers ophthalmology services that are reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Ophthalmology services include intravitreal injections of Eylea and Lucentis to treat eye diseases such as wet age-related macular degeneration. Medicare pays for an intravitreal injection (which is considered a minor surgery) as part of a global surgical package that includes the preoperative, intraoperative, and postoperative services routinely performed by the physician. Medicare pays for Eylea and Lucentis separately from the intravitreal injection. Chapter 12, section 40.1 of the Centers for Medicare & Medicaid Services' Medicare Claims Processing Manual states that separate payment can be made for other services provided by the same physician on the same day as the global surgery if the services are significant and separately identifiable or unrelated to the surgery. We will review claims for intravitreal injections of Eylea and/or Lucentis and the other services billed on the same day as the injection, including evaluation and management services, to determine whether the services were reasonable and necessary and met Medicare requirements. tags
Completed (partial) OS Review of Office of Intergovernmental and External Affairs Charge Card Programs Office of Audit Services W-00-19-59443;
A-03-19-00501;
W-00-22-59443
2023 Under the Government Charge Card Abuse Prevention Act of 2012 (Charge Card Act) and Office of Management and Budget Memorandum M-13-21, Implementation of the Government Charge Card Abuse Prevention Act of 2012, agencies must establish and maintain safeguards and internal controls for the charge card program. Offices of Inspectors General (OIGs) are required to conduct annual risk assessments of agency purchase card and travel card programs to analyze the risks of illegal, improper, and erroneous purchases. HHS-OIG's risk assessment of HHS's charge card program for FY 2017, identified Office of Intergovernmental and External Affairs (IEA) as having a high risk of inappropriate travel card and purchase card transactions. Because IEA's charge card program was assessed as high risk, the Charge Card Act requires HHS-OIG to conduct a further review. We will review the IEA's travel card and purchase card programs to determine whether the programs complied with Federal requirements. tags
Completed (partial) Centers for Medicare & Medicaid Services Home Health Compliance with Medicare Requirements Office of Audit Services A-06-16-05005;
A-02-17-01025;
A-02-16-01001;
A-05-16-00057;
A-05-16-00055;
A-01-16-00500;
A-07-16-05092;
A-07-16-05093;
A-05-17-00022;
A-02-17-01022;
A-03-17-00004;
A-04-16-06195;
A-03-17-00009;
A-02-19-01013;
W-00-19-35712;
W-00-16-35712;
W-00-16-35501;
W-00-17-35712;
various reviews
2023 The Medicare home health benefit covers intermittent skilled nursing care, physical therapy, speech-language pathology services, continued occupational services, medical social worker services, and home health aide services. For CY 2014, Medicare paid home health agencies (HHAs) about $18 billion for home health services. Centers for Medicare & Medicaid Services's Comprehensive Error Rate Testing (CERT) program determined that the 2014 improper payment error rate for home health claims was 51.4 percent, or about $9.4 billion. Recent OIG reports have similarly disclosed high error rates at individual HHAs. Improper payments identified in these OIG reports consisted primarily of beneficiaries who were not homebound or who did not require skilled services. We will review compliance with various aspects of the home health prospective payment system and include medical review of the documentation required in support of the claims paid by Medicare. We will determine whether home health claims were paid in accordance with Federal requirements. tags
Revised Other OIG Reviews of Non-Federal Audits Office of Audit Services W-00-19-40005 2024 In accordance with the Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS awards at 45 CFR Part 75, State, local, and Indian tribal governments; colleges and universities; and nonprofit organizations receiving Federal awards are required to have annual organization-wide audits of all Federal funds that they receive. OIG reviews the audits and reports to ensure they meet applicable standards, identifies any follow-up work needed, and identifies issues that may require management attention. OIG also provides upfront technical assistance to non-Federal auditors to ensure they understand Federal audit requirements and to promote effective audit work. We analyze and record electronically the audit findings reported by non-Federal auditors for use by HHS managers. Our reviews inform HHS managers about the management of Federal programs and identify significant areas of internal control weaknesses, noncompliance with laws and regulations, and questioned costs that require formal resolution by Federal officials. We will continue to review the quality of audits conducted by non-Federal auditors, such as public accounting firms and State auditors, in accordance with the uniform grant guidance. tags
Completed (partial) Centers for Medicare & Medicaid Services Review of State Uncompensated Care Pools Office of Audit Services W-00-19-31537;
A-04-19-04070
2023 Some State Medicaid agencies operate uncompensated care pools (UCPs) under waivers approved by CMS. Section 1115 of Title XIX of the Social Security Act gives CMS authority to approve experimental, pilot, or demonstration projects that it considers likely to help promote the objectives of the Medicaid program. The purpose of these projects, which give States additional flexibility to design and improve their programs, is to demonstrate and evaluate State-specific policy approaches to better serve Medicaid populations. To implement a State demonstration project, States must comply with the special terms and conditions (STCs) of the agreement between CMS and the State. The purpose of the UCPs is to pay providers for uncompensated cost incurred in caring for low-income (Medicaid and uninsured) patients. Through UCPs, States pay out hundreds of millions of dollars to providers and receive Federal financial participation. However, in some States there has previously been little oversight of the payments. We will determine whether selected States' Medicaid agencies made payments to hospitals under the UCPs that were in accordance with the STCs of the waiver and with applicable Federal regulations. tags
Completed (partial) Substance Abuse and Mental Health Services Administration Projects for Assistance in Transition from Homelessness Program Office of Audit Services A-02-19-02006;
W-00-19-50100;
W-00-21-50100;
A-02-21-02001
2023 HHS provides Federal funds to various States to administer the Projects for Assistance in Transition from Homelessness (PATH) program. The PATH program supports the delivery of outreach and various services to individuals with serious mental illness and those with co-occurring substance use disorders who are experiencing homelessness or are at imminent risk of becoming homeless. During Federal fiscal year 2018, the Substance Abuse and Mental Health Services Administration (SAMHSA), the HHS agency that administers and oversees the PATH program, awarded approximately $62 million in grant funds to various States to operate the PATH program. We will determine whether some of these grant recipients complied with Federal requirements in providing PATH program services. tags
Revised Centers for Medicare and Medicaid Services Medicaid Managed Care Organizations' Denials Office of Audit Services W-00-19-31535 2023 The State Medicaid agency and the Federal Government are responsible for the financial risk for the costs of Medicaid services. State Medicaid agencies contract with managed care organizations (MCOs) to ensure that beneficiaries receive covered Medicaid services. The contractual arrangement shifts the financial risk from the State Medicaid agency and the Federal Government to MCOs, which can create an incentive for MCOs to deny beneficiaries' access to covered services. Our audits will determine whether Medicaid MCOs complied with Federal requirements when denying access to requested medical and dental services, behavioral health services, and associated drug prescriptions that required prior authorization. Managed Care, Medicaid
Completed (partial) Centers for Medicare & Medicaid Services Review of Monthly ESRD-Related Visits Billed by Physicians or Other Qualified Healthcare Professionals Office of Audit Services A-07-19-05117;
W-00-19-35822;
W-00-22-35822
2023 Most physicians and other practitioners (e.g., clinical nurse specialists, nurse practitioners, or physician's assistants) who manage the care of patients who receive outpatient dialysis services at end-stage renal disease (ESRD) facilities are paid a monthly capitation payment (MCP) for ESRD-related physician services. The MCP amount is based on the number of visits provided within each month and the age of the ESRD beneficiary. The physician or other practitioner can bill only one of three current procedural terminology (CPT) codes for ESRD-related visits of one per month, two to three per month, or four or more per month (CMS, Medicare Claims Processing Manual, Pub. No. 100-04, chapter 8, § 140.1). The Comprehensive Error Rate Testing program's special study of the Healthcare Common Procedure Coding System codes for ESRD-related services found that for some codes, approximately one-third of the payments for ESRD-related services were improper payments due to insufficient documentation, incorrect coding, or no documentation submitted (CMS, Medicare Quarterly Provider Compliance Newsletter Guidance to Address Billing Errors, volume 5, issue 3, April 2015). We will review whether physicians or other qualified healthcare professionals billed monthly ESRD-related visits in accordance with Federal requirements (Social Security Act, §§ 1815(a) and 1833(e)). tags
Completed (partial) Centers for Medicare & Medicaid Services Medicaid Personal Care Services Office of Audit Services A-02-19-01016;
W-00-19-31536
2023 Personal care services (PCS) is a Medicaid benefit for the elderly, people with disabilities, and people with chronic or temporary conditions. It assists them with activities of daily living and helps them remain in their homes and communities. Examples of PCS include bathing, dressing, light housework, money management, meal preparation, and transportation. Prior OIG reviews identified significant problems with States' compliance with PCS requirements. Some reviews also showed that program safeguards intended to ensure medical necessity, patient safety, and quality, and prevent improper payments were often ineffective. We will determine whether improvements have been made to the oversight and monitoring of PCS and whether those improvements have reduced the number of PCS claims not in compliance with Federal and State requirements. tags
Completed (partial) Centers for Medicare & Medicaid Services MCO Payments for Services After Beneficiaries' Deaths Office of Audit Services A-06-16-05004;
A-05-19-00007;
A-04-19-06223;
A-07-20-05125;
A-04-15-06190;
W-00-20-31497;
W-00-19-31497
2023 Previous OIG reports found that Medicare paid for services that purportedly started or continued after beneficiaries' dates of death. We will identify Medicaid managed care payments made on behalf of deceased beneficiaries. We will also identify trends in Medicaid claims with service dates after beneficiaries' dates of death. tags
February 2022 OS Review of HHS Government Purchase, Travel, and Integrated Charge Card Programs Office of Audit Services W-00-22-59041 2023 The Government Charge Card Abuse Prevention Act of 2012 (Charge Card Act) requires Inspectors General (IGs) to conduct periodic risk assessments of their agencies' charge card programs to analyze the risks of illegal, improper, or erroneous purchases. The Charge Card Act requires IGs to use the risk assessments to determine the necessary scope, frequency, and number of IG audits or reviews of the charge card programs. It requires Federal agencies to establish and maintain safeguards and internal controls for purchase cards, convenience checks, travel cards, and integrated cards. The Office of Management and Budget has instructed IGs to submit annual status reports on purchase and travel card audit recommendations beginning January 31, 2014, for compilation and transmission to Congress and the Government Accountability Office. We will review HHS's charge card programs (i.e., purchase, travel, or integrated cards) to assess the risks of illegal, improper, or erroneous purchases. HHS's charge card programs enable cardholders to pay for commercial goods, services, and travel expenses. tags
Revised Centers for Medicare & Medicaid Services Medicare Part B Payments for Podiatry and Ancillary Services Office of Audit Services W-00-19-35818; W-00-21-35818 2023 Medicare Part B covers podiatry services for medically necessary treatment of foot injuries, diseases, or other medical conditions affecting the foot, ankle, or lower leg. Part B generally does not cover routine foot-care services such as the cutting or removal of corns and calluses or trimming, cutting, clipping, or debridement (i.e., reduction of both nail thickness and length) of toenails. Part B may cover these services, however, if they are performed (1) as a necessary and integral part of otherwise covered services, (2) for the treatment of warts on the foot, (3) in the presence of a systemic condition or conditions, or (4) for the treatment of infected toenails. Medicare generally does not cover evaluation and management (E&M) services when they are provided on the same day as another podiatry service (e.g., nail debridement performed as a covered service). However, an E&M service may be covered if it is a significant separately identifiable service. In addition, podiatrists may order, refer, or prescribe medically necessary ancillary services such as x-rays, laboratory tests, physical therapy, durable medical equipment, or prescription drugs. Prior OIG work identified inappropriate payments for podiatry and ancillary services. We will review Part B payments to determine whether podiatry and ancillary services were medically necessary and supported in accordance with Medicare requirements. tags
Revised Centers for Medicare & Medicaid Services Medicare Outpatient Outlier Payments for Claims With Credits for Replaced Medical Devices Office of Audit Services W-00-19-35819; W-00-21-35819 2023 Item Summary CMS requires hospitals to submit a zero or token charge when they receive a full credit for a replacement device, but CMS does not specify how charges should be reduced for partial credits. CMS makes an additional payment (an outpatient outlier payment) for hospital outpatient services when a hospital's charges, adjusted to cost, exceed a fixed multiple of the normal Medicare payment. 42 CFR § 419.43(d). Prior OIG reviews focused on finding unreported credits for medical devices and recommended that CMS recoup Medicare funds for the overstated ambulatory payment classification payment only. This audit focuses on overstated Medicare charges on outpatient claims that contain both an outlier payment and a reported medical device credit. We will determine whether Medicare payments for replaced medical devices and their respective outlier payments were made in accordance with Medicare requirements. tags
Completed (partial) Centers for Medicare & Medicaid Services Physicians Billing for Critical Care Evaluation and Management Services Office of Audit Services A-03-18-00003;
W-00-18-35816;
W-00-22-35816;
A-03-20-00002;
various reviews
2023 Critical care is defined as the direct delivery of medical care by a physician(s) for a critically ill or critically injured patient. Critical care is usually given in a critical care area such as a coronary, respiratory, or intensive care unit, or the emergency department. Payment may be made for critical care services provided in any location as long as the care provided meets the definition of critical care. Critical care is exclusively a time-based code. Medicare pays physicians based on the number of minutes they spend with critical care patients. The physician must spend this time evaluating, providing care and managing the patient's care and must be immediately available to the patient. This review will determine whether Medicare payments for critical care are appropriate and paid in accordance with Medicare requirements. tags
Revised All STAFFDIV/
OPDIVs
Identification of HHS Cybersecurity Vulnerabilities Office of Audit Services W-00-18-42021; W-00-18-42022 2024 HHS OIG will perform a series of IT audits at the HHS Office of the Secretary and its Operating Divisions (OPDIVs) in an effort to identify cybersecurity vulnerabilities and possible compromise of the HHS Office of the Secretary and its OPDIVs' systems and networks. tags
Revised Centers for Medicare & Medicaid Services Review of Post-Operative Services Provided in the Global Surgery Period Office of Audit Services W-00-18-35810; W-00-22-35810 2023 Section 523 of Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires CMS to collect data on post-operative services included in global surgeries and requires OIG to audit and verify a sample of the data collected. We will review a sample of global surgeries to determine the number of post-operative services documented in the medical records and compare it to the number of post-operative services reported in the data collected by CMS. We will verify the accuracy of the number of post-operative visits reported to CMS by physicians and determine whether global surgery fees reflected the actual number of post-operative services that physicians provided to beneficiaries during the global surgery period. tags
Completed (partial) Centers for Medicare & Medicaid Services Medicare Part B Payments for End-Stage Renal Disease Dialysis Services Office of Audit Services W-00-18-35811;
A-05-20-00010
2023 Medicare Part B covers outpatient dialysis services for beneficiaries diagnosed with end-stage renal disease (ESRD). Prior OIG work identified inappropriate Medicare payments for ESRD services. Specifically, OIG identified unallowable Medicare payments for treatments not furnished or documented, services for which there was insufficient documentation to support medical necessity, and services that were not ordered by a physician or ordered by a physician that was not treating the patient. (Social Security Act §§ 1862(a)(l)(A) and 1833(e), 42 CFR §§ 410.32(a) and (d), 42 CFR §§ 410.12(a)(3), 424.5(a)(6), and 424.10). Additionally, prior OIG reviews identified claims that did not comply with Medicare consolidated billing requirements (the Act § 1881(b)(14), Medicare Claims Processing Manual, Pub. No. 100-04, Ch. 8 and Medicare Benefit Policy Manual, Pub. No. 100-02, Ch. 11). We will review claims for Medicare Part B dialysis services provided to beneficiaries with ESRD to determine whether such services complied with Medicare requirements. tags
Completed (partial) Centers for Medicare & Medicaid Services Medicare Payments Made Outside of the Hospice Benefit Office of Audit Services W-00-20-35797;
A-09-20-03026;
A-09-20-03015
2023 According to 42 CFR 418.24(d), in general, a hospice beneficiary waives all rights to Medicare payments for any services that are related to the treatment of the terminal condition for which hospice care was elected. The hospice agency assumes responsibility for medical care related to the beneficiary's terminal illness and related conditions. Medicare continues to pay for covered medical services that are not related to the terminal illness. Prior OIG reviews have identified separate payments that should have been covered under the per diem payments made to hospice organizations. We will produce summary data on all Medicare payments made outside the hospice benefit, without determining the appropriateness of such payments, for beneficiaries who are under hospice care. In addition, we will conduct separate reviews of selected individual categories of services (e.g., durable medical equipment, prosthetics, orthotics and supplies, physician services, outpatient) to determine whether payments made outside of the hospice benefit complied with Federal requirements. tags
Completed (partial) Centers for Medicare & Medicaid Services Noninvasive Home Ventilators - Compliance With Medicare Requirements Office of Audit Services A-04-18-04066;
W-00-18-35809;
W-00-22-35809
2023 For items such as noninvasive home ventilators (NHVs) and respiratory assist devices (RADs) to be covered by Medicare, they must be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Depending on the severity of the beneficiary's condition, an NHV or RAD may be reasonable and necessary. NHVs can operate in several modes, i.e., traditional ventilator mode, RAD mode, and basic continuous positive airway pressure (CPAP) mode. The higher cost of the NHVs' combination of noninvasive interface and multimodal capability creates a greater risk that a beneficiary will be provided an NHV when a less expensive device such as a RAD or CPAP device is warranted for the patient's medical condition. Prior OIG work identified significant growth in Medicare billing for NHVs in the years since they reached the market. We will determine whether claims for NHVs were medically necessary for the treatment of beneficiaries' diagnosed illnesses and whether the claims complied with Medicare payment and documentation requirements. tags
Completed (partial) Centers for Medicare & Medicaid Services States' Procurement of Private Contracting Services for the Medicaid Management Information System Office of Audit Services W-00-18-31532;
A-06-18-09002
2023 The Medicaid Management Information System (MMIS) is an integrated group of procedures and computer processing operations designed to meet principal objectives such as processing medical claims. Medicaid reimburses States' MMIS administrative costs at enhanced rates of 90 and 75 percent. Many States use private contractors to design, develop, and operate their MMIS. When procuring MMIS contracting services, States are required to follow the same policies and procedures used for procurements paid with non-Federal funds. Additionally, States must receive CMS's prior approval to receive enhanced Federal matching funds for MMIS administrative costs related to private contractors. States have reportedly had issues with private MMIS contractors, including with initial procurements. We will determine if selected States followed applicable Federal and State requirements related to procuring private MMIS contracting services and claiming Federal Medicaid reimbursement. tags
Revised Centers for Medicare & Medicaid Services CMS Medicare Overpayment Recoveries Related to Recommendations in OIG Audit Reports Office of Audit Services W-00-18-35807 2023 HHS is responsible for resolving Federal audit report recommendations related to its activities, grantees, and contractors within 6 months after formal receipt of the audit reports. From October 1, 2014, to December 31, 2016, OIG issued 153 audit reports that related to the Medicare program and that contained 193 monetary recommendations totaling $648 million. Of the $648 million in recommended overpayment recoveries, CMS agreed to collect $566 million applicable to 190 recommendations. We will determine the extent to which CMS: (1) collected agreed upon Medicare overpayments identified in OIG audit reports and (2) took corrective action in response to the recommendations in our prior audit report examining CMS' overpayment recoveries (A-04-10-03059). In that report, we recommended that CMS enhance its systems and procedures for recording, collecting, and reporting overpayments. We also recommended that CMS provide guidance to its contractors on how to document that overpayments were actually collected. tags
Completed (partial) Office of the Assistant Secretary for Financial Resources Grantee Compliance With Cost Principles for Organizations With Multiple HHS Discretionary Funding Sources Office of Audit Services A-05-18-00008;
A-06-18-02002;
A-02-18-02011;
W-00-18-59433;
W-00-19-59433;
A-01-19-02500;
A-04-19-08069
2023 Department of Health and Human Services (HHS) grantees must maintain financial management systems that contain written procedures for determining the reasonableness, allocability, and allowability of costs in accordance with applicable Federal cost principles and the terms and conditions of the award (45 CFR § 75.302(b)(7)). Grantees also must maintain accounting records that are supported by source documentation (45 CFR § 75.302(b)(3)) and financial management systems that provide for accurate and complete disclosure of the financial results of each project or program sponsored by HHS (45 CFR § 75.302(b)(2)). We will review select grantees receiving HHS grant funding from multiple sources to determine whether they are allocating and claiming costs in accordance with Federal requirements. We will also review procedures in place for HHS oversight and coordination between the participating grant programs. tags
Completed (partial) Centers for Medicare & Medicaid Services Medicaid School-Based Costs Claimed Based on Contingency Fee Contractor Coding Office of Audit Services A-04-18-07075;
W-00-18-31529;
A-02-20-01012;
A-02-18-01019
2023 Several State Medicaid agencies retain consultants to assist with preparing Medicaid claims for school-based activities. Consultants often are paid a contingency fee based on the percentage of Federal funds reimbursed to the State. During a prior review, we found that one consultant developed unsupported timestudies that it used to develop payment rates for school-based health services. Based on those rates, the State claimed unallowable Federal funds. Consultants developed timestudies using a similar methodology in many other States. We will initiate a multiple State review with a roll-up report to CMS to determine whether consultants developed school-based Medicaid rates based on unsupported timestudies and unallowable costs in these States tags
Completed (partial) Centers for Medicare & Medicaid Services State Compliance With Requirements for Reporting and Monitoring Critical Incidents Office of Audit Services A-09-17-02006;
A-06-17-04003;
A-04-17-04063;
A-02-17-01026;
A-04-17-08058;
A-04-17-03084;
A-06-17-02005;
A-09-19-02005;
A-06-17-01003;
A-02-17-01026;
A-03-17-00202;
W-00-17-31040;
A-04-18-07078;
A-01-20-00003;
A-01-20-00007
2023 The Centers for Medicare & Medicaid Services requires States to implement an incident reporting system to protect the health and welfare of the Medicaid beneficiaries who receive services in community-based settings or nursing facilities. During prior audits, OIG found that some States did not always comply with Federal and State requirements for reporting and monitoring critical incidents such as abuse and neglect. We will review additional State Medicaid Agencies to determine whether the selected States are in compliance with the requirements for reporting and monitoring critical incidents. Our work will focus on Medicaid beneficiaries residing in both community-based settings and nursing facilities. tags
Completed (partial) Centers for Medicare & Medicaid Services States' Collection of Rebates on Physician-Administered Drugs Office of Audit Services A-02-16-01012;
A-06-16-00018;
A-05-16-00013;
A-05-16-00014;
W-00-16-31400;
A-07-21-07003;
A-07-21-06096;
various reviews
2023 States are required to collect rebates on covered outpatient drugs administered by physicians in order to be eligible for Federal matching funds (SSA § 1927(a)). Previous OIG work identified concerns with States' collection and submission of data to Centers for Medicare & Medicaid Services, including national drug codes that identify drug manufacturers, thus allowing States to invoice the manufacturers responsible for paying rebates (Deficit Reduction Act of 2005). We will determine whether States have established adequate accountability and internal controls for collecting Medicaid rebates on physician-administered drugs. We will assess States' processes for collecting national drug code information on claims for physician-administered drugs and subsequent processes for billing and collecting rebates. tags
Completed (partial) Centers for Medicare & Medicaid Services States' Collection of Rebates for Drugs Dispensed to Medicaid MCO Enrollees Office of Audit Services A-06-16-00004;
A-07-16-06065;
A-09-16-02027;
A-09-16-02028;
A-09-16-02029;
A-02-16-01011;
A-09-16-02031;
A-06-16-00001;
W-00-16-31483;
various reviews
2023 Medicaid MCOs are required to report enrollees' drug utilization to the State for the purpose of collecting rebates from manufacturers. Section 2501(c) of the Patient Protection and Affordable Care Act expanded the rebate requirement to include drugs dispensed to MCO enrollees. We will determine whether States are collecting prescription drug rebates from pharmaceutical manufacturers for Medicaid MCOs. Drugs dispensed by Medicaid MCOs were excluded from this requirement until March 23, 2010. tags
Completed (partial) Centers for Medicare & Medicaid Services Selected Inpatient and Outpatient Billing Requirements Office of Audit Services A-04-17-08057;
A-04-17-08055;
A-01-15-00515;
A-05-16-00064;
A-04-16-04049;
A-05-16-00062;
A-05-17-00026;
A-07-17-05102;
A-02-18-01018;
A-02-18-01025;
A-05-19-00024;
A-02-20-01004;
W-00-20-35538;
W-00-17-35538;
various reviews
2023 This review is part of a series of hospital compliance reviews that focus on hospitals with claims that may be at risk for overpayments. Prior OIG reviews and investigations have identified areas at risk for noncompliance with Medicare billing requirements. We will review Medicare payments to acute care hospitals to determine hospitals' compliance with selected billing requirements and recommend recovery of overpayments. Our review will focus on those hospitals with claims that may be at risk for overpayments. W-00-17-35538 tags
Completed (partial) Centers for Medicare & Medicaid Services Competitive Bidding for Medical Equipment Items and Services - Mandatory Review Office of Audit Services A-05-14-00049;
W-00-14-35241;
various reviews
2023 Federal law requires OIG to conduct postaward audits to assess Centers for Medicare & Medicaid Services's competitive bidding program. (Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), § 154(a)(1)(E)). We will review the process Centers for Medicare & Medicaid Services used to conduct competitive bidding and to make subsequent pricing determinations for certain medical equipment items and services in selected competitive bidding areas under rounds 1 and 2 of the competitive bidding program. tags
Completed (partial) Centers for Medicare & Medicaid Services Contractor Pension Cost Requirements Office of Audit Services A-07-17-00528;
A-07-20-00598;
A-07-21-00607;
W-00-17-35067;
W-00-22-35094;
A-07-21-00602;
A-07-21-00603;
various reviews
2023 Medicare contractors are eligible to be reimbursed a portion of their pension costs and are required to separately account for the Medicare segment pension plan assets based on the requirements of their Medicare contracts and Cost Accounting Standards. We will determine whether Medicare contractors have calculated and claimed reimbursement for Medicare's share of various employee pension costs in accordance with their Medicare contracts and applicable Federal requirements. We will determine whether contractors have fully implemented contract clauses requiring them to determine and separately account for the employee pension assets and liabilities allocable to their contracts with Medicare. We will also review Medicare contractors whose Medicare contracts have been terminated, assess Medicare's share of future pension costs, and determine the amount of excess pension assets as of the closing dates. Applicable requirements are found in the FAR at 48 CFR Subpart 31.2; Cost Accounting Standards 412 and 413; and the Medicare contract, Appendix B, § XVI. W-00-17-35067 tags
Completed (partial) Centers for Medicare & Medicaid Services Contractor Postretirement Benefits and Supplemental Employee Retirement Plan Costs Office of Audit Services A-07-18-00552;
A-07-17-00501;
A-07-17-00498;
A-07-17-00499;
A-07-17-00500;
A-07-17-00502;
A-07-17-00521;
A-07-20-00591;
A-07-20-00600;
A-07-21-00609;
A-07-21-00611;
A-07-21-00614;
A-07-21-00615;
A-07-21-00613;
W-00-17-35095;
W-00-21-35095;
A-07-21-00604;
A-07-21-00605;
various reviews
2023 Centers for Medicare & Medicaid Services reimburses a portion of its contractors' postretirement health benefits costs and the supplemental employee retirement plans costs. The reimbursement is determined by the cost reimbursement principles contained in the FAR, Cost Accounting Standards as required by the Medicare contracts. We will review the postretirement health benefit costs and the supplemental employee retirement plans of Medicare contractors to determine the allowability, allocability, and reasonableness of the benefits and plans, as well as the costs charged to Medicare contracts. Criteria are in the FAR at 48 CFR §§ 31.201 through 31.205. tags
Completed (partial) Centers for Medicare & Medicaid Services Part D Sponsors Reporting of Direct and Indirect Remunerations Office of Audit Services A-03-18-00006;
A-03-18-00007;
W-00-18-35514; A-03-18-xxxxx
2023 Medicare calculates certain payments to sponsors on the basis of amounts actually paid by the Part D sponsors, net of direct and indirect remuneration (DIR). (42 CFR pt. 423, subpart G.) DIR includes all rebates, subsidies, and other price concessions from sources (including, but not limited to, manufacturers and pharmacies) that decrease the costs incurred by Part D sponsors for Part D drugs. CMS requires that Part D sponsors submit DIR reports for use in the payment reconciliation process. We will determine whether Part D sponsors complied with Medicare requirements for reporting DIR. tags
Completed (partial) Centers for Medicare & Medicaid Services Consumer-Directed Personal Assistance Program Office of Audit Services A-02-16-01026;
W-00-16-31035;
2023 Medicaid Consumer-Directed Personal Assistance Programs provide an alternative way of receiving home care services in which consumers have more control over who provides their care and how it is provided. Rather than assigning a home care agency that controls selection, training, and scheduling of aides, the consumer, or the family member, friend, or guardian directing his or her care, performs all these functions usually done by the agency. Eligible individuals include those eligible for services provided by a certified home health agency, a long-term home health care (waiver) program, AIDS home care program, or personal care (home attendant). Prior OIG work has shown vulnerabilities in personal care programs resulting in ineligible beneficiaries and Medicaid payments that do not comply with Federal and State regulations. We will determine whether selected States made Medicaid payments for consumer-directed personal assistance program claims in accordance with applicable Federal and State regulations. tags
Completed (partial) Centers for Medicare & Medicaid Services Recovery of Federal Funds Through Judgments/Settlements Office of Audit Services A-05-17-00041;
A-03-17-00203;
A-07-18-02814;
W-00-17-31522;
A-05-17-00000;
A-06-20-04004
2023 Any State action taken as a result of harm to a State's Medicaid program must seek to recover damages sustained by the Medicaid program as a whole, including both Federal and State shares. On October 28, 2008, CMS issued a letter (SHO #08-004) to State health officials that clarified language from Section 1903(d) of the Social Security Act, stating that the Federal Government is entitled to the Federal Medical Assistance Percentages (FMAP) proportionate share of a States entire settlement or final judgment amount. We will determine whether selected States reported and returned the applicable FMAP share of the settlement and judgment amounts to the Federal Government. tags
Revised Centers for Medicare & Medicaid Services Nationwide Medicare Electronic Health Record Incentive Payments to Hospitals Office of Audit Services W-00-20-35795 2023 Medicare incentive payments were authorized over a 5-year period to hospitals that adopted electronic health record (EHR) technology (Recovery Act, 4102). From January 1, 2011, through December 31, 2016, the Centers for Medicare & Medicaid Services (CMS) made Medicare EHR incentive payments to hospitals totaling $14.6 billion. The Government Accountability Office identified improper incentive payments as the primary risk to the Medicare EHR incentive program. A Department of Health and Human Services, Office of Inspector General (OIG), report describes the obstacles that CMS faces in overseeing the Medicare EHR incentive program. In addition, previous OIG reviews of Medicaid EHR incentive payments found that State agencies overpaid hospitals by $66.7 million and would in the future overpay these hospitals an additional $13.2 million. These overpayments resulted from inaccuracies in the hospitals calculations of total incentive payments. We will review the hospitals incentive payment calculations to identify potential overpayments that the hospitals would have received as a result of the inaccuracies. tags
Completed (partial) Centers for Medicare & Medicaid Services Medicaid Claims for Opioid Treatment Program Services Office of Audit Services A-02-17-01021;
A-06-20-08000;
A-07-20-04118;
W-00-17-31523;
W-00-20-31523;
A-09-20-02009;
A-01-20-00006
2023 Medicaid is a significant source of coverage and funding for behavioral health treatment services, including treatment of substance abuse. Some Medicaid State agencies provide payment for Opioid Treatment Program (OTP) services. Services can be provided at freestanding and hospital-based OTPs. We will determine whether selected State agencies complied with certain Federal and State requirements when claiming Medicaid reimbursement for OTP services. tags
Completed (partial) Centers for Medicare & Medicaid Services Medicaid Targeted Case Management Office of Audit Services A-07-16-03215;
A-07-17-03219;
W-00-17-31082;
A-07-17-03219;
A-07-21-03246
2023 The Social Security Act, § 1915(g)(2), defines case management services as those assisting individuals eligible under the State plan in gaining access to needed medical, social, educational, and other services. Case management services do not include the direct delivery of an underlying medical, educational, social, or other service for which an eligible individual has been referred. Payments for case management services may not duplicate payments made to public agencies under other program authorities for the same service. Prior OIG work in one State identified 18 percent of such claims as unallowable, with an additional 20 percent as potentially unallowable. We will determine whether Medicaid payments for targeted case management services in selected States were made in accord with Federal requirements. tags
Completed Centers for Medicare & Medicaid Services Treatment of Authorized Generic Drugs Office of Audit Services A-06-18-04002 2019 An authorized generic drug is one that the manufacturer holding the title to the original new drug application permits another manufacturer to sell under a different national drug code.'' Provisions in 42 CFR § 447.506(b) provide that the manufacturer holding title to the original new drug application of the authorized generic drug must include the sales of this drug in its average manufacturer price (AMP) only when such drugs are being sold by the manufacturer directly to a wholesaler. Manufacturers that also include the sales of an authorized generic to a secondary manufacturer could lower the AMP and, consequently, a lower rebate would be paid to the State. We will review drug manufacturers' treatment of sales of authorized generics in their calculation of AMP for the Medicaid drug rebate program. We will determine whether manufacturers included sales of authorized generics to secondary manufacturers in their AMP calculations. tags
Completed (partial) Centers for Medicare & Medicaid Services Duplicate Payments for Beneficiaries with Multiple Medicaid Identification Numbers Office of Audit Services A-04-16-07061;
A-02-20-01007;
A-04-20-07094;
W-00-20-31374;
W-00-16-31374;
various reviews
2023 During a preliminary data match, OIG identified a significant number of individuals who were assigned more than one Medicaid identification number and for whom multiple Medicaid payments were made for the same period. We will review duplicate payments made by States on behalf of Medicaid beneficiaries with multiple Medicaid identification numbers and identify States' procedures or other controls for preventing such payments. tags
Completed (partial) Centers for Medicare & Medicaid Services Medical Loss Ratio - Recoveries of MCO Remittances from Profit-Limiting Arrangements Office of Audit Services A-06-18-09001;
W-00-18-31508
2023 When a State recovers a prior expenditure, it must refund the Federal share by reporting the recovery to Centers for Medicare & Medicaid Services at the FMAP used to calculate the amount it had originally received (SSA § 1903(d)(2); Centers for Medicare & Medicaid Services State Medicaid Manual, § 2500.6(B)). In its final rule (81 Fed. Reg. 27498 (May 6, 2016)), Centers for Medicare & Medicaid Services encouraged States to adopt provisions in contracts with managed care plans that would require remittances from the MCOs if a minimum medical loss ratio is not met. A medical loss ratio is a tool that can help ensure that the majority of capitated payments are used to deliver services to beneficiaries. Prior OIG reviews found that some States have adopted such remittance provisions. We will review States and managed care plans with contract provisions that require remittances from managed care plans if a minimum percentage of total costs to be expended for medical services (medical loss ratio) is not met. We will determine whether the Federal share of recoveries of MCO payments that States received through profit-limiting methodologies is returned to the Federal Government. Centers for Medicare & Medicaid Services reimburses each State at the FMAP for the quarter in which the expenditure was made (SSA § 1903(a)(1)). tags
Revised Centers for Medicare & Medicaid Services Managed Long-Term-Care Reimbursements Office of Audit Services W-00-17-31510 2023 Medicaid managed care plans are subject to Federal requirements (42 CFR Part 438). Some States contract with MCOs to provide long-term services. We will review States' reimbursements made to managed long-term-care plans to determine whether those reimbursements complied with certain Federal and State requirements. tags
Completed (partial) Centers for Medicare & Medicaid Services Third-Party Liability Payment Collections in Medicaid Office of Audit Services W-00-22-31517; A-05-21-00013 2023 Medicaid beneficiaries may have additional health insurance through third-party sources. Previous OIG work described problems that State Medicaid agencies had in identifying and collecting third-party payments. States are to take all reasonable measures to ascertain the legal liabilities of third parties with respect to health care items and services (SSA § 1902(a)(25)). Medicaid is the payer of last resort and providers are to identify and refund overpayments received. We will determine if States have taken action to ensure that Medicaid is the payer of last resort by identifying whether a third-party payer exists and if the State correctly reports the third-party liability to Centers for Medicare & Medicaid Services. tags
Completed (partial) Centers for Medicare & Medicaid Services Delivery System Reform Incentive Payments Office of Audit Services A-02-17-01007;
A-06-17-09002;
W-00-17-31516; various reviews
2023 Delivery System Reform Incentive Payments are incentive payments made under Section 1115 waivers to hospitals and other providers that develop programs or strategies to enhance access to health care, increase the quality and cost-effectiveness of care, and increase the health of patients and families served. States must be able to demonstrate outcomes and ensure accountability for allocated funding. These incentive payments have significantly increased funding to providers for their efforts related to the quality of services. For example, one State made incentive payments totaling more than $6 billion in a 5-year period. We will ensure that select States adhered to applicable Federal and State requirements when they made incentive payments to providers. tags
Completed (partial) Centers for Medicare & Medicaid Services Payments for Medicare Services, Supplies, and DMEPOS Referred or Ordered by Physicians Compliance Office of Audit Services A-09-17-03002;
W-00-17-35748;
W-00-22-35748
2023 Centers for Medicare & Medicaid Services requires that physicians and nonphysician practitioners who order certain services, supplies, and/or DMEPOS be Medicare-enrolled physicians or nonphysician practitioners and be legally eligible to refer and order services, supplies, and DMEPOS (ACA § 6405). If the referring or ordering physician or nonphysician practitioner is not eligible to order or refer, then Medicare claims should not be paid. We will review select Medicare services, supplies, and DMEPOS referred or ordered by physicians and nonphysician practitioners to determine whether the payments were made in accordance with Medicare requirements. tags
Completed (partial) Centers for Medicare & Medicaid Services Ambulance Services - Supplier Compliance with Payment Requirements Office of Audit Services A-02-16-01021;
A-09-17-03018;
W-00-17-35574;
W-00-22-35574;
various reviews
2023 Medicare pays for emergency and nonemergency ambulance services when a beneficiary's medical condition at the time of transport is such that other means of transportation would endanger the beneficiary (SSA § 1861(s)(7)). Medicare pays for different levels of ambulance service, including basic life support, advanced life support, and specialty care transport (42 CFR § 410.40(b)). Prior OIG work found that Medicare made inappropriate payments for advanced life support emergency transports. We will determine whether Medicare payments for ambulance services were made in accordance with Medicare requirements. tags
Completed (partial) Centers for Medicare & Medicaid Services Review of Hospices' Compliance with Medicare Requirements Office of Audit Services A-02-16-01023;
A-02-16-01024;
A-02-18-01001;
A-09-18-03016;
A-09-18-03017;
A-09-18-03028;
A-09-20-03034;
A-09-20-03035;
A-09-18-03024;
A-09-18-03009;
W-00-16-35783;
W-00-18-35783;
various reviews;
A-02-19-01018;
A-02-20-01001
2023 Hospice provides palliative care for terminally ill beneficiaries and supports family and other caregivers. When a beneficiary elects hospice care, the hospice agency assumes the responsibility for medical care related to the beneficiary's terminal illness and related conditions. Federal regulations address Medicare conditions of and limitations on payment for hospice services (42 CFR Part 418, Subpart G). We will review hospice medical records and billing documentation to determine whether Medicare payments for hospice services were made in accordance with Medicare requirements. tags