Each fall, the Department of Health and Human Services (HHS) Office of Inspector General (OIG) puts out its Work Plan for the upcoming fiscal year to summarize its initiatives and priorities for new and ongoing work of HSS programs. Below is a summary of the key areas the OIG will focus on in 2017:
Drug waste of single-use vial drugs: In its review, the OIG will determine the amount of waste for the 20 single-use-vial drugs with the highest amount paid for waste as identified by the “JW” modifier by Medicare and provide specific examples of where a different size vial could significantly reduce waste.
Medicare payments for chronic care management: Payments for chronic care management services (non-face-to-face services provided to Medicare beneficiaries who have multiple chronic conditions that place the patient at significant risk of death, acute exacerbation/decompensation or functional decline where the significant chronic conditions are expected to last at least 12 months or until the death of the patient) will be reviewed to verify they met Medicare requirements.
Medicare payments for transitional care management: Also, the OIG will determine whether payments for transitional care management services (services provided to a patient whose medical and/or psychosocial problems require moderate- or high-complexity medical decision making during transitions in care from an inpatient hospital setting, partial hospital, observation status in a hospital or skilled nursing facility/nursing facility to the patient’s community setting) met Medicare requirements.
Prolonged services & the reasonableness of the services: The OIG will review Medicare claims for additional care provided to a beneficiary after an evaluation and management service was performed to determine whether payments to the physician were reasonable and met requirements.
Monitoring Medicare payments for clinical diagnostic laboratory tests—mandatory review: Medicare payments for clinical diagnostic laboratory tests performed in 2016 will be analyzed, and they will monitor the CMS’s establishment of the new Medicare payment system for the top 25 diagnostic tests.
Comparison of average sales prices to average manufacturer prices—mandatory review: The OIG will review Medicare Part B drug prices by comparing ASPs to AMPs and identify drug prices that exceed a designated threshold for reimbursements.
Use of electronic health records to support care coordination through ACOs: The OIG will review the extent to which providers participating in ACOs in the Medicare Shared Savings Program (MSSP) use EHRs to exchange health information to achieve their care coordination goals. They will assess providers’ use of EHRs to identify best practices and possible challenges to the exchange and use of health data, such as degree of interoperability, financial barriers or information blocking.