Early last fall, the Department of Health and Human Services (HHS) Office of Inspector General (OIG) released its OIG Work Plan for fiscal year 2018–2019, which is a two-year framework for the audits, inspections, evaluations and investigative activities planned in support of its vision, mission, and strategic goals and objectives to maintain HHS program integrity. The OIG continues to look at key areas that affect quality patient care and outcomes, and determined it would be more beneficial to release their projects work on an ongoing basis instead of biannual updates. The OIG considers several factors when creating Work Plan items, including legal mandates, congressional requests, budgetary concerns, as well as the potential for positive impact. The new format will include an ongoing list of active work plan items, which will comprise newly initiated Work Plan items and notifications of completed items.
Key areas of potential risk that rheumatology practices should be aware of include the following:
Financial Impact of Health Risk Assessments & Chart Reviews on Risk Scores in Medicare Advantage
Payments to Medicare Advantage (MA) organizations are risk adjusted, based on beneficiary information, to determine which MA organizations have higher expected costs. Health risk assessments and chart reviews are an integral part of this process. The OIG seeks to determine which diagnoses solely generated by their integral process correlate with high- and low-risk scores and payments.
Identify Patients at Risk of Opioid Misuse
Because opioid abuse and overdose deaths are at crisis levels in the U.S., the OIG is analyzing data from 2013–2016 on opioid overdose trends from the Centers for Disease Control and Prevention to select multiple states for review. They will review the oversight of opioid prescribing and monitoring of opioid use in the selected states, specifically on policies and procedures, data analytics, programs, outreach, and other efforts. To support HHS’s ongoing efforts to identify and disseminate effective practices to address the opioid epidemic in the U.S., the OIG will highlight these statewide efforts throughout 2019.
Critical Care Evaluation & Management Services
For 2019, the OIG will determine whether Medicare payments for critical care are appropriate and are being paid in accordance with Medicare requirements. Payments for chronic care management services (non-face-to-face services provided to Medicare beneficiaries who have multiple significant 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 if they were in accordance with Medicare requirements.