The OIG added 12 new items to its Work Plan in the August 2018 update. Hot topics related to Centers for Medicare & Medicaid Services (CMS) oversight in this month's Work Plan include: state oversight of opioids; potential abuse/neglect of children receiving Medicaid; oversight of nursing facility staffing levels; hospital compliance with Medicare's transfer policy; physician billing for critical care services; blood lead screening tests in children; and website security testing. Another three items added to the Work Plan related to Administration for Children and Families oversight: review of federal programs administered by American Indian and Alaska Native Tribes; ACF Child Care Development Fund, program integrity; and ORR-funded facilities' efforts to ensure the health and safety of unaccompanied children. Below are brief descriptions of the new CMS-related items.
1. Review of States' Oversight of Opioids
The OIG will review data collected by the Centers for Disease Control and Prevention to ascertain any opioid overdose trends from 2013 to 2016 in select states. The review will include an analysis of policies and procedures, data analytics, programs and outreach in relation to opioid prescribing and monitoring of opioid abuse.
2. Potential Abuse and Neglect of Children Receiving Medicaid Benefits
Prior OIG reviews have focused on reporting and investigating potential abuse or neglect of vulnerable patient populations in different health care settings, from group homes to skilled nursing facilities. The OIG plans to determine the prevalence of Medicaid claims indicating potential abuse or neglect of children receiving Medicaid benefits.
3. CMS Oversight of Nursing Facility Staffing Levels
Nursing facilities receiving Medicaid and Medicare payments are required to provide sufficient licensed nursing services 24 hours a day, including a registered nurse for at least 8 consecutive hours every day. Inadequate staffing levels can negatively affect a resident's quality of care. The OIG will examine nursing staff levels that are reported to the Payroll-Based Journal, which analyzes staffing patterns. The OIG plans to review the data to ensure accuracy and that facilities are meeting staffing requirements.
4. Hospitals' Compliance with Medicare's Transfer Policy with the Resumption of Home Health Services and the Use of Condition Codes
CMS payments to acute care hospitals for inpatient stays under Medicare Part A are based on prospective rates. When a hospital discharges a beneficiary, the hospital receives the full amount for the corresponding diagnosis-related group (DRG). On the other hand, when a hospital transfers a beneficiary to another facility or to home health, services are paid a graduated per diem rate, not to exceed the full DRG payment. A hospital can apply specific condition codes to the claim and receive the full DRG payment for transfers to home health services. The OIG plans to review whether Medicare appropriately paid hospitals' inpatient claims subject to the post- acute care transfer policy when (1) patients resumed home health services after discharge or (2) hospitals applied condition codes to claims to receive a full DRG payment.
5. Physicians Billing for Critical Care Evaluation and Management Services
Medicare pays physicians for critical care services based on the number of minutes they spend with critical care patients, provided that the services rendered meet the definition of critical care. There is no strict location requirement as to where physicians provide critical care services but services are typically provided in an intensive care unit or emergency department. The OIG will be examining whether Medicare payments for critical care are appropriate and paid in accordance with Medicare requirements.
6. Blood Lead Screening Tests, Follow-up Services, and Treatment for Medicaid-Enrolled Children
Children enrolled in the Medicaid program must receive blood lead screenings and are entitled to receive follow-up services and treatment for conditions identified through screenings (e.g., elevated blood lead levels (EBLLs)). Previous OIG reports found low rates of lead screenings, but the OIG has not evaluated follow-up services for Medicaid-enrolled children with EBLLs. The OIG will review the percentage of children under 26 months of age who received screenings that tested positive for EBLLs and received additional care as well as why those with EBLLs did not receive screenings or follow-up treatment.
7. Penetration Test of the Affordable Care Act Website and Associated Systems
The OIG will be conducting security testing on the healthcare.gov website and the information technology infrastructure for the Federally Facilitated Marketplace established under the Affordable Care Act. The review is to determine whether CMS has implemented effective information security controls.
8. Medicare Payments for Clinical Diagnostic Laboratory Tests in 2017: Year 4 of Baseline Data
As required under the Protecting Access to Medicare Act of 2014, the OIG will be releasing annual analysis of the top 25 laboratory test expenditures for 2017.
9. Medicare Market Shares of Mail Order Diabetic Test Strips from April to June 2018
Before each round of the Medicare competitive bidding program, the OIG is required to report on the Medicare market share of both mail order and non-mail-order diabetic test strips (DTS). The OIG will be releasing two data briefs, with the first exploring the Medicare market share of mail order DTS from the period of April through June 2018. The second data brief will examine the Medicare market share of non-mail-order DTS for the same three-month period.