The OIG added six new items to its Work Plan with the January 2018 update, as listed in the chart below. Consistent with prior Work Plan missives, the OIG continues to focus its efforts on reducing prescription opioid misuse. Additionally, similar to the December 2017 Work Plan update, the Medicare Advantage industry may be interested to know the OIG is examining elements impacting risk-adjusted payments to Medicare Advantage organizations. Those involved in the orthotic device industry should be aware that the OIG is scrutinizing reimbursement for certain off-the-shelf orthotic devices. Furthermore, the OIG is analyzing claims data to determine the prevalence of potential abuse to Medicare beneficiaries. Lastly, the OIG will examine states that receive block grants related to the Child Care Development Fund to ensure program integrity. Below are brief descriptions of the six new items.
The OIG reported in its July 2017 data brief, Opioids in Medicare Part D: Concerns About Extreme Use and Questionable Prescribing (OEI-02-17-00250), that approximately 500,000 patients received high amounts of opioids in 2016 and approximately 90,000 of those patients were at serious risk of opioid abuse or overdose. The OIG will release a toolkit with information regarding the OIG's approach to analyzing opioid claims data to produce patient-level opioid data and its calculation of Morphine Equivalent Dose (MED) levels for these patients.
Noting the significant increased growth in billing for certain back and knee braces (HCPCS codes L0648, L0650 and L1833), the OIG will evaluate whether Medicare beneficiaries are being supplied such orthotic devices without a physician encounter within the previous 12 months and will analyze billing trends nationwide.
The Centers for Medicare & Medicaid Services (CMS) provides risk-adjusted payments to Medicare Advantage (MA) organizations based on certain clinical and demographic information from the prior year. The OIG will examine the extent to which diagnoses generated solely by health risk assessments and chart reviews were associated with higher risk scores and higher MA payments. Similarly, the OIG will review the extent to which diagnoses that were removed as a result of a chart review were associated with a lower risk score and lower MA payment.
The OIG will study diagnoses at treating medical facilities to determine the prevalence of potential abuse or neglect of Medicare beneficiaries. Additionally, the OIG will seek to establish whether the potential abuse or neglect occurred at a medical facility or at another location.
States are required to have a plan for the oversight and coordination of health care services for any child in foster care placement if the state is to receive federal funding. The OIG will review states that use the Statewide Automated Child Welfare Information System (SACWIS) as their mechanism for monitoring psychotropic, ADHD and opioid medications prescribed to children in foster care. The OIG will additionally review the Administration for Children and Families' efforts to ensure that the children in foster care receive medications in accordance with state requirements.
Lastly, the Child Care Development Fund (CCDF) program, which provides block grants to subsidize low-income families' child care expenses, has been identified as a federal program that is susceptible to significant improper payments. The OIG will examine (i) how states monitor subrecipients of CCDF funds for appropriate program integrity activities, and (ii) the outcomes of state's efforts to monitor CCDF subrecipients.