Updates to OIG Work Plan Affecting Medicare Fraud Units, Skilled Nursing Facilities, and AIDS Relief Funds

Medicaid Fraud Control Units

Medicaid Fraud Control Units (MFCUs) play an important part in identifying, investigating, and prosecuting fraud from Medicaid providers.

For example, the MFCU in the state of New York was instrumental in bringing a $568,750 settlement for the state’s Medicaid program. The case involved allegations that a physician was up-coding their bills for medical services and billed for smoking cessation counseling services that were not sufficiently documented.

In the state of Florida, the MFCU, working with MFCUs from multiple other states and federal prosecutors, helped secure a settlement for $40 million against Apria Healthcare. It was alleged that Apria Healthcare submitted false claims to state Medicaid programs seeking reimbursement for non-invasive ventilator (NIV) rentals that Medicaid beneficiaries either did not use or medical professionals deemed not medically necessary.

There are 53 MFCUs located in the 50 States, the District of Columbia, Puerto Rico, and the Virgin Islands. The Office of Inspector General (OIG) provides oversight for MFCUs and administers a Federal grant award to fund a portion of each MFCU's operational costs.

In this recently added work plan item, the OIG will perform onsite reviews of a sample of MFCUs. They also plan to issue an annual report analyzing the statistical information reported by MFCUs, describing the outcomes of MFCU criminal and civil cases. The report will also identify trends in MFCU case results.

Hospitalizations of Skilled Nursing Facility Residents

Prior OIG work identified instances where nursing facility residents were hospitalized with urinary tract infections (UTI) when their care plans, if followed by nursing facilities, may have prevented the hospitalizations.

In particular audit, the OIG concluded the nursing facility did not always provide services to its residents in accordance with their care plans, as required by Federal regulations, before they were hospitalized with UTIs. Specifically, the nursing staff did not monitor and document residents’ hydration status, monitor and document residents’ conditions, or document residents’ urine appearances as their care plans required. For this audit, the OIG concluded the nursing facility staff did not follow the residents’ care plans for 22 of the 23 stays and in many cases, there were significant lapses in providing these services.

In addition to their own work, OIG recognizes that Centers for Medicare & Medicaid (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. OIG's review of claims showed that skilled nursing facility (SNF) residents often present with one of these five conditions or sepsis on inpatient hospitalization.

With this in mind, the OIG will review inpatient hospitalizations of SNF residents with any of the aforementioned conditions or sepsis and determine whether the SNF provided services to residents in accordance with their care plans and professional standards of practice.

Recipients of AIDS Relief Funds

For the fiscal years 2019, 2020, and 2021 the Centers for Disease Control and Prevention (CDC) received over $5.4 billion as a part of a federal program to enhance HIV treatment and prevention by using public health, innovation, and data-driven approaches to achieve the global goal of HIV/AIDS epidemic control.  These funds are distributed as a part of the President's Emergency Plan for AIDS Relief (PEPFAR).  The CDC works as a partner with various organizations such as civil and faith-based organizations, private sector organizations, and other on-the-ground partners to enhance ways for finding, treating, and preventing HIV.

In the past, the OIG has conducted numerous audits and has found weaknesses and lack of controls. Some audit findings include noncompliance with one or more U.S. Department of Health and Human Services (HHS) or CDC policies when awarding PEPFAR funds, not performing cost analyses before issuing some of the grant awards, and issuing several Notices of Awards with missing or incorrect reporting requirements.  As a result of these and other findings, the OIG has issued numerous recommendations to strengthen compliance and internal controls.

In continuing their oversight work, the OIG plans to determine whether selected recipients: (1) managed and expended PEPFAR funds in accordance with award requirements, and (2) have controls to mitigate potential risk to the PEPFAR program.

Conclusion

These are some of many recently added OIG Work Plan items. All compliance professionals in the healthcare industry should be reviewing the OIG Work Plan and, when appropriate, proactively monitor the same areas in their own organizations.

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