In our recent story, “Compliance programs stress effectiveness” (Behavioral Healthcare, Nov./Dec. 2013 issue), Fabio van der Merwe, director of quality improvement and compliance at DeKalb Community Services Board (Atlanta, Ga.) noted that each year, the Office of the Inspector General (OIG) for the Department of Health and Human Services releases an annual work plan.
This plan, he says, “puts compliance officers ‘on notice’ as to the focus of federal Medicare and Medicaid enforcement activity for the coming year.” In its recently unveiled 2014 work plan, the OIG committed to continuing a range of investigative activities involving behavioral health.
And, in a likely response to ongoing controversy involving the suspension of 15 New Mexico Medicaid behavioral health providers, the OIG work plan indicated that states and their Medicaid Anti-Fraud Units (MFAUs) will, for the first time, face review of their processes for initiating provider payment suspensions following what are deemed to be “credible” allegations of Medicaid fraud. The work plan says that states and their MFAUs will also face ongoing OIG scrutiny about:
· Progress in addressing system vulnerabilities identified in CMS audits
· Accuracy of their Medicaid eligibility determinations pursuant to ACA Medicaid expansion rules
· The collection and verification of information associated with ownership of provider entities
· Their practices for timely identification and termination of providers suspended by Medicare or by Medicaid programs in other states
The OIG work plan for Medicaid managed care organizations (MCOs) says that they can anticipate OIG reviews regarding:
· Diligence in developing and applying Medicaid fraud-prevention practices
· Rate-setting and reimbursement practices
· Classification of medical and administrative costs in calculating medical loss ratio (MLR) and, when required, timely payments to states
· Adequacy of provider networks in ensuring patient access to Medicaid care services.
And, according to the plan, behavioral health providers can expect plenty of OIG scrutiny as well. The OIG’s Medicaid enforcement program promises continued investigation of provider organizations with regard to:
· Inappropriate dispensing of opioids
· Dispensing of atypical antipsychotics to children
· Eligibility of providers and beneficiaries for home health services
· Day care and continuing mental health day treatment for adults
· Billings associated with outpatient mental health services
The OIG’s Medicare work plan will focus reviews on:
· Evaluation and management (E & M) billings
· Partial hospitalization services by CMHCs and hospital outpatient departments
· Credentialing of mental health providers
· Payments related to incarcerated beneficiaries