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[ Music ] Welcome to OIG Outlook 2014. I'm Roberta Baskin,
Director of Media Communications for the Office of Inspector General. The OIG oversees the
complex world of Federal health care programs, and our 2014 Work Plan is a blueprint of our
oversight and enforcement efforts. They're designed to protect both the people who rely
on those health care programs and the taxpayers who pay for them. Over the next half-hour,
our leadership will discuss those plans for the year ahead. But first, we'll hear from
our top leadership at OIG: our Inspector General Dan Levinson and our Principal Deputy Inspector
General, Joanne Chiedi. Dan? Hello and welcome. Our mission here at the
Office of Inspector General is to protect the integrity of over 300 health and human
services. For over 30 years, we have fought against fraud, waste and abuse. In so doing,
we work to protect the millions of Americans who rely on health and human services programs
and the investment of our taxpayers. This is a period of great transition in health
care as insurance marketplace models are introduced and as payment models transition from volume-
to value-based. These transitions intend to produce higher quality of care at lower costs.
OIG's oversight of new health insurance marketplaces will focus on four primary areas of risk:
payment accuracy, eligibility controls, contracting oversight, and privacy and security issues.
Many new models place great reliance on data and health information technology. We will
continue to focus on the use of health information technology, including electronic health records.
Where vulnerabilities are detected, we will offer recommendations for improvement. Our
work is built on the core values of relevance, impact, customer focus and innovation. Robertaů.
Thanks, Dan. Those core values lead right into our Principal Deputy Inspector General,
Joanne Chiedi, introducing our shared goals to drive positive change in 2014 and beyond.
Joanne? Thanks, Roberta. The Office of Inspector General
has responsibility for overseeing HHS programs that account for 25 cents of every Federal
dollar spent. We approach our mission by focusing on three key goals. Goal one is to fight fraud,
waste and abuse. In this program, you'll hear about our planned efforts to fight fraud and
abuse in areas such as prescription drugs, and home- and community-based services. Goal
two is to promote quality, safety and value. A key focus of our planned work is on the
quality and care of nursing homes and how often beneficiaries are harmed during their
stay in nursing homes. Goal three is to secure the future of HHS programs. Health IT will
remain a top priority. Continued oversight is needed to guard against misuses that could
result in improper payments and substandard quality. OIG will continue to remain nimble
and responsive to changes as we conduct our oversight and assessments of new and existing
programs in HHS. Over the next half-hour, you'll be learning more about OIG's goals
in 2014 and beyond, from our deputy inspectors general. Thank you for tuning in.
[ Music ] The Office of Audit Services is the largest
civilian audit organization in the Federal government. Its Deputy Inspector General is
Gloria Jarmon. Welcome, Gloria. You lead some 600-plus auditors. Talk about the issue on
everyone's mind: the Affordable Care Act. How do you plan to do oversight?
Well, Roberta, we actually have a strategic approach in HHS OIG for this work, where we're
focusing on areas initially of highest risk. And those areas include looking at the payment
accuracy. We're also looking at enrollment eligibility. We're looking at contract management
issues, security issues. We have other work that relates to grants under the Affordable
Care Act and additional work in the Medicaid area.
And what type of work are you required to do, required by Congress?
We actually have a report that's required by July 1st, where we will be reporting on
the effectiveness of the procedures and safeguards to prevent the enrollment of inaccurate or
fraudulent applicants into the health plans that are part of the marketplaces.
What type of coordination -- given this big picture, what type of coordination do you
have to do with other Federal agencies? It involves a lot of coordination because,
as you can imagine, there's several other auditors who are also doing work in this area,
including GAO, IRS auditors, and most of the state auditors are doing work in this area.
So, we coordinate closely with them to make sure our work compliments each other and is
overall very comprehensive. In the intro, Joanne Chiedi mentioned improper
payments as one of our key goals. Tell us about that audit work.
We do a lot of work related to improper payments here at HHS. For one thing, the department
has the largest number of reported improper payments in the Federal government, over $65
billion, which is over half of the reported improper payments government-wide. So, it's
very important that we're working closely with the department to have recommendations
to help reduce that number. HHS is also the largest grant-making organization
in the Federal government, awarding over 78,000 grants last year, totaling more than $340
billion. This has to be a huge area of your oversight work.
Yes, it is. We do a lot of work related to grants oversight, also. As mentioned, we're
doing work on the Affordable Care Act grants, but we're also doing work on grants that were
made related to Hurricane Sandy, where there's grant money that went to HeadStart, mental
health services. Our overall interest in doing this oversight work of grants is to make sure
that the money went to the right people and is being spent properly.
HHS also awards a large number of contracts: over $19 billion in 2013. What are your oversight
plans for contracts? Our oversight plans for contracts, since we're
also doing work in that area related to the Affordable Care Act, where we're looking at
contractor performance and management. We're looking at what should have happened, what
did happen and what are some of the lessons learned, related to contract management and
performance. What about Medicare oversight? What would
you be highlighting in the year ahead? Medicare is, as you can imagine, is a large
area of our work. We continue to do work related to hospital compliance, like we did in 2013.
And we're also doing compliance work at home health agencies. And those are just a couple
of examples of the work we've been doing in that area.
Robert Baskin: And with the Medicaid expansion under the Affordable Care Act, what are you
looking out for there? In the Medicaid area, as in past years, we
do a lot of oversight work related to Medicaid, and we will continue to do that. We will be
doing additional oversight because of the impact of the Affordable Care Act. But some
of the work that we do in the Medicaid area we'll be doing in 2014 includes looking at
state drawdowns, to make sure the amount drawed-down can be compared to how much was spent by the
states. And we're also looking at whether rebates have been collected by the states
related to the pharmaceutical administered drugs.
Thank you, Gloria, for this little glimpse of your audit work priorities. You and your
auditors are going to have a very busy year ahead.
Thank you, Roberta. [ Music ]
Now a look at the work of the Office of Evaluation and Inspections, led by Deputy Inspector General
Stuart Wright. Stuart's in charge of what we think of as the academic branch of OIG.
Medicare and Medicaid command the majority of OEI's time, but what are some other arenas
that you do evaluations for? Well, the majority of our work does pertain
to Medicare and Medicaid. We do evaluation work across the department's program. So we
also look at FDA, NIH and CDC. Now, how do you choose the types of evaluations
that you're going to tackle in 2014? We select our evaluations based on risk in
accordance with organizational goals. We look at areas with fraud, waste and abuse in mind,
and we also look to see whether departmental programs are working as they're intended to
work. Well, out of the huge bandwidth that you have,
what are three areas that you're going to focus on for evaluations in the year ahead?
Three areas that we're going to focus on would be quality of care, accuracy of payments and
access to care. The work that you've done on adverse events
and patient harm has gotten a lot of attention. Just briefly share some of those findings.
Sure. We previously reported on the extent to which adverse events -- these are instances
where patient harm actually occurs in the hospital setting. We analyzed Medicare beneficiaries
to determine how frequently how that occurred and found that more than 13 percent of beneficiaries
actually had an adverse event occur to them in the hospital.
And in the year ahead, you're going to be expanding that work into nursing homes. Give
us some headlines on that. Sure. We'll be expanding that work to look
at adverse events in skilled nursing facilities. In addition, we will assess the extent to
which those events could have been preventable, and we will assess the Medicare costs associated
with those adverse events. Your Medicare evaluation in management work
looks at very small dollars, like a hundred dollars, but it really adds up. What's the
significance? You're correct, Roberta. While evaluation
in management's codes -- these are the services that Medicare pays for doctor visits -- are
small, they add up to approximately $33 billion a year in payments.
Thirty-three billion a year. Correct. We previously reported on the trends
in Medicare payments and the extent to which physicians consistently billed at the highest
code levels. We will now be reporting on the extent to which those codes are accurate in
terms of Medicare payments and the extent to which Medicare paid for services that they
shouldn't have been paying. And finally, your Medicaid managed care access
work, what kinds of assessments will you be doing with the states?
During the upcoming year, we will be assessing the extent to which states place requirements
on their Medicaid managed care networks in terms of ensuring that beneficiaries have
access. In addition to looking at what states have, in terms of requirements and the oversight
that they perform with respect to those requirements, we will actually be assessing the extent to
which beneficiaries can schedule appointments with providers.
And so, what's the impact of that on patients? Obviously, there's a real quality of care
impact. Beneficiaries need to be able to schedule appointments timely, when they need care.
Thanks, Stuart, for sharing these insights on what you can anticipate in 2014 for OIG's
upcoming evaluations and inspections. Thank you, Roberta.
[ Music ] Next, we'll hear from the head of the Office
of Management and Policy about delivering the needed resources to support our mission.
Welcome to Deputy Inspector General Paul Johnson. Paul, briefly explain what it means to deliver
the tools needed across OIG, from auditors to special agents.
Sure. People are the heartbeat of our organization at OIG. We have people across the organization
who have vast expertise in HHS programs. With that expertise, they also have specific needs
to do their jobs on a daily basis. So, what we do in our office is we work in partnership
with people across OIG to make sure they have the resources and the systems that they need
to complete their mission. One of OIG's goals is advancing excellence
and innovation. How do you plan to do that in the upcoming year?
Really, by the very nature of our work, we do that every day. We partner with HHS programs
across the nation, and our people bring their expertise and bring innovation and excellence,
so we seed innovation in HHS on a daily basis. Another big focus for OIG is data analysis.
How is it supporting our fraud-fighting efforts? Sure. One of the first things we do is we
partner with HHS programs to get the data that is most critical. Then we perform analysis
of that data. We look at trends. We look for spikes. We look for decreases. We look for
trends across the whole system of data. And from that, we can make conclusions about where
we should target our resources. Sometimes we see increases in payments in programs,
and then we'll do the next step: we'll target our resources to those areas so we can have
the greatest impact. A great example of that is our Medicare Fraud Strike Forces. In these
areas, we're able to target our resources, and we're seeing the results on that based
on data analysis. Well, in addition to fighting fraud, how else
is OIG using data? It's really an agency-wide initiative. Across
OIG, all of our staff is looking for data to use, to best target our work, so we can
have the greatest impact. Well, give us an example of how data analytics
has had an impact. In the mental health area, we've been able
to see great decreases in payments. In community mental health centers?
Community mental health centers. Absolutely. We've been doing a lot of work in community
mental health centers over the years with our partners. Now we're able to take data,
look at the decrease in payments, and we're talking about decreases of hundreds of millions
of dollars. And that tells us that payments are going to the right providers, who are
providing the right service to the public. I hate to ask, but what are the challenges
ahead in 2014? Like most Federal agencies, resources have
been a challenge over the last couple of years. But we are working very hard to meet those
challenges. Our staff is being innovative and looking for ways to ensure excellence
in everything we do. So, we're very excited about the future.
Thank you, Paul, for your enthusiastic support, as well as sharing the challenges that we
face in the coming year. Thanks, Roberta.
[ Music ] Turning now to our law enforcement efforts,
Gary Cantrell is our top cop in health care, leading our Office of Investigations with
some 500 special agents across the country. Welcome, Gary. I know that I can't ask you
who will be investigated in the year ahead, so just start with a quick look back at what
your investigative work accomplished last year.
Last year, our investigations resulted in outstanding outcomes. We had a record number
of criminal convictions. We had a record number of civil actions, resulting in almost 5 billion
dollars in investigative receivables. Well, with fewer resources now, does data-driven
enforcement play a bigger role? We continue to use data to operate more efficiently
and effectively. First of all, we've used it to allocate our resources in areas where
we've seen fraud hotspots. So, this is illustrated by our Medicare Fraud Strike Force, as they're
located in nine cities throughout the country. So, we work with our law enforcement partners,
basing our operations in fraud hotspots, and we've found that that's been a very effective
tool. And we also use data every day in the course of our investigations to shift through
these cases, which can be very complex, much more quickly and efficiently.
So give us a sense of what kinds of trends you're following.
Well, we've seen some major trends, fraud trends, related to prescription drugs. And
not only in the area of pain medication abuse, which we've seen over the last several years,
but we're also seeing fraud schemes related to just pure financial greed, interest in
stealing money from the government: billing for drugs that aren't necessary, that are
expensive and never even dispensing them. So, this is both a concern for patient harm,
where there's been abuse of these pain medications, and also a financial risk for the government.
Well, take us behind closed doors to home health and personal care services. What kinds
of schemes are you seeing there? Home-based services are another area where
we see a lot of fraud. Unfortunately, many patients are home-bound and they need to have
care provided to them in their homes. All too often, services are not being provided.
The necessary services are never delivered. And in some cases, it's delivered, but it's
not necessary. So, the patients aren't actually home-bound and shouldn't be receiving services
in the home. That's done sometimes by paying kickbacks to induce individuals to participate
in these schemes. Well, you've touched on patient harm, but
we say so much about dollars saved or dollars lost. Talk a little bit more about patient
harm. Give us an example. Yeah. Unfortunately, many of our investigations
-- it's not just a financial crime. Patients are being put in harm's way. The most egregious
example that we've seen in the last year was a radiology tech, working in a hospital to
divert drugs for his own abuse, was taking necessary pain medications from the patients,
using the syringe, and then it was being re-used to provide saline solution to patients who
needed pain medication. All the while, he was infected with Hepatitis C, infecting over
40 patients in multiple states, throughout the country. Twenty of those patients were
Medicare patients, and three of them were Medicaid patients. When we identify cases
like this where our patients are being put in harm's way, we will pursue these aggressively
and take action swiftly. That is a really shocking example. Since the
Affordable Care Act is so much in the spotlight, what kinds of concerns do you have on the
enforcement side there? Well, we're monitoring for fraud schemes related
to the Affordable Care Act. And right now, we're trying to educate consumers to ensure
that they're not the victims of these fraud schemes. Identity theft is certainly something
we're concerned about and we're watching for. And we will also pursue any allegations of
fraud relating to Affordable Care Act or consumer fraud very aggressively.
Gary, thanks for sharing some of the trends that you're seeing and what your enforcement
priorities look like for 2014. Thank you.
[ Music ] Finally, we hear from the Chief Counsel of
the Office of Counsel to the Inspector General. Leading a full service in-house law firm is
our top lawyer, Greg Demske. And Greg leads a team of lawyers overseeing compliance and
protecting government health care programs from fraud. Welcome, Greg, and just say a
few words about your role across all of OIG. Sure, Roberta. First, we are the lawyers for
OIG, which means we're advising the investigators, auditors, evaluators on the work that they're
doing, day to day. And that's similar to what OIG's Counsel's Offices would do across government.
But in addition to that, we have some special responsibilities. For example, we have administrative
enforcement authority to exclude providers from participating in Federal health care
programs. Very important.
And also to issue civil money penalties, or CMPs, against those who commit fraud against
our programs. You also provide guidance to the entire health
care community. What are some examples of that?
That's right. That's one of our other special responsibilities: guidance. And Congress has
required us to give some guidance. For example, under the anti-kickback statute -- this is
a statute that is very broad and covers the entire health care arena -- we are required
to issue safe harbor regulations and advisory opinions that help define the contours of
that broad statute. But in addition to what we're required to do, OIG has a longstanding
commitment to providing guidance to providers who are trying to do the right thing and promote
compliance from within. So, for example, we've issued compliance program guidance, fraud
alerts, bulletins, videos; all of which is available on the website.
What are some significant changes to regulations that you're proposing in the year ahead?
Well, we have regulations that govern some of the guidance that we provide but also our
enforcement actions. And we don't issue a lot of regulations in OIG, but in 2014, we
plan to issue proposed regulations in three areas: CMPs, exclusions and safe harbors.
And these proposed regulations will really update and modernize what we already have
in place and address changes to the law, saying the Affordable Care Act or other provisions.
And we'll get public comment, which will allow us to bring our regulations up to date.
Looking ahead, what are some ways that you'll be using your administrative enforcement authorities?
Well, I see two trends that have started and will continue even more so in the future.
One, we are using data and working with the auditors and evaluators, as well as investigators
in OIG, to identify areas where we should look to do administrative enforcement, but
also, particular subjects that we should pursue. And secondly, we are concentrating, more than
ever, on bringing cases where the enforcement action supports guidance we've given. So,
for example, if we've said certain conduct is problematic and violates the law, we're
going to look to pursue cases for those people who violate that guidance. That's designed
to provide a level playing field for those providers that are playing by the rules.
You do a lot of outreach to the provider community. So, what are some new ways that you'll promote
compliance? Well, in addition to the ones that I mentioned
before, one of the areas that we provided guidance to in the past is for boards of directors
at health care entities. And we've provided free documents in the past, but we've continued
to hear from compliance officers that there's a need for more guidance for members of boards
of directors. So, we plan in 2014 to issue new guidance in that area. And, really, all
the guidance that we provide recognizes, number one, that we can't be everywhere. We can't
be the cop on the beat, looking over the shoulder of every provider. And secondly, that the
vast majority of providers are trying to comply with the law in a complex regulatory environment.
So, we're going to try to give them the tools to comply from the provider side.
Great point. Thank you, Greg Demske, for wrapping up our program with how your lawyers promote
compliance, protect the public and hold those accountable who steal from Federal health
care programs. And thank you, again, to all of OIG's leadership for their contributions
to this program. Please visit our website for an in-depth look at our oversight work
and many resources. To stay connected to OIG's work, please sign up for our email updates
and follow us on Twitter. Thanks for watching and have a healthy and happy 2014.
[ Music ]