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OIG Defines its Priorities in 2014-2018 Strategic Plan

Posted in Fraud & Abuse, Home Health & Hospice, Hospitals & Health Systems, Long-term Care/Skilled Nursing Facilities, Pharmacies, Physicians, State & Federal Audits, Investigations & Litigation

Written by: Brian Dunphy and Ellyn Sternfield

Outlining its high-level priorities and goals for the next five years, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) published its Strategic Plan for 2014-2018.  In the Strategic Plan, OIG identified four broad goals:  (i) fight fraud, waste, and abuse; (ii) promote quality, safety, and value; (iii) secure the future; and (iv) advance excellence and innovation.  OIG’s strategies to accomplish each of these four goals will be of interest to health care providers and are listed below.

Goal 1: Fight fraud, waste, and abuse

  • Enhance health care fraud enforcement by building on successful models such as the Medicare Fraud Strike Force teams.
  • Continue to implement and refine self-disclosure protocols.
  • Identify and recover improper payments.
  • Utilize exclusion of individuals and entities from federal health care programs to “protect HHS programs and beneficiaries.”

Goal 2: Promote quality, safety, and value

  • Investigate and refer for prosecution cases involving patient abuse or grossly deficient care of Medicare or Medicaid patients.
  • Promote quality of care in nursing facilities and community-based settings.
  • Continue to investigate prescription drug fraud.
  • Assess new payment and service delivery programs that are “intended to achieve value through care coordination” and evaluate “the reliability and integrity of quality, outcomes, and performance data” in connection with these programs.

Goal 3: Secure the future

  • Prioritize work on billing and payment errors.
  • Review and recommend changes to value-based payment methodologies to “maximize overall value, protect program integrity, and foster value and high performance.”
  • Advise “program administrators and policymakers on promoting the secure and effective use of data and technology.” In particular, OIG will focus on protecting the privacy and security of personally identifiable information and ensuring the security and integrity of electronic health records.

Goal 4: Advance excellence and innovation

  •  Leverage technology and data analysis, such as analyzing billing patterns, to decide how to allocate OIG’s resources to uncover fraud.

Our Observations

OIG’s Strategic Plan outlines its priorities in broad brush strokes and largely repeats past plans and priorities.  That is not surprising given that the OIG is feeling the pinch of sequestration:  closing offices, contracting staff, and imposing internal spending limits.  Nonetheless, the Strategic Plan promotes the OIG’s mission through fighting health care fraud and assessing/protecting program integrity as new health care payment and delivery models evolve.

Over the next several years, we anticipate that OIG will:

  • Try to flex its exclusion authority by pursuing more exclusion efforts involving individuals as opposed to entities;
  • Leverage available data and data analysis to identify potential health care fraud cases;
  • Continue to examine and revise voluntary disclosure protocols and practices; and
  • Place less focus on quality-of-care cases, which we expect will continue to take a back seat to corporate false claims civil enforcement efforts.  While OIG often prioritizes quality-of-care initiatives, these cases generally do not produce the eye-popping financial recoveries that allow OIG to promote the return on investment of its efforts.