OIG posts a report and news about enforcement actions - 7/17

Good morning to all from Washington, DC. Today OIG posts a report and news about enforcement actions. As always, you can use the links provided to go directly to the new material.   ------------------------------------------------------------------------------     Early Implementation of the Consumer Operated and Oriented Plan Loan Program (OEI 01-12-00290) http://go.usa.gov/jbyu   WHY WE DID THIS STUDY The Patient Protection and Affordable Care Act established a loan program to foster the creation of nonprofit, consumer-governed health insurance issuers called CO OPs that will offer qualified health plans in the individual and small group markets.  Goals of the CO-OP program include promoting integrated care, quality, and efficiency.  As of January 2, 2013, the Centers for Medicare & Medicaid Services (CMS) had awarded loans totaling $1.98 billion to 24 CO-OPs.  The applicants that receive this funding are new entities that may face financial and operational challenges in a competitive insurance market.  CMS manages the CO-OP program and must implement it in a short time so that CO-OPs will be ready to enter the market of Affordable Insurance Exchanges—i.e., competitive marketplaces for health insurance.    HOW WE DID THIS STUDY We reviewed applications from the first 18 CO-OPs that were awarded funding.  We interviewed senior staff from these CO-OPs to describe how CO-OPs plan to meet program requirements and goals, such as consumer governance, integrated care, and increased quality.  We also interviewed CMS staff and reviewed CMS’s documentation related to oversight of the 18 CO-OPs to assess their progress during the startup phase and assess CMS’s oversight of the CO-OP program.    WHAT WE FOUND In their applications, CO-OPs broadly described various ways to meet program requirements related to consumer governance.  CO-OP applications identified primary care, electronic health data, and outsourcing as the main mechanisms for achieving integrated care at lower costs while improving quality.  Despite challenges, CO-OPs have made progress toward achieving licensure and met 90 percent of their milestones during the period of our review from February through September 2012.  CMS’s oversight strategy includes frequent monitoring and early intervention to ensure that CO-OPs adhere to program requirements and goals.   WHAT WE CONCLUDE Although CO-OPs appear to be making progress, at the time of our review they were still hiring staff, obtaining licensure, and building necessary infrastructure.  In addition, the extent to which any particular CO-OP can achieve program goals depends on a number of unpredictable factors, such as each State’s Exchange operations, market competition, and enrollment.   ------------------------------------------------------------------------------   July 16, 2013; U.S. Department of Justice Florida Health Care Medical Director and Six Therapists Arrested for Alleged Roles in $63 Million Fraud Scheme http://go.usa.gov/burG ------------------------------------------------------------------------------   July 16, 2013; U.S. Attorney; Eastern District of New York Brooklyn Money Launderer Sentenced to 37 Months in Prison in Connection with $77 Million Medicare Fraud Scheme http://go.usa.gov/burG ------------------------------------------------------------------------------   July 16, 2013; U.S. Attorney; Middle District of Tennessee Behavioral Analyst Pleads Guilty To Health Care Fraud http://go.usa.gov/burG ------------------------------------------------------------------------------   July 15, 2013; U.S. Attorney; Eastern District of Tennessee Morristown Dentist Indicted For TennCare Fraud http://go.usa.gov/burG ------------------------------------------------------------------------------   July 11, 2013; U.S. Attorney; Eastern District of Missouri University City Doctor Sentenced For Overbilling Medicare And Medicaid http://go.usa.gov/burG ------------------------------------------------------------------------------   State Enforcement Actions Updated http://go.usa.gov/buYC ------------------------------------------------------------------------------   That’s all we have for today. If we can be of any further assistance, please send an Email to public.affairs@oig.hhs.gov I hope your week is going well.   Marc Wolfson – Office of External Affairs OIG’s privacy policy can be found at http://oig.hhs.gov/notices/privacy-notice.asp Follow us on Twitter: http://twitter.com/OIGatHHS Inquiries? Contact us: Public.Affairs@oig.hhs.gov Manage your OIG subscriptions: update your preferences or unsubscribe Questions about this service? Support@GovDelivery.com This email was sent to buzzhairs.health@blogger.com using GovDelivery, on behalf of the U.S. Dept. of Health & Human Services · 200 Independence Avenue SW · Washington DC 20201 · 1-877-696-6775