OIG posts 3 reports and news about enforcement actions - 8/30

Good morning to all from Washington, DC. Today OIG posts three reports and news about enforcement actions. As always, you can use the links provided to go directly to the new material.   ------------------------------------------------------------------------------     Medicaid Drug Pricing in State Maximum Allowable Cost Programs (OEI-03-11-00640) http://go.usa.gov/Dr5w   WHY WE DID THIS STUDY   To take advantage of lower market prices for certain multiple-source drugs, States may use the Federal upper limit (FUL) and/or State Maximum Allowable Cost (MAC) programs.  However, FUL amounts have often exceeded market prices, and the Affordable Care Act (ACA), P.L. 111‑148, required CMS to change the method it uses to calculate these amounts.  Unlike the FUL program, State MAC programs give States flexibility in determining which drugs to include and in setting reimbursement rates.  Because drug use is expected to increase under the ACA provisions that expand Medicaid, an aggressive MAC program may help States contain Medicaid drug costs.     HOW WE DID THIS STUDY   In January 2012, we surveyed the 45 States (including the District of Columbia) with MAC programs to identify the methods used to set MAC prices and criteria used to select covered MAC drugs.  We also obtained the MAC prices and drugs covered at that time.  We compared States’ criteria for selecting drugs and setting prices in their MAC programs.  We also calculated the aggregate percentage difference between each State’s MAC prices and the FUL amounts in effect for the first quarter of 2012 (based on published prices), as well as the draft FUL amounts set by the ACA (based on average manufacturer price).  Finally, we identified the State with the most aggressive MAC program and calculated the potential national savings had all States used this program.       WHAT WE FOUND   Most of the 45 States with MAC programs used acquisition cost to set MAC prices.  In comparison, the pre-ACA FUL amounts were, on average, nearly double State MAC prices in January 2012, in the aggregate.  However, the post-ACA FUL amounts were lower, on average, than MAC prices, in the aggregate.  Although these amounts were required to take effect in October 2010, as of May 2013 CMS had not implemented them.  Unlike the FUL program, State MAC programs give States flexibility in setting their coverage requirements.  As a result, State MAC programs covered a wide range of drugs—significantly more than are covered under the FUL program.  Lastly, we found that States could achieve additional cost savings by using more aggressive MAC pricing formulas and inclusion criteria.  We identified Wyoming’s MAC program as the one that could produce the greatest savings.     WHAT WE RECOMMEND   We recommend that CMS complete the implementation of the post-ACA FUL amounts.  We also recommend that CMS encourage States to reevaluate their MAC programs for additional cost‑saving opportunities.  CMS concurred with our recommendations.   ------------------------------------------------------------------------------   Frequency of Medicare Recertification Surveys for Hospices Is Unimproved (OEI-06-13-00130) http://go.usa.gov/DrN5   WHY WE DID THIS STUDY   This memorandum report follows up on the 2007 OIG report Medicare Hospices:  Certification and Centers for Medicare & Medicaid Services Oversight (OEI-06-05-00260), which found that the most recent recertification survey for 14 percent of State-surveyed hospices had occurred more than 6 years previously, with an average of 9 years.  Further, when surveys did occur, 46 percent of the surveyed hospices received citations for health deficiencies, with the most frequently cited deficiencies related to care planning and quality issues.  We recommended that CMS seek statutory or regulatory timeframes for the frequency of hospice recertification surveys by State survey agencies, and suggested a timeframe of 3 years.  CMS did not concur with the recommendation, indicating that conducting more frequent surveys would require congressional action to allocate additional resources.  CMS policy sets targets for the frequency of hospice recertification surveys by State survey agencies.  These targets vary over time based on available resources and priorities.      HOW WE DID THIS STUDY   We analyzed national survey data for all hospices that had Medicare payments in 2011 and that were subject to surveys by State survey agencies on behalf of CMS, a total of 2,483 hospices.  We determined the certification survey frequency for each State-surveyed hospice by calculating the time between the date of the most recent certification survey (either initial certification or recertification) and the index date, February 28, 2013.  We determined the proportion of hospices that had not been surveyed within the 6 years preceding the index date, both nationally and by State, and compared those results to our prior findings.   WHAT WE FOUND   We found that the frequency of recertification surveys has not improved since 2005.  Seventeen percent of State-surveyed hospices had not been recertified within the 6 years prior to the index date of February 28, 2013, with some hospices experiencing longer intervals since their last survey.  We also found that in 12 States, more than 25 percent of hospices had not been recertified within the previous 6 years.  These findings illustrate that CMS’s use of fluctuating annual targets does not ensure timely recertification surveys of all hospices and raises concerns about whether CMS and contracted State survey agencies can ensure hospice compliance with Medicare CoPs and quality-of-care requirements for hospices.    Therefore, we reiterate the recommendation that CMS seek statutory or regulatory timeframes for the frequency of hospice recertification surveys.   CMS could consider setting this survey frequency standard at 3 years, to match the 3-year interval used by accrediting organizations (as approved by CMS); however, given resource limitations, setting a mandatory frequency—even for an interval of more than 3 years—could help to ensure improvement in survey frequency and avoid lengthy intervals between surveys for individual hospices.     ------------------------------------------------------------------------------     GAO Forum Highlights Report: Data Analytics for Oversight and Law Enforcement http://go.usa.gov/Dr5B     Oversight and law enforcement agencies play an important role in eliminating fraud, waste, and abuse. Sharing data, knowledge, and analytic tools can assist government agencies in this effort. However, while there is a tremendous amount of information the government can use in preventing and detecting fraud, waste, and abuse, using and leveraging these data can be challenging.     In January 2013, GAO, the Council of the Inspectors General on Integrity and Efficiency, and the Recovery Accountability and Transparency Board convened a forum with the purpose of exploring ways in which oversight and law enforcement agencies use data analytics to assist in the prevention and detection of fraud, waste, and abuse, as well as identifying the most-significant challenges to realizing the potential of data analytics and actions that the government can take to address these challenges. HHS OIG played a significant role in helping plan and conduct this forum.     This report summarizes the key themes that emerged from the discussion in the forum. Specifically, the report discusses the challenges and opportunities in (1) accessing and using data and (2) sharing data. In addition, participants identified next steps to address these challenges and capitalize on opportunities.     ------------------------------------------------------------------------------   August 28, 2013; U.S. Attorney; District of New Mexico Former Non-Native Employee of Indian Health Services Pleads Guilty to Fraudulent Acquisition of Controlled Substances http://go.usa.gov/jPWd   ------------------------------------------------------------------------------   State Enforcement Actions Updated http://go.usa.gov/jPZ3 ------------------------------------------------------------------------------   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 has gone well and you are able to enjoy the upcoming Labor Day weekend.   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