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From Health Law Daily, November 19, 2014

OIG decides Marketplace, Meds, Medicaid expansion among ‘top challenges’

By Melissa Skinner, JD

On the heels of the release of the Office of Inspector General (OIG) fiscal year (FY) 2015 Work Plan, the OIG announced a list of ten management challenges faced by HHS now and in the upcoming year. The report, entitled “Fiscal Year 2014 Top Management and Performance Challenges Identified by the Office of Inspector General,” was like the OIG Work Plan in that it emphasized administration of the Medicare and Medicaid programs by CMS and the federal Food, Drug and Cosmetic Act by the FDA (see OIG continues focus on Medicare, Medicaid payments, November 3, 2014). Yet, in identifying the top challenges the OIG also put great emphasis on issues stemming from the implementation of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) (OIG Report, November 18, 2014).

Marketplaces. The OIG described the implementation, oversight, and operation of the Marketplaces operated by CMS on behalf of 36 states as “among the most significant challenges for [HHS] in [FY] 2014,” and stated it would continue to be such a challenge in 2015. Among those specific issues that the OIG has found and anticipates will continue to exist in 2015 are: (1) ensuring accurate eligibility determinations; (2) processing enrollments; (3) dealing with re-enrollees; (4) identifying and handling those with qualifying life change events; and (5) communicating accurate information to coverage issuers and consumers in a timely fashion. As such, OIG recommended that CMS focus on certain key areas in regard to state and federal Marketplaces including payments, eligibility, management, administration, and security. While the OIG acknowledged the progress made in the administration of the Marketplaces since the beginning of the first open enrollment period in 2015, it also stressed that improvements must be continued.

Part D. The OIG described the second management challenge as simply: “ensuring appropriate use of prescription drugs in Medicare and Medicaid.” In general, the OIG noted that costs for prescription drugs reimbursed through Medicare Part D alone totaled $66.9 billion in 2012. However, the OIG referenced its own 2014 report, which highlighted patterns for HIV drugs that indicated that “beneficiaries are receiving inappropriate prescription drugs and selling them illegally, pharmacies are billing for drugs beneficiaries never received, or that beneficiaries Medicare identification numbers were stolen.” Further, the OIG noted negative trends of diversion and abuse of both controlled and non-controlled substances. In turn, the OIG explained that, despite the progress CMS has made in increasing oversight of the Part D program, it also needs to “increase Plan D plan sponsor’s abilities to limit questionable utilization of drugs, particularly drugs that are vulnerable to diversion and recreational abuse.”

Medicaid expansion. In its third top management challenge, labeled “protecting an expanding Medicaid program from abuse, fraud, and waste,” the OIG described the “long-standing program integrity challenges” that are now relevant to an expansion of Medicaid benefits to 27 new states and the District of Columbia pursuant to the ACA. In particular, the following aspects of the expansion should be zeroed in on, according to the OIG: (1) improving Medicaid data’s effectiveness; (2) swift and efficient identification and recovery of improper payments; (3) managed care program integrity and access for beneficiaries; and (4) state policies that tend to inflate federal costs.

Other top challenges. In addition to these areas, the OIG recognized and emphasized seven more top challenges including:

  • Promotion of value and detection and prevention of waste and fraud in Medicare Parts A and B;

  • Improvement and focus on quality care in nursing homes, hospices and, home-and community-based providers

  • Ensuring the meaningful use and security of electronic health information;

  • Ensuring effective and efficient operation of public health and human services programs;

  • Implementation and continuation of effective financial and administrative management

  • Protecting HHS grants and contract funds from fraud, waste, and abuse;

  • Protecting public health by ensuring safety of food, drugs, and medical devices.

For each of these challenges the OIG report acknowledged the progress made so far in the field, made recommendations as to how improvements could continue, and suggested OIG resources that could aid in that progress.

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