The Department of Health and Human Services’ Office of the Inspector General is giving the healthcare industry, state and federal healthcare agencies a heads up for 2015.

Across Medicare and Medicaid — and Medicare Advantage and Part D drug plans and Medicaid managed care organizations — OIG investigators intend to probe a range of issues, problems and trends, with the aim of holding the almost $3 trillion and growing U.S. healthcare system accountable. Insurers with Medicare and Medicaid plans should be prepared for audits from the OIG and subsequent public scrutiny in the media.

Medicare Advantage
In 2015 and beyond, the OIG intends to examine the soundness of Medicare Advantage rates, risk and payment adjustments.

“We will review the extent to which MA encounter data reflecting the items and services provided to MA plan enrollees are complete and consistent and are verified for accuracy by CMS,” the OIG wrote in its 2015 work plan, noting that previous audits have indicated “vulnerabilities in the accuracy of risk adjustment data reporting.”

The agency is also going to follow up on sufficiency of documentation for supporting beneficiary diagnosis.

“We will review the medical record documentation to ensure that it supports the diagnoses MA organizations submitted to CMS for use in CMS’s risk-score calculations and determine whether the diagnoses submitted complied with Federal requirements.”

Medicare Part D
For Medicare Part D drug plans, one target will be coverage gap discounts. The OIG is going to review the data submitted by Part D sponsors used to calculate these discounts and determine whether the beneficiary payments and the amount paid to sponsoring plans are correct.

The OIG also intends to compare Medicare Part D and Medicaid pharmacy reimbursement and rebates, and determine whether states are collecting the right rebates from drug makers for their Medicaid programs and managed care organizations.

Medicaid
In Medicaid more broadly, the OIG will be honing in on a number of areas.

“We will review states’ managed care plan reimbursements to determine whether MCOs are appropriately and correctly reimbursed for services provided. We will ensure that the data used to set rates are reliable and include only costs for services covered under the State plan as required by or costs of services authorized by CMS,” the OIG wrote.

Previous work by the Government Accountability Office has found that CMS oversight of states’ rate-setting required improvement and they may not be auditing or independently verifying MCO-reported data used in rate setting.

The OIG is going to audit whether MCO medical cost ratios and required refunds to states have been met, and also determine whether plan expenses were properly classified as medical or administrative. Prior OIG work found that MCO medical cost ratios were not met and that required refunds to states were not made.
The agency is also planning to review how MCOs are faring in meeting beneficiary protections — such as provider network adequacy and accessibility — and dealing with grievances and appeals.

The OIG’s full 2015 work plan.