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Office of Inspector General

OIG issues fraud warning for Marketplaces

Posted on September 18, 2013

The US Department of Health and Human Services Office of Inspector General (OIG) issued a consumer alert concerning potential signs of fraud in the health insurance Marketplaces. The OIG alert addresses specific actions that may indicate fraudulent activity around the Marketplaces. Some of the actions consumers should be wary of include:

  • individuals asking consumers for money to enroll in Marketplaces or Obamacare;
  • sham or look-a-like websites;
  • persistent, high-pressure solicitation to purchase insurance; and
  • individuals asking consumers for personally identifiable information without previous contact.

Additionally, OIG used this alert to remind Medicare beneficiaries that they do not need to enroll in the Marketplace.

The Centers for Medicare and Medicaid Services (CMS) also released a tip sheet alerting consumers on ways in which they can protect themselves against fraud in the Marketplaces.

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OIG report details security risks of data hub

Posted on August 5, 2013

A new report from the US Department of Health and Human Services Office of Inspector General (OIG) chronicled observations from the implementation of the Centers for Medicare and Medicaid Services (CMS) data service hub. Under the Affordable Care Act (ACA), CMS created the data service hub to aggregate, but not store, data from several federal agencies required to make the Marketplaces operate. The report found that if CMS delays any more of the security preparedness components in implementing the Marketplaces, it is likely that CMS will possess “limiting information” on the potential privacy and security risks associated with the data services hub.

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OIG releases report concerning implmentaion of CO-OP programs

Posted on July 25, 2013

A new report released by the US Department of Health and Human Services Office of Inspector General (OIG) purports that Consumer Operated and Oriented Plan (CO-OP) issuers have achieved 90% of their implementation goals. Under the Affordable Care Act (ACA), CO-OP loans were provided to create non-profit health plans that were effectively consumer initiated and executed in 24 states. Although these CO-OPs have been successful in development, much uncertainty and concern still remains around the ultimate success of these programs. The report, Early Implementation of the Consumer Operated and Oriented Plan Loan Program, found that many factors, such as competition in state insurance Exchanges and the health status of enrollees, will determine whether or not CO-OPs will be beneficial for plan participants.

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OIG calls for increased oversight of HealthCare.gov Plan Finder

Posted on April 9, 2013

A recent report released by the US Department of Health and Human Services Office of Inspector General (OIG) finds that the Centers for Medicare and Medicaid Services (CMS) should better oversee the information provided by private insurers to HealthCare.gov Plan Finder to make certain that the information presented is accurate. The purpose of Plan Finder is to provide consumers in the individual and small group markets with information on various insurance coverage options. The OIG report denoted several reasons for additional oversight:

  • 13% of insurers expected to provide pricing and benefit data to Plan Finder did not do so, and CMS did not follow-up with these insurers.
  • CMS does not require the CEO or CFO of the insurance company to certify the submitted data.
  • 14% of the plans sampled by OIG were not available for sale or the insurance representative could not identify the name of their product on Plan Finder.

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OIG updates guidance on evaluating state false claims act legislation

Posted on March 18, 2013

Updated guidelines released by the US Department of Health and Human Services Office of the Inspector General (OIG) provide new information for evaluating state false claims act legislation. The updates adhere to various amendments made to the federal False Claims Act of 2009 and 2010. Several recent legislative endeavors, including the Affordable Care Act (ACA), have altered the foundation and scope by which the False Claims Act operates. One ACA example found within the OIG updates is how states will receive their share of any Medicaid recoveries made under the federal False Claims Act.

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OIG finds most states on track to comply with ACA technical demands

Posted on February 21, 2013

According to a report published by the U.S. Department of Health and Human Services’ (HHS) Office of Inspector General (OIG), 35 States reported that they anticipate implementing streamlined eligibility and enrollment systems, streamlined application forms, and data sharing and matching by January 1, 2014, as mandated under section 1413 of the Affordable Care Act (ACA). However, the report also describes challenges reported by States, such as implementing the requirements by the target date and upgrading outdated eligibility and enrollment systems. The report details various funding issues related to implementing needed changes. According to the paper, States also reported needing information and guidance, particularly on the Secretary’s application form, the planned Federal data services hub, and the calculation of Modified Adjusted Gross Income (MAGI). The OIG report concluded that the Centers for Medicare & Medicaid Services (CMS) should continue to provide guidance to States as they prepare to implement the streamlined eligibility and enrollment systems.

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OIG releases study on Medicare payments and fraud

Posted on September 26, 2012

According to a study recently released by Office of the Inspector General (OIG), between 2001 and 2010, Medicare payments for Part B goods and services increased by 43 percent, from $77 billion to $110 billion. During this same time, Medicare payments for evaluation and management (E/M) services increased by 48 percent, from $22.7 billion to $33.5 billion. E/M services have been vulnerable to fraud and abuse. In 2009, two health care entities paid over $10 million to settle allegations that they fraudulently billed Medicare for E/M services. The Centers for Medicare & Medicaid Services (CMS) also found that certain types of E/M services had the most improper payments of all Medicare Part B service types in 2008. The OIG report is the first in a series of evaluations of E/M services.

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House Republicans target IRS, FFEs

Posted on June 21, 2012

Two House Republicans introduced new legislation to block an Internal Revenue Service (IRS) rule that will offer tax credits for buying health insurance in Federally Facilitated Exchanges (FFEs). Reps. Scott DesJarlais and Phil Roe maintain that since the Affordable Care Act (ACA) only authorized tax credits for the purchase of insurance on state-run exchanges—and not for federally operated exchanges—the IRS rule cannot offer tax credits in both marketplaces. The legislation would affect many of the estimated 16 million people expected to gain coverage, as about 30 states are expected to have federally run exchanges. Under the IRS rule, premium tax credits will be available to individuals between 100 and 400 percent of the federal poverty level who purchase coverage inside of both state and federal exchanges beginning in 2014. Additional subsidies are available for individuals up to 250 percent of the federal poverty level.

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OIG report finds that contractors are unable to identify overpayments due to flawed CMS database

Posted on February 21, 2012

A study released by the Department of Health and Human Services Office of the Inspector General (OIG) presents an early assessment of the efforts of Review Medicaid Integrity Contractors (Review MIC) to conduct data analysis to identify potential overpayments and provide or recommend audit leads to the Centers for Medicare & Medicaid Services (CMS). The objectives were: (1) to determine the extent to which Review MICs completed assignments, recommended audit leads, and identified potential fraud; and (2) to describe barriers that Review MICs encountered in their program integrity activities.

The OIG recommend that CMS…

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CMS releases ACO final rule, others agencies weigh-in

Posted on October 20, 2011

The Centers for Medicare and Medicaid Services (CMS) released the much anticipated Accountable Care Organization (ACO) final rule, implementing section 3022 of the Affordable Care Act (ACA), which contains provisions relating to Medicare payments to providers of services and suppliers participating in ACOs under the Medicare Shared Savings Program. The rule on Medicare ACOs relaxes eligibility requirements for doctors and hospitals to participate by halving the number of performance measurements (65 to 33), removing the electronic medical records (EMR) requirement, and eliminating some financial risks. CMS also extended the deadline for ACO applications through 2012. As enticement to rural doctors and physician-owned practices, CMS said it would dedicate $170 million to said providers to start ACOs. Regulators estimate that between 50 and 270 ACOs will be established in the next 3 years, which will affect the care of 4% of Medicare beneficiaries.

Multiple federal agencies also released rules and guidance on fraud & abuse and antitrust issues related to ACOs. The HHS Office of Inspector General (OIG) issued an interim final rule (IFR) on the waiver of certain fraud and abuse provisions and the Department of Justice (DOJ) issued a statement on health care antitrust enforcement policies.

To read more about ACOs, click here.

For the ACO final rule fact sheet, click here.

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