Home Health & Hospice Week

The OIG isn’t letting up on its Medicare Advantage focus any time soon, it appears.

Since 2022, the HHS Office of Inspector General has issued 30 reports that target Medicare Advantage compliance, nine specifically in the last year. And a new release suggests OIG’s increasing interest in managed care is only going to get more intense.

The OIG outlines the latest crop of fraudulent and abusive behavior that impacts federal healthcare programs in its Semiannual Report to Congress released on June 3 and covering Oct 1, 2023, through March 31, 2024 (see home health details in HHHW by AAPC, Vol. XXXIII, No. 20). “Oversight of managed care — a rapidly changing sector with significant emerging risks — continues to be a priority,” says Inspector General Christie Grimm in the report.

Grimm continued, “In this reporting period … OIG continued to find that some Medicare Advantage plans are receiving higher payments than they should because they submit data that make plan enrollees appear sicker than they are.”

Plus: The OIG has added an MA topic to its Work Plan this month. “Medicare Advantage Organizations’ Use of Prior Authorization for Post-Acute Care” will examine the fact that “prior OIG work found that MAOs sometimes denied prior authorization requests for post-acute care after a qualifying hospital stay even though the requests met Medicare coverage rules.”

The OIG will examine “selected MAOs’ processes for reviewing prior authorization requests for post-acute care in long-term acute care hospitals, inpatient rehabilitation facilities, and skilled nursing facilities,” it says. While that doesn’t appear to include home health, the OIG “will also review the extent to which the selected MAOs denied requests for post-acute care and examine the care settings to which patients were discharged from the hospital,” the watchdog agency adds.

The OIG expects to issue the report on the topic in 2026, it indicates. More details are at https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000873.asp.