This is a sample audit tool Date: Physician: Please complete the following (information should be documented in the patient's chart) __________ Diagnosis not documented __________ Signature needed on _______________ __________ Documentation does not support charge __________ Discrepancy in dictation compared to handwritten __________ Reason for test not documented __________ Other ___________________________________________ This is just a sample of what your audit tool will include. Of course, your audit tool will be more detail. You are creating an audit tool that can be used in coding or reimbursement along with the written portion of the assignment. Scoring Rubric for OIG Report CATEGORY 30 20 10 Information is organized Information is organized, with well-constructed but paragraphs are not paragraphs. well-constructed. 0 Organization Information is very organized with wellconstructed paragraphs and subheadings. Information Identifies and explains Explains content of OIG Identifies section of OIG Does not identify section section of OIG plan used section used but does not plan used but does not of OIG plan used to create audit tool identify specific section explain content of section Audit tool Contains all needed components of an audit tool for the chosen section of the OIG work plan Mechanics No grammatical, spelling Almost no grammatical, A few grammatical or punctuation errors. spelling or punctuation spelling or punctuation errors errors. Many grammatical, spelling, or punctuation errors. Sources All sources (information and graphics) are accurately documented in the APA format. Some sources are not accurately documented. Contains components related to the chosen section of the OIG work plan but does not contain collection information All sources (information and graphics) are accurately documented, but a few are not in the APA format. The information appears to be disorganized. Contains collection Does not relate to chosen information but does not section of OIG work plan contain components related to the chosen section of OIG work plan All sources (information and graphics) are accurately documented, but many are not in the APA format. 2010 ______________________________________________________________________________ A Message From the Office of Inspector General We are pleased to present the Office of Inspector General (OIG) Work Plan for fiscal year (FY) 2010. This publication describes activities that we plan to initiate or continue with respect to the programs and operations of the Department of Health and Human Services (HHS) in the next year. To place the Work Plan in context, we describe below our mission and activities, organization, program integrity resources, work-planning process, and related matters. Mission and Activities OIG's operational mission is to protect program integrity and the well-being of program beneficiaries by detecting and preventing waste, fraud, and abuse; identifying opportunities to improve program economy, efficiency, and effectiveness; and holding accountable those who do not meet program requirements or who violate Federal laws. We carry out our mission by conducting audits, evaluations, and investigations; providing guidance to industry; and, when appropriate, imposing civil monetary penalties (CMP), assessments, and administrative sanctions. We work closely with HHS and its Operating and Staff Divisions; the Department of Justice (DOJ); and other agencies in the executive branch, Congress, and States to bring about systemic changes, successful prosecutions, negotiated settlements, and recovery of funds. Organization OIG is organized into six components through which we carry out our mission and support functions: the Office of Audit Services (OAS), Office of Evaluation and Inspections (OEI), Office of Investigations (OI), Office of Counsel to the Inspector General (OCIG), Office of Management and Policy (OMP), and Immediate Office of the Inspector General (IO). OIG is headquartered in Washington, DC, and has a nationwide network of approximately 90 regional and field offices with almost 80 percent of our staff working outside Washington, DC. The following bullets describe the functions of the components that carry out our audit, evaluation, investigation, enforcement, and compliance activities. OAS provides auditing services for HHS, either by conducting audits with its own audit resources or by overseeing audit work done by others. Audits examine the performance of HHS programs and/or its grantees and contractors in carrying out their respective responsibilities and are intended to provide independent assessments of HHS's programs and operations. These assessments help reduce waste, abuse, and mismanagement and promote economy and efficiency throughout HHS. OEI conducts national evaluations to provide HHS, Congress, and the public with timely, useful, and reliable information on significant issues. These evaluations focus on preventing fraud, waste, or abuse and promoting economy, efficiency, and effectiveness of HHS programs. OEI reports also present practical recommendations for improving program operations. ______________________________________________________________________________ FY 2010 Office of Inspector General Work Plan i A Message From the Office of Inspector General ______________________________________________________________________________ OI conducts criminal, civil, and administrative investigations of fraud and misconduct related to HHS programs, operations, and beneficiaries. With investigators working in almost every state and the District of Columbia, OI actively coordinates with DOJ and other Federal, State, and local law enforcement authorities. The investigative efforts of OI often lead to criminal convictions, administrative sanctions, or CMPs. OCIG provides general legal services to OIG, rendering advice and opinions on HHS programs and operations and providing all legal support for OIG's internal operations. OCIG represents OIG in all civil and administrative fraud and abuse cases involving HHS programs, including False Claims Act, program exclusion, and CMP cases. In connection with these cases, OCIG also negotiates and monitors corporate integrity agreements. OCIG renders advisory opinions, issues compliance program guidance, publishes fraud alerts, and provides other guidance to the health care industry concerning the anti-kickback statute and other OIG enforcement authorities. Program Integrity Resources OIG's program integrity resources derive from multiple sources, including a single discretionary appropriation1 and multiple statutory funding streams provided through other legislation. On average, the discretionary appropriation represents approximately 20 percent of our total annual funding, while separate statutory funding streams that are mandated for our oversight of Medicare and Medicaid provide approximately 80 percent. Accordingly, our annual budget is devoted largely to oversight of Medicare and Medicaid, consistent with our statutory mandates. Work Planning Process At the beginning of each FY, we issue our annual Work Plan, which describes the specific audits and evaluations that we have underway or plan to initiate in the FY ahead with our discretionary and statutorily mandated resources. The Work Plan also provides general focus areas for our investigative, enforcement, and compliance activities. To develop proposals for specific projects and activities, we undertake a comprehensive work-planning process. We engage our stakeholders to identify the issues of greatest priority and with the greatest potential impact on HHS programs or beneficiaries. In addition, we coordinate with and keep current with the work of other oversight entities. We also stay attuned to the latest developments and events affecting the Nation's health care, public health, and human services programs and beneficiaries. Work planning is an ongoing and dynamic process, and adjustments are made throughout the year to meet priorities and to anticipate and respond to emerging issues with the resources available. We assess relative risks in the programs for which we have oversight authority to identify the areas most in need of attention, and, accordingly, to set priorities for the sequence and proportion of resources to be allocated. In evaluating specific work plan proposals, we consider a number of factors, including the following: 1 OIG refers to its annual appropriation, made as part of the overall appropriation for HHS, as its \"discretionary appropriation.\" This is distinguished from the permanent appropriation for the Health Care Fraud and Abuse Control Program (HCFAC) contained in the Social Security Act, 1817(k), and other funds appropriated by Congress in other legislation for specified purposes. ______________________________________________________________________________ FY 2010 Office of Inspector General Work Plan ii A Message From the Office of Inspector General ______________________________________________________________________________ requirements for OIG reviews, as set forth in laws, regulations, or other directives; requests made or concerns raised by Congress, HHS's management, or the Office of Management and Budget (OMB); significant management and performance challenges facing HHS; work performed by partner organizations; management's actions to implement our recommendations from previous reviews; and timeliness. A Note About This Edition This edition of the OIG Work Plan, effective as of October 2009, describes ongoing and planned assignments, providing for each assignment the subject, scope of the review, and criteria related to the program being reviewed. It also provides review identification codes and the year in which we expect the report to be issued and indicates whether the work will be in progress at the start of the FY or will be a new start during the year. Typically, a review designated as \"work in progress\" will result in reports issued in FY 2010, but a review slated to begin in FY 2010 (\"new start\") could result in FY 2010 or FY 2011 reports, depending upon when the assignments are initiated during the year and the complexity and scope of the examinations. In this Work Plan, our ongoing and planned reviews are grouped into two major parts: \"Centers for Medicare & Medicaid Services\" (CMS) describes reviews related to Medicare, Medicaid, information systems controls, the Childrens Health Insurance Program, and related investigations and legal counsel to OIG. \"Public Health and Human Services Programs and Departmentwide Issues\" describes reviews related to agencies such as the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), the National Institutes of Health (NIH), the Administration on Aging (AoA), and the Administration for Children and Families (ACF). This part also describes departmentwide issues, such as financial accounting and information systems management. Our planned reviews related to the American Recovery and Reinvestment Act of 2009 (Recovery Act) are provided in Appendix A of this document. This edition and prior editions of the Work Plan are available on our Web site at http://oig.hhs.gov/publications.asp. If you have questions about this publication, please contact our Office of External Affairs at 202-619-1343. You may report potential instances of waste, fraud, or abuse related to HHS's programs to the OIG Hotline at 1-800-HHS-TIPS (1-800-447-8477) or HHSTips@oig.hhs.gov. ______________________________________________________________________________ FY 2010 Office of Inspector General Work Plan iii A Message From the Office of Inspector General ______________________________________________________________________________ Table of Contents Centers for Medicare & Medicaid Services 1 Medicare Program ......................................................................................................... 1 Medicare Part A and Part B .......................................................................................... 2 Hospitals................................................................................................................................................... 3 Part A Hospital Capital Payments........................................................................................................................3 Provider-Based Status for Inpatient and Outpatient Facilities .............................................................................3 Part A Inpatient Prospective Payment System Wage Indexes .............................................................................3 Hospital Payments for Nonphysician Outpatient Services Under the Inpatient Prospective Payment System....4 Payments to Organ Procurement Organizations ..................................................................................................4 Inpatient Rehabilitation Facility Submission of Patient Assessment Instruments ...............................................4 Critical Access Hospitals .....................................................................................................................................4 Medicare Disproportionate Share Payments ........................................................................................................5 Duplicate Graduate Medical Education Payments ...............................................................................................5 Interrupted Stays at Inpatient Psychiatric Facilities Payments.............................................................................5 Provider Bad Debts ..............................................................................................................................................5 Medicare Secondary Payer...................................................................................................................................6 Reliability of Hospital-Reported Quality Measure Data ......................................................................................6 Hospital Admissions With Conditions Coded Present-on-Admission .................................................................6 Hospital Readmissions .........................................................................................................................................6 Adverse Events: Various Reviews ......................................................................................................................7 Payments for Diagnostic X Rays in Hospital Emergency Departments...............................................................8 Oversight of Hospitals' Compliance With the Emergency Medical Treatment and Labor Act ...........................8 Observation Services During Outpatient Visits ...................................................................................................9 Coding and Documentation Changes Under the Medicare Severity Diagnosis Related Group System ..............9 Financial Status of Hospitals in the New Orleans Area .......................................................................................9 Home Health Agencies ............................................................................................................................ 9 Part B Payments for Home Health Beneficiaries .................................................................................................9 Home Health Agencies: Accurately Coding Claims for Medicare Home Health Resource Groups.................10 Medicare Home Health Payments for Insulin Injections ...................................................................................10 Home Health Agency Outlier Payments ............................................................................................................10 Home Health Prospective Payment System Controls ........................................................................................10 Home Health Agency Profitability.....................................................................................................................11 Medicare Home Health Payments for Diabetes Self-Management Training Services.......................................11 Oversight of Home Health Agency Outcome and Assessment Information Set Data .......................................11 Nursing Homes ...................................................................................................................................... 12 Part B Services in Nursing Homes: Mental Health Needs and Psychotherapy Services...................................12 Medicare Requirements for Quality of Care in Skilled Nursing Facilities ........................................................12 Accuracy of Skilled Nursing Facility Resource Utilization Groups Coding......................................................12 Nursing Home Emergency Preparedness and Evacuations During Selected Natural Disasters.........................12 Criminal Background Checks for Nursing Facility Employees .........................................................................13 Oversight of Poorly Performing Nursing Homes...............................................................................................13 Part B Services in Nursing Homes: Overview ..................................................................................................13 Nursing Home Residents Aged 65 or Older Who Received Antipsychotic Drugs ............................................13 Other Part A and Part B Providers Payments..................................................................................... 14 Physician Billing for Medicare Hospice Beneficiaries ......................................................................................14 Trends in Medicare Hospice Utilization ............................................................................................................14 Medicare Incentive Payments for E-Prescribing................................................................................................14 Place-of-Service Errors ......................................................................................................................................15 ______________________________________________________________________________ FY 2010 Office of Inspector General Work Plan v Table of Contents ______________________________________________________________________________ Ambulatory Surgical Center Payment System...................................................................................................15 Evaluation and Management Services During Global Surgery Periods.............................................................15 Medicare Payments for Part B Imaging Services...............................................................................................15 Services Performed by Clinical Social Workers ................................................................................................16 Outpatient Physical Therapy Services Provided by Independent Therapists .....................................................16 Appropriateness of Medicare Payments for Polysomnography .........................................................................16 Laboratory Test Unbundling by Clinical Laboratories ......................................................................................16 Medicare Billings With Modifier GY ................................................................................................................17 Geographic Areas With a High Density of Independent Diagnostic Testing Facilities ....................................17 Enrollment Standards for Independent Diagnostic Testing Facilities ................................................................17 Physician Reassignment of Benefits ..................................................................................................................17 Medicare Providers' Compliance With Assignment Rules................................................................................18 Payments for Services Ordered or Referred by Excluded Providers..................................................................18 Ambulance Services Used To Transport End-Stage Renal Disease Beneficiaries.............................................18 Medicare Payments for Transforaminal Epidural Injections..............................................................................19 Comprehensive Error Rate Testing Program: FY 2008 Transportation Claims Error Rate .............................19 Comprehensive Error Rate Testing Program: Fiscal Year 2008 Part A and Part B Error Rates .......................19 Medicare Services Billed With Dates of Service After Beneficiaries' Dates of Death......................................20 Durable Medical Equipment and Supplies .......................................................................................... 20 Physician Self-Referral for Durable Medical Equipment Services ....................................................................20 Medicare Payments for Various Categories of Durable Medical Equipment ....................................................20 Medicare Payments for Durable Medical Equipment Claims With Modifiers ..................................................21 Comprehensive Error Rate Testing Program: Durable Medical Equipment Corrective Actions ......................21 Appropriateness of Durable Medical Equipment Categorization.......................................................................21 Enteral Nutrition Therapy Services in Nursing Homes......................................................................................22 Medicare Pricing for Parenteral Nutrition..........................................................................................................22 Medicare Part B Payments for Home Blood-Glucose-Testing Supplies............................................................22 Medicare Payments for Power Wheelchairs ......................................................................................................22 Medicare Payments to Durable Medical Equipment Suppliers for Power Wheelchairs ....................................23 Repair and Servicing of Capped Rental Durable Medical Equipment ...............................................................23 Medicare Enrollment and Monitoring for Suppliers of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies and Home Health Agencies .................................................................................23 Part B Payments for Prescription Drugs ............................................................................................. 24 Comparing Average Sales Prices to Widely Available Market Prices...............................................................24 Comparing Average Sales Prices to Average Manufacturer Prices ...................................................................24 Oversight of Manufacturers' Average Sales Price Data Submissions................................................................24 Medicare Drug Payments Under the Hospital Outpatient Prospective Payment System...................................24 Medicare Payments for End-Stage Renal Disease Drugs...................................................................................25 Renal Dialysis Facilities' Dosing Guidelines for Erythropoiesis-Stimulating Agents.......................................25 Billing for Immunosuppressive Drugs ...............................................................................................................25 Payments for Off-Label Anticancer Pharmaceuticals and Biologicals ..............................................................26 Potentially Fraudulent Medicare Claims for Budesonide in South Florida........................................................26 Medicare Part A and Part B Contractor Operations ........................................................................... 26 Preaward Reviews of Contract Proposals ..........................................................................................................26 Contractors' Administrative Costs .....................................................................................................................26 Medicare Summary Notice ................................................................................................................................27 Quality Improvement Organizations' Beneficiary Complaint Process ..............................................................27 First Level of the Medicare Appeals Process.....................................................................................................27 Handling of Hotline Referrals ............................................................................................................................27 Medicare and Medicaid Data Match Project......................................................................................................27 Accuracy and Completeness of the National Provider Identifier .......................................................................28 Implementation of Payment Suspensions...........................................................................................................28 Collection of Medicare Overpayments Referred by Program Safeguard Contractors .......................................28 Recovery Audit Contractors' Referrals of Potential Fraud and Abuse ..............................................................29 Transition From Program Safeguard Contractors to Zone Program Integrity Contractors ................................29 Provider Education and Training: Medicare-Affiliated Contractors' Progressive Correction Action ..............29 ______________________________________________________________________________ FY 2010 Office of Inspector General Work Plan vi Table of Contents ______________________________________________________________________________ Contractors' Conflicts of Interest: Oversight and Monitoring by the Centers for Medicare & Medicaid Services......................................................................................................................................................29 Competitive Bidding Program: Supplier Influence on Physician Prescribing ..................................................30 Pension Segmentation ........................................................................................................................................30 Pension Costs Claimed.......................................................................................................................................30 Unfunded Pension Costs ....................................................................................................................................30 Pension Segment Closing...................................................................................................................................30 Postretirement Benefits and Supplemental Employee Retirement Plan Costs ...................................................31 Medicare Part C (Medicare Advantage) ..................................................................... 31 Enhanced Payments for Certain Beneficiary Types...........................................................................................31 Administrative Costs Included in Medicare Advantage Bid Submissions.........................................................31 Investment Income Earned by Medicare Advantage Plans ................................................................................32 Disenrollments From Medicare Advantage Plans..............................................................................................32 Managed Care Encounter Data ..........................................................................................................................32 Medicare Advantage Risk Adjustment Validation.............................................................................................33 Beneficiary Appeals in the Medicare Advantage Program ................................................................................33 Marketing of Medicare Advantage Plans by Sales Agents ................................................................................33 Medicare Advantage Plans' Oversight of Contractors.......................................................................................33 Health Care Organizations' Compliance With Standards on Culturally and Linguistically Appropriate Services in Medicare..................................................................................................................................34 Medicare Part D Prescription Drug Program ............................................................ 34 Duplicate Drug Claims for Hospice Beneficiaries .............................................................................................34 Duplicate Medicare Part A and Part B Claims Included With Part D Claims....................................................35 Medicare Part D Reconciliation Calculations ....................................................................................................35 Medicare Part D Data Submitted by Sponsors for Reconciliations....................................................................35 Medication Therapy Management Program.......................................................................................................36 Less-Than-Effective and Terminated Drugs in Part D.......................................................................................36 Aberrant Part D Claims......................................................................................................................................36 Medicare Prescription Drug Plans' Formulary Changes....................................................................................36 True Out-of-Pocket Costs for Part D..................................................................................................................37 Beneficiaries' Experiences With Low-Income Subsidies and Availability of Drug Benefits............................37 Bid Submission by Part D Sponsors ..................................................................................................................37 Administrative Costs Included in Bid Submissions ...........................................................................................38 Part D Sponsors' Audits of Pharmacies .............................................................................................................38 Disenrollment of Deceased Beneficiaries ..........................................................................................................38 E-Prescribing in Part D ......................................................................................................................................38 Oversight of Pharmacy Benefit Managers .........................................................................................................38 Oversight of Prescription Drug Event Data .......................................................................................................39 Part D Drug Claims With Inactive or Invalid Physician Identifier Numbers.....................................................39 Medicare Part D Payments for Drugs Prescribed or Provided by Excluded Providers ......................................39 Investment Income Earned by Part D Plans.......................................................................................................39 Part D Pharmaceutical Manufacturer Rebates....................................................................................................40 Alternative Calculation of Part D Rebates .........................................................................................................40 Drug Costs Paid by Part D Sponsors Under Retail Discount Generic Programs ...............................................40 Medicare Part D Program Audit Overview........................................................................................................40 Audits of Part D Sponsors' Financial Records...................................................................................................41 Medicare Part D Sponsors' Internal Controls for Fraud, Waste, and Abuse......................................................41 Medicare Part D Price Concessions ...................................................................................................................41 Medicaid Program ....................................................................................................... 42 Medicaid Hospitals ................................................................................................................................ 42 State Medicaid Agency Policies to Deny Payment for Hospital-Acquired Conditions......................................42 Hospital Outlier Payments .................................................................................................................................42 ______________________________________________________________________________ FY 2010 Office of Inspector General Work Plan vii Table of Contents ______________________________________________________________________________ Provider Eligibility for Medicaid Reimbursement .............................................................................................43 Medicaid Disproportionate Share Hospital Payment Distribution .....................................................................43 Supplemental Payments to Private Hospitals.....................................................................................................43 Potentially Excessive Medicaid Payments for Inpatient and Outpatient Services .............................................43 Medicaid Home, Community, and Nursing Home Care ..................................................................... 44 Community Residence Rehabilitation Services .................................................................................................44 Targeted Case Management...............................................................................................................................44 Medicaid Payments to Continuing Day Treatment Providers ............................................................................44 Medicaid Home Health Agency Claims.............................................................................................................45 Medicaid Payments for Personal Care Services.................................................................................................45 Compliance With States' Requirements for Medicaid-Funded Personal Care Service Attendants ...................45 Medicaid Payments for Medicare-Covered Home Health Services ...................................................................46 State and Federal Oversight of Home- and Community-Based Services in Assisted Living Facilities .............46 State and Federal Oversight of Home- and Community-Based Services...........................................................46 Medicaid Adult Day Health Service Payments for Ineligible and Absent Beneficiaries ...................................46 Oversight of Nursing Home Minimum Data Set Data .......................................................................................47 Transparency Within Nursing Facility Ownership.............................................................................................47 States' Administration and Use of Civil Monetary Penalty Funds in Medicaid Nursing Homes ......................47 Medicaid Nursing Home Patients: Quality of Care...........................................................................................47 Medicaid Incentive Payments for Nursing Facility Quality-of-Care Performance Measures ............................48 Medicaid Waiver Administrative Costs .............................................................................................................48 Medicaid Prescription Drugs ................................................................................................................ 48 Timely Submission of Average Manufacturer Price Data..................................................................................48 Calculation of Average Manufacturer Prices .....................................................................................................49 Recalculation of Base Date Average Manufacturer Prices ................................................................................49 States' Medicaid Drug Claims ...........................................................................................................................49 Federal Upper Payment Limit Drugs .................................................................................................................49 Pharmacy Prescription Drug Claims ..................................................................................................................50 Medicaid Payments for Drugs Not Approved for Use by Children ...................................................................50 Medicaid Third-Party Liability for Prescription Drug Payments.......................................................................50 Compound Drugs ...............................................................................................................................................50 Additional Rebates of Brand-Name Drugs ........................................................................................................51 Medicaid Reimbursement for Unapproved Drugs .............................................................................................51 The Deficit Reduction Act of 2005: Impact on Medicaid Rebates for Authorized Generic Drugs...................51 States' Accountability Over Medicaid Drug Rebate Programs..........................................................................52 Update of States' Collection of Medicaid Rebates for Physician-Administered Drugs.....................................52 Medicaid Claims for Drugs Purchased Under Retail Discount Generic Programs ............................................52 Review of Medicaid Reimbursement to 340B Entities ......................................................................................52 High-Cost HIV/AIDS Drugs..............................................................................................................................53 Pharmacy Benefit \"Carve Out\" ..........................................................................................................................53 Reporting Lowest Accepted Reimbursement Rates ...........................................................................................53 States' Use of the Average Manufacturer Price To Establish Medicaid Pharmacy Reimbursements................54 Zero-Dollar Unit Rebate Amounts for Drugs in Medicaid's Drug Rebate Program..........................................54 Other Medicaid Services ....................................................................................................................... 54 Medicaid Dental Services ..................................................................................................................................54 Family Planning Services...................................................................................................................................55 Medicaid Payments for Transportation Services................................................................................................55 Early and Periodic Screening, Diagnostic, and Treatment Services ..................................................................55 Payments to Terminated and/or Excluded Medicaid Providers and Suppliers...................................................55 Medicaid Claims With Inactive or Invalid Physician Identifier Numbers .........................................................55 Rehabilitative Services.......................................................................................................................................56 Medical Services for Undocumented Aliens......................................................................................................56 Medicaid Payments for Personal Emergency Response Services ......................................................................56 Medicaid Physical and Occupational Therapy Services: Appropriateness of Payments...................................56 Medicaid Administration ....................................................................................................................... 57 Contingency Fee Payment Arrangements ..........................................................................................................57 ______________________________________________________________________________ FY 2010 Office of Inspector General Work Plan viii Table of Contents ______________________________________________________________________________ Medicaid Payments for Services Under Section 1915(b) Managed Care Freedom of Choice Waivers.............57 Medicaid Managed Care Fraud and Abuse Safeguards .....................................................................................57 Medicaid Managed Care Marketing Practices ...................................................................................................57 Sections 1915(b) and (c) Concurrent Waivers ...................................................................................................58 Medicaid Payments for Services Provided Under Section 1915(c) Home- and Community-Based Service Waivers .........................................................................................................................................58 Enrollment of Excluded Medicaid Providers .....................................................................................................58 State Agencies' Redeterminations of Medicaid Eligibility ................................................................................58 Medicaid Administrative Costs..........................................................................................................................59 Medicare/Medicaid Credit Balances ..................................................................................................................59 Medicaid Management Information System Costs ............................................................................................59 State Buy-In of Medicare Coverage...................................................................................................................59 Medicaid Services to Incarcerated Juveniles......................................................................................................60 Medicaid's All-Inclusive Rate for Reimbursement to the Indian Health Service ..............................................60 States' Effort To Improve Third-Party Liability Payment Collections in Medicaid ..........................................60 States' Use of the Public Assistance Reporting Information System to Reduce Medicaid Benefits Received From More Than One State .......................................................................................................60 States' Compliance With Estate Recovery Provisions of the Social Security Act.............................................61 Medicaid Claims That Exceed Timely Filing Requirements .............................................................................61 State Medicaid Agencies' Reclassification of Non-Federal Claims...................................................................61 Feasibility of Applying Medicare National Correct Coding Initiative Edits to Medicaid Claims .....................62 States' Efforts in Medicaid Enrollment, Outreach, and Retention .....................................................................62 Medicare and Medicaid Information Systems and Data Security ........................... 62 Medicare Annual Reports to Congress on Contractor Information Systems Security Programs .......................62 Medicare Contractor Information Technology Closeout Audits ........................................................................62 Medicare Part D Selected Controls for Systems Tracking True Out-of-Pocket Costs .......................................63 Medicare Part D Implementation of Supporting Systems at Small- and Medium-Size Plans and Plans New to Medicare........................................................................................................................................63 Medicare and Medicaid Security of Portable Devices Containing Personal Health Information at Contractors and Hospitals..........................................................................................................................63 Medicare and Medicaid Health Information Data Privacy.................................................................................64 Medicaid Management Information Systems Business Associate Agreements.................................................64 Medicaid Security Controls Over State Web-Based Applications .....................................................................64 Medicaid Security Controls at the Mainframe Data Center That Processes States' Claims Data ......................64 Children's Health Insurance Program ....................................................................... 65 Medicaid and Children's Health Insurance Program Citizenship Requirements ...............................................65 Children's Health Insurance Program Administrative Costs .............................................................................65 Dually Enrolled Beneficiaries in a State ............................................................................................................66 Medicaid and Children's Health Insurance Program Payment Error Rate Measurement ..................................66 Compliance With Payment Error Rate Measurement Program: Medicaid and Children's Health Insurance Program Eligibility Determinations ..........................................................................................66 Investigative and Legal Activities Related to Centers for Medicare & Medicaid Services Programs and Operations........................................................................... 67 Health Care Fraud ..............................................................................................................................................67 Exclusions From Program Participation ............................................................................................................68 Provider Self-Disclosure ....................................................................................................................................69 Resolution of False Claims Act Cases and Negotiation of Corporate Integrity Agreements .............................69 Providers' Compliance With Corporate Integrity Agreements ..........................................................................69 Advisory Opinions, Fraud Alerts, and Other Industry Guidance .......................................................................70 Civil Monetary Penalties....................................................................................................................................70 ______________________________________________________________________________ FY 2010 Office of Inspector General Work Plan ix Table of Contents ______________________________________________________________________________ Public Health and Human Service Programs and Departmentwide Issues 71 Public Health Programs.............................................................................................. 71 Agency for Healthcare Research and Quality..................................................................................... 72 Bioterrorism Epidemic Outbreak Response Model............................................................................................72 Centers for Disease Control and Prevention ...................................................................................... 72 Monitoring of Subrecipient Emergency Preparedness Expenditures .................................................................72 States' 24/7 Reporting Systems .........................................................................................................................73 Fraud and Abuse Safeguards for the Vaccines for Children Program................................................................73 Community Health Centers Adoption of Recommendations for Human Immunodeficiency Virus Testing in Health Care Settings .................................................................................................................73 Grantees' Implementation of National Breast and Cervical Cancer Early Detection Program Management Guidance ..............................................................................................................................74 Deemed Exports.................................................................................................................................................74 Contracting Procedures ......................................................................................................................................74 Food and Drug Administration............................................................................................................. 74 Food Facility Inspections ...................................................................................................................................74 Oversight of State Food Facility Inspections .....................................................................................................75 Oversight of Food Safety Operations.................................................................................................................75 Complaint Investigation Process........................................................................................................................75 Foreign Clinical Trials .......................................................................................................................................75 The Food and Drug Administration's Oversight of Investigational New Drug Applications ............................76 Oversight of Blood Establishments....................................................................................................................76 Health Resources and Services Administration................................................................................. 76 Ryan White CARE Act Payer of Last Resort Provision ....................................................................................76 Oversight of the Ryan White Core Medical Services Requirement ...................................................................76 Oversight of Health Centers...............................................................................................................................77 Reporting Adverse Actions to the Healthcare Integrity and Protection Data Bank ...........................................77 Health Education Assistance Loan Program Defaulters ....................................................................................77 Indian Health Service............................................................................................................................. 78 Provision of Dialysis and Mental Health Services at Indian Health Services Facilities ....................................78 Accounting for Medication Inventory................................................................................................................78 Background Investigations To Protect Indian Children .....................................................................................78 Indian Health Service Loan and Repayment Programs......................................................................................78 Tribal Governments' Third-Party Collections in Emergency Medical Services Programs................................79 National Institutes of Health ................................................................................................................. 79 Superfund Financial Activities for Fiscal Year 2009 .........................................................................................79 National Institute of Environmental Health Science's Grant Process ................................................................79 Colleges' and Universities' Compliance With Cost Principles..........................................................................79 Use of Data and Safety Monitoring Boards in Clinical Trials ...........................................................................79 National Center for Research Resources' Oversight of Clinical and Translational Science Awards.................80 National Institute of Allergy and Infectious Diseases' Oversight of Project BioShield Grants .........................80 Financial Interests Held by Institutions Receiving National Institutes of Health Research Grants ...................81 Substance Abuse and Mental Health Services Administration ........................................................ 81 Substance Abuse Prevention and Treatment Block Grants ................................................................................81 Progress in Meeting Performance Goals for the Substance Abuse Treatment Block Grant Program................81 Cross-Cutting Public Health Activities ................................................................................................ 81 Oversight of Federal Advisory Committee Special Government Employee Conflicts of Interest.....................81 Use of Public Health Preparedness and Response for Bioterrorism Program Funds for Employee Compensation ............................................................................................................................................82 Pandemic Influenza Planning.............................................................................................................................82 Rollup of Departmental Laboratories' Implementation of Select Agent Regulations........................................82 Public Health Investigations................................................................................................................. 83 Violations of Select Agent Requirements ..........................................................................................................83 ______________________________________________________________________________ FY 2010 Office of Inspector General Work Plan x Table of Contents ______________________________________________________________________________ Public Health Legal Activities............................................................................................................... 83 Human Service Programs........................................................................................... 83 Administration on Aging ....................................................................................................................... 84 Aging Programs in One State.............................................................................................................................84 Performance Data for the Senior Medicare Patrol Projects................................................................................84 Administration for Children and Families ........................................................................................... 84 Foster Care and Adoption Assistance Training Costs and Administrative Costs...............................................84 Foster Care Per Diem Rates ...............................................................................................................................84 Costs Billed by Child-Placing Agencies ............................................................................................................85 Group Home and Foster Family Agency Rate Classification ............................................................................85 Adoption Assistance Subsidies ..........................................................................................................................85 Foster Care Claims for the Placement of Delinquent Children ..........................................................................85 Foster Care Preplacement/Candidacy Costs.......................................................................................................86 Foster Children Over 19 Years Old....................................................................................................................86 Oversight of System Design of Statewide Automated Child Welfare Information Systems .............................86 Foster Care Program Collection and Reporting of Child Support Payments .....................................................86 Services for Recently Arrived Refugees ............................................................................................................87 Licensing Standards and Health and Safety Monitoring at Child Care Facilities ..............................................87 Federal Employers' Payment Submissions to Child Support State Disbursement Units ...................................87 Undistributable Child Support Collections ........................................................................................................87 Interest Earned on Child Support Enforcement Funds.......................................................................................88 Increasing Child Support Collections ................................................................................................................88 Characteristics of Child Support Arrears ...........................................................................................................88 Investigations Under the Child Support Enforcement Task Force Model .........................................................89 Departmentwide Issues .............................................................................................. 89 Financial Statement Audits................................................................................................................... 89 Audits of Fiscal Years 2009 and 2010 Financial Statements .............................................................................89 Fiscal Year 2010 Statement on Auditing Standards Examinations ....................................................................90 Fiscal Years 2009 and 2010 Financial-Related Reviews ...................................................................................90 Other Financial Accounting Reviews .................................................................................................. 91 The President's Emergency Plan for AIDS Relief Funds ..................................................................................91 Public Welfare Cost Allocation Plan .................................................................................................................91 Annual Accounting of Drug Control Funds .......................................................................................................91 Use of Appropriated Funds in Program Support Center Contracting ................................................................92 Contracting Procedures ......................................................................................................................................92 Non-Federal Audits............................................................................................................................................92 Reimbursable Audits..........................................................................................................................................92 Requested Audit Services ..................................................................................................................................93 Automated Information Systems ......................................................................................................... 93 Information System Security Audits ..................................................................................................................93 Federal Information Security Management Act of 2002 and Critical Infrastructure Protection .......................93 Information Technology Systems' General Controls.........................................................................................94 Other Departmental Issues ................................................................................................................... 94 Use of Discounted Airfares by Employees ........................................................................................................94 State Protections for Persons With Disabilities in Residential Settings .............................................................94 Classifications of Federal Pass-Through Funding Recipients............................................................................94 Appendix A: Recovery Act Work Plan 95 Centers for Medicare & Medicaid Services ............................................................... 95 Medicare Part A and Part B................................................................................................................... 95 Breach Notification and Medical Identity Theft in Medicare ............................................................................95 ______________________________________________________________________________ FY 2010 Office of Inspector General Work Plan xi Table of Contents ______________________________________________________________________________ Medicare Incentive Payments for Electronic Health Records............................................................................95 Medicaid Program ....................................................................................................... 96 Medicaid Hospitals ................................................................................................................................ 96 Medicaid Disproportionate Share Hospital Payments........................................................................................96 Medicaid Administration ....................................................................................................................... 96 Medicaid Incentive Payments for Electronic Health Records............................................................................96 Temporary Increases in Federal Medical Assistance Percentages .....................................................................96 States' Compliance With Requirements for Claiming Increased Federal Medical Assistance Percentages ......97 States' Use of Increased Recovery Act Funding................................................................................................97 State Controls Over Increased Federal Medical Assistance Percentages...........................................................97 State Medicaid Program Integrity Efforts ..........................................................................................................97 Reconciliation of Expenditure Reports to Claim Data .......................................................................................97 Medicaid High-Risk Providers...........................................................................................................................98 Transitional Medical Assistance Programs ........................................................................................................98 Medicaid Qualified Individual Programs ...........................................................................................................98 Medicare and Medicaid Information Systems and Data Security ..................................................... 98 Early Assessment of CMS Oversight of Recovery Act Incentives for Electronic Health Records....................98 Health Information Technology System Enhancements ....................................................................................99 Contractor System Enhancements......................................................................................................................99 Public Health Programs