New OIG Audits Coming

The Office of the Inspector General (OIG) of the U.S. Department of Health & Human Services (HHS) just released summary data for 2015. It was a busy year. There were 4,112 exclusions, 925 criminal actions, and 682 civil actions for matters such as false claims and civil monetary penalties.

Of particular interest to healthcare providers is the growth in the number of exclusions. RACmonitor took a look back at the historical record. Between 1977 to around 1982, there were only a handful of exclusions. But they have grown rapidly since. By 1991, OIG was excluding 1,000 providers per year. By 2001, that number had risen to around 2,800 per year. By the end of 2015, the OIG was running at an exclusion rate of around 3,800 per year, a little more than 15 providers per day.

One would assume that eventually this growth in exclusions will taper off, but for the time being, there seems to be nothing standing in the way of the trend continuing.

The OIG currently is branching out in several new directions. One important new effort is aimed at combating the growing heroin and prescription opioid crisis sweeping across the United States. Data from the Centers for Disease Control and Prevention (CDC) indicates that fatal overdoses from heroin have risen by more than 325 percent, and the addiction rate now is more than 2 per 1,000 persons. That adds up to 640,000 addicts across the country for heroin alone. There also is a severe problem with prescription opioids. From 1999 to 2010, they caused more than five times the number of deaths than cocaine and heroin overdoses combined. More than 82 percent of prescription opioid overdose deaths were unintentional. As a result, HHS has declared that prescription opioid overdose deaths constitute an epidemic.

To crack down on the overuse of opioid prescriptions, the OIG is joining a coalition including the FBI, DEA, and various state agencies. A pilot project is being launched in Massachusetts. The focus is going to be on prescriptions for hydrocodone, oxycodone, morphine, and codeine. The OIG already has prosecuted a number of cases in which providers take cash and blindly write prescriptions. It is going to increase audits in this area.

Although originally tasked with combating fraud and abuse in federal healthcare programs, we now will see the OIG assisting more actively in criminal prosecutions and coordinating more closely with state authorities. In other words, inspection and auditing powers are being used for social engineering. That’s a new role for the OIG.

The OIG also is sharpening its focus in other areas.

For example, in response to chronic problems in long-term care, the agency is pushing to set up a system of national background checks for all facility employees. This is based on section 6201 of the Patient Protection and Affordable Care Act. Long-term care facilities and providers in participating states must conduct state and national background checks on prospective employees, including a check of state abuse and neglect registries, state criminal history records, and national fingerprint-based criminal history records. For the time being, interested states can apply for participation and get matching federal funds for the work. The long-term goal is to have a nationwide program put into place.

Based on Section 502 of the Medicare Access and CHIP (Child Health Insurance Program) Reauthorization Act (MACRA) of 2015, the OIG has been directed “to establish procedures to ensure that Medicare payments are not furnished to … individuals not lawfully present in the United States.” It is foreseeable that providers eventually may be required to verify the immigration or nationality status of some individuals. It is unclear how this is going to be implemented, as are the penalties that will be assessed if the provider makes a mistake. What will happen in so-called sanctuary cities?  This part of the Act also applies to incarcerated or deceased individuals. Since every law has its genesis in the real world, we can assume that there is a major problem of Medicare payments being made to dead people.

The OIG also is planning on getting much more involved in how states finance and run their healthcare programs. Many states finance some of their Medicaid spending by imposing taxes on healthcare providers. But there are federal rules (42 CFR §§ 433.55 & 433.68) that control the extent of state power in this area, and the rules must be followed for a state to continue taking advantage of medical assistance programs. These taxes must be broad-based and uniformly imposed. Another federal-state issue is how to run state Medicaid fraud control units. OIG is auditing these state units for compliance with federal regulations and policy. So this means that the OIG is auditing the states themselves and enforcing compliance with federal law. Look for some fireworks in these areas.

On another front, OIG’s Office of the National Coordinator for Health Information Technology will be taking a crack at the problem of inter-operability of health-related information systems. Auditing is focusing on whether provider information systems meet the standards for electronic health records. So apart from a provider getting its claims audited, now the specific format of computer-stored meta data concerning claims will be a new target.

My guess is that much of this auditing work eventually will be done by artificial intelligence that endlessly searches for problems throughout your information systems.

This post originally appeared in RACmonitor on February 15, 2016

Suicide, Starvation Drugs Alcohol

This blog is a written by Herbert O’Yardley.  We present it here because it is interesting reading, but it contains controversial views on the healthcare situation in the United States.

By Herbert O. Yardley, Guest contributor.

INTRODUCTION

I always like to start my commentaries with a warning. It’s always the same thing…..”I would NOT read this if I were You”. And there’s always the same Good reason (or so I like to tell myself). I’m usually Right; or at least Right enough to leave you with that sinking feeling somewhere inside. And, after writing all sorts of things over 3-4 decades, I have developed a style which is beguiling and (potentially) entertaining, but unfortunately plants the seeds that tend to sprout over time to the “discomfiture” of the reader. (As in waking up in the middle of the night in a cold sweat with heart palpitations.) (But I’m sure we’re all used to that by now…..) So, don’t blame Roche for anything in here. In fact. he may be the answer to your problem. (At least if you’re a doctor being hounded by the Feds for doing whatever you do.)

Let’s just say it up front……It sucks getting Old. We’re all going to Die. No arguments, doubts or prayers are going to change that. This leads to 2 major conclusions: (unfortunately, my B.S. is in Math, so I tend to think that way….) 1) You better do whatever it is you want to do RIGHT NOW……because there is no Tomorrow; and 2) If you have any desire, idea or opportunity to make things better, YOU BETTER GET MOVING….because there is no Tomorrow (unless you consider being a vegetable on life-support, sucking the financial lifeblood out of your insurance company or government as an acceptable alternative)…..( which I guess most people do).

And that explains (to a limited extent) the title of this piece. Oh Yeah. Did I mention that I’m over 60, have no Health Insurance, and haven’t been to a Doctor in over 40 years? So clearly, “Healthcare” is not a big priority – at least not in the common sense of the word. I’m dead already.

THE “ECONOMICS” OF HEALTH CARE

It all started a very long time age, but I only have detailed knowledge from maybe the Late Middle Ages when the nascent Global Economy began to take shape. Of course in our time there is always the (in-) famous calculation by a respected global institution which concluded that since the “Potential Economic Life-Value” (and that is my term) of a person in the Third World is significantly less than that of one in the First or Second, it makes (“Economic”) sense to dump nuclear and other industrial wastes and perform possibly life-threatening activities in those less developed regions. Although this is just the “MBA mentality” run a muck, look around…..so is everything. (Thank you Ivy League.) Once you start putting a numerical value on human life, those who produce more or have a greater “economic potential” are necessarily more valuable to Society and should be given better treatment to extend their lives as long as possible – provided of course they remain productive. The major problem with this logic is that it is extremely difficult to judge the true (economic or other) value of an individual, particularly in the early stages of life.

As repugnant as this approach may be, it does have a certain steeled, Malthusian logic which most people can understand even as they reject it. What is not so easy to understand, is the current numeric calculus – performed by Doctors and the Healthcare Industry – which matches treatment options to the potential paying power of the patient or his Insurance Company. This sentence goes a long way toward explaining why the Government declined to provide Americans with Universal Healthcare or Insurance, since publicly financed Healthcare would allow doctors and hospitals to spend virtually unlimited funds keeping people alive.But the reality is clear; Healthcare, like almost everything else, is a limited resources, and as such some means must be developed to “ration” it. The system simply cannot provide everyone with unlimited access to the latest, most expensive treatments or drugs (at least not given its present structure), and as a result some individuals – perhaps even the majority – will always be under-served.

But it’s too late to turn back now. The geniuses at Harvard and similar institutions have decided that Healthcare is the “Economic Engine” of the future. And Why not? America (and the rest of the First World) is getting older. We’ve abused or bodies with (over-) work – and play, drugs and alcohol and hyper-competition, and destroyed our minds with CNBC, Fox News and (more than likely) Internet Porn. Every day 3750 Baby Boomers turn 65 – or whatever the real number is. Tell me this is not a “No-Brainer” for the Industry of Tomorrow? And, with good Healthcare, we should all live to be 100, requiring even more Healthcare, Medical Insurance and (untested and unreliable) Pharmaceuticals. Suicide is looking better and better.

TOO OLD TO ROCK N’ ROLL

The title of this piece refers to the options available to those “economically un-viable”, often elderly individuals who no longer contribute to Society – at least in monetary terms. The formula was perfected during the “Velvet” Revolutions which followed the disintegration of the Soviet Union and the fall of the Berlin Wall in the late 1980s. An interesting phenomenon – unparalleled in Modern History – accompanied these event.  Life expectancies began to decline – and decline rapidly – in the effected areas as Global (Radical) Capitalism replaced “outdated” Communist/Socialist Economic and Social institutions and values. The reason of course was that older individuals – often retired and on a fixed pension – and those unable to generate income in new – often highly inflated – monetary units were literally forced into starvation and death. (At least younger females could always become Prostitutes or Mail-Order Brides.)

In addition to mounting economic pressures, the psychological effects of the overnight change in Social and Economic values took a heavy toll on those who spent their lives believing (or at least pretending to believe) in the former structures. At least the good news is that the 3 options form a “virtuous cycle” whereby spending the majority of your meager pension on alcohol leaves that much less for food which ultimately leads to starvation and death. Either way, you are no longer a burden to Society. And for those of you who think it can’t happen here, Think again.

17 DAYS TO LIVE

A few years ago, my sister and I began to notice that people we knew – or friends of friends – were being told by their doctors that there was nothing they could do for them and they had (basically) 17 days to live. After a little thought we realized that this would give them just enough time to find a lawyer, draft a will and settle their affairs. We know between 10-12 individuals of all ages that have received this diagnosis, with diseases ranging from various forms of cancer to advanced liver failure. The interesting thing about these people is that many of them seemed in reasonable health before going to the doctor. Our favorite story involves a young woman (late teens) who was told she had advanced ovarian cancer and that there was nothing they could do, giving her about a month to live. She told them she didn’t believe it, that they were wrong and went about her business. She lived almost two more decades, had children and a full life. Another friend of mine was told he had pancreatic cancer and could die any day. They wouldn’t even admit him into the hospital, and sent him straight to Hospice. He went home and started drinking. A year later he finally succumbed, but it had as much to do with a fall he took while drunk which displaced his hip, making him unable to walk as anything else. I could go on, but the point is this: Life is fragile. Spend your time wisely. Oh Yea. And never go to the doctor.

CONCLUSIONS

I don’t know what Life is about; and I’m not happy about that. But I do know this. Living in constant mental, physical, or emotional pain and suffering is not the answer. I suppose we all have to die, so the point is NOT expending resources postponing the inevitable, but making the time leading up to the Final Curtain rich and fulfilling. This is where Healthcare (and Alternative Approaches) can truly add to the quality of life (and Economic Value for you MBA-types) of Individuals and Society. But also where only a fraction of most Healthcare dollars are spent (at least according to every study commonly sited by the Media). And as the Republicans like to point out, there is also Personal Responsibility – at least for those who have limited Economic Potential and few resources and alternatives. On the other hand, a former Master of the Universe gets a mechanical heart that according to the media doesn’t beat and can run for decades. So go figure.

What can I say. Life sucks. It’s a bad ride on a downhill slope that cost too much and has few rewards. So as one with limited Economic Value I am well on the way to implementing the preferred strategy. Cheap Beer and (Fukashima-tainted) Cat Food, a damn good start. DNR.