Using the CIGIE Quality Standards for Inspection and Evaluation
It is important for every industry to have a framework of quality standards by which to measure performance and to establish credibility. Most people have heard of the Yellow Book, or The Generally Accepted Government Auditing Standards, that is used by audit organizati...
Veterans Affairs Health Care Added to GAO High Risk List
In 2015, the Veterans Affairs (VA) Health Care achieved a distinction held by two other large Federal health care programs – Medicare and Medicaid – that of being designated a Government Accountability Office (GAO) high risk program. VA Health Care was added to the GAO High R...
OIG Work Plan for 2016 Highlights New Program Evaluations and Oversight
The HHS OIG released its Work Plan for FY 2016 on November 2nd. The Work Plan outlines audits, evaluations, and other activities OIG is conducting or plans to conduct in the coming fiscal year. Much of the planned work for FY 2016 focuses on cut and dry payment reviews with t...
How Effective are Criminal Background Checks Really?
A U.S. Department of Health and Human Services Office of Inspector General (OIG) report from October, 2012 offers some interesting insights into the usefulness of criminal background checks for nurse aides. To get to these insights, some setup is needed.
Nurse aides work in ...
Medicaid Health Homes Program Operation
Section 2703 of the Affordable Care Act created an optional Medicaid State Plan benefit – Health Homes – to coordinate care for individuals who have Medicaid and have:
2 or more chronic conditions;
1 chronic condition and are at risk for a second; or
1 serious and pers...
Healthcare Secret Shopping: An Effective Tool for Detecting Fraud and Abuse
The Government Accountability Office (GAO) made headlines recently when sharing news that 11 of 12 fictitious applicants obtained coverage for health insurance through the Federal marketplace. GAO targeted the Federal marketplace with secret shopping – constructing fictitious...
Medicaid Encounter Data Problems Continue
In May 2009, the U.S. Department of Health and Human Services Office of Inspector General (OIG) released a report regarding Medicaid managed care encounter data. The OIG found all 40 States with capitated managed care reported collecting encounter data from their managed car...
Ambulance Billing Fraud and False Claims
Medicare ambulance claims, just like everything involved with Medicare, must meet certain requirements to be considered valid ambulance transport claims. The main factor is the transport must be considered “medically necessary” under Federal Law. To do this, two specific crit...
No Wrong Door LTSS Program Evaluations and Planning
The No Wrong Door (NWD) system is intended to streamline access to long-term services and support (LTSS) options for older adults and individuals living with disabilities. NWD grants are collectively overseen by the Administration for Community Living, the Centers for Medicar...
Inappropriate Medicare Payments for Chiropractic Services More Common than Other Services
In May 2015, the U.S. Department of Health and Human Services Office of Inspector General (OIG) issued a report finding all claims for the provider under review failed to support medical necessity. OIG concluded virtually all payments the provider received were unallowable.
W...
