The Office of Inspector General (OIG) for the U.S. Department of Health & Human Services (HHS) recently released its annual publication identifying the top management and performance challenges facing HHS.  In the 2018 edition, OIG’s top challenges include ensuring program integrity and effective administration of Medicare and Medicaid.  Per OIG, the top twelve management and performance challenges facing HHS are:

1. Preventing and treating opioid abuse;
2. Ensuring program integrity in Medicare Fee-for-Service and effective administration of Medicare;
3. Ensuring program integrity and effective administration of Medicaid;
4. Ensuring value and integrity in managed care and other innovative healthcare payment and service delivery models;
5. Protecting the health and safety of vulnerable populations;
6. Improving financial and administrative management and reducing improper payments;
7. Protecting the integrity of HHS grants;
8. Ensuring the safety of food, drugs, and medical devices;
9. Ensuring quality and integrity in programs serving American Indian/Alaska Native populations;
10. Protecting HHS data, systems, and beneficiaries from cybersecurity threats;
11. Ensuring that HHS prescription drug programs work as intended; and
12. Ensuring effective preparation and response to public health emergencies.

Regarding the challenges HHS faces relating to Medicare program integrity, OIG noted that the key components of the challenge are:  (1) reducing improper payments to providers; (2) combating fraud; (3) fostering prudent payment policies; and (4) maximizing the promise of health information technology.  With respect to reducing improper payments, OIG noted that it has identified especially high rates of improper payments for home healthcare, hospice care, durable medical equipment, chiropractic services, care in skilled nursing facilities, and certain hospital services.  OIG recommends that CMS strengthen oversight for billing in these areas.  With respect to combating fraud, OIG stated that CMS should fully employ program integrity tools to prevent payment to fraudulent providers and improve its use of the performance results within the Fraud Prevention System, which runs predictive algorithms and other analytics to identify potentially fraudulent claims. 

OIG also identified Medicaid program integrity as a top management and performance challenge.  The key components of this challenge, according to OIG, are:  (1) improving the reliability of national Medicaid data; (2) reducing improper payments; (3) combating fraud; and (4) ensuring appropriate Medicaid eligibility determinations.  With respect to national Medicaid data, OIG noted the numerous issues with the incompleteness and lack of reliability of Medicaid data, which, according to OIG, hampers the ability to identify potential fraud, waste, or quality concerns.   OIG noted that CMS should make timely data management and uniform reporting a priority.  With respect to reducing improper payments, OIG recommends that CMS continue to engage with state Medicaid agencies to develop corrective action plans and address state-specific reasons for improper payments.  Regarding the challenges facing HHS relating to combating potential fraud and ensuring appropriate Medicaid eligibility determinations, the overall theme from OIG is that CMS should work directly with the states to implement state-specific tools to address these challenges.

OIG’s summary of the components of each of these twelve challenges, HHS’s progress in addressing each challenge, and recommended next steps for each challenge are set forth in detail in the 2018 Top Management and Performance Challenges publication, available here.