Insurance Marketplace Tops The List Of The OIG's Annual Summary Of Challenges

By Christine Kern, contributing writer

The Office Of Inspector General study identifies the top vulnerabilities and obstacles for HHS.

The Department of Health and Human Services’ Office of Inspector General has published its annual summary of the most pressing management and performance challenges facing HHS. The 2014 Top Management and Performance Challenges lists ten issues reflecting continuing vulnerabilities that OIG has identified for HHS over recent years as well as new and emerging issues that HHS will face in the coming year.

OIG outlines each challenge by category and examines any progress and recommendations for the future. “These challenges reflect continuing vulnerabilities that OIG has identified for HHS over recent years as well as new and emerging issues that HHS will face in the coming year,” according to auditors.

The top challenge facing HHS is the implementation, operation, and oversight of health insurance marketplaces, which auditors also predict will continue to present a top management and performance challenge in FY 2015.

“In 2015, CMS and the Health Insurance Marketplaces face new and ongoing challenges including, for example, ensuring accurate eligibility determinations; processing enrollments, re-enrollments, and qualifying life change events; and communicating timely and accurate information to health insurance issuers and consumers,” argues OIG.

OIG also asserts the “effective coordination with, and timely provision of accurate data to, the Internal Revenue Service will be particularly important for sound administration of the premium tax credit program.” In addition, auditors make the case that CMS will “need to be attentive to state Marketplace operations to ensure state compliance with requirements, including transmitting accurate and timely data used for federal payments.”

Below are the report’s top ten concerns:

• Implementing, Operating, and Overseeing the Health Insurance Marketplaces
• Ensuring Appropriate Use of Prescription Drugs in Medicare and Medicaid
• Protecting an Expanding Medicaid Program From Fraud, Waste, and Abuse
• Fighting Waste and Fraud and Promoting Value in Medicare Parts A and B
• Ensuring Quality in Nursing Home, Hospice, and Home- and Community-Based Care
• The Meaningful and Secure Exchange and Use of Electronic Health Information
• Effectively Operating Public Health and Human Services Programs To Best Serve Program Beneficiaries
• 8: Ensuring Effective Financial and Administrative Management
• Ensuring Effective Financial and Administrative Management
• Protecting HHS Grants and Contract Funds From Fraud, Waste, and Abuse
• Ensuring the Safety of Food, Drugs, and Medical Devices

Of particular interest to many in the healthcare industry is the emphasis on Meaningful Use and the transition to EHRs. Under the HITECH Act, eligible providers and hospitals were granted incentive payments for adopting, implementing, upgrading, or demonstrating Meaningful Use of EHRs. The report concludes that, as HHS moves to link payments with quality of care, outcomes, or performance as part of the reforms in healthcare, “it will need to ensure that EHR and other health information data are accurate and reliable and are protected from misuse.”

While the report obviously focuses on increasing efficiency and reducing waste, it also paid particular attention to the prevention of fraud. The OIG stated, “Waste in health care programs is a multi-dimensional problem. Key areas of focus for reducing waste in Medicare Parts A and B include reducing improper payments, fighting fraud, fostering economical payment policies, and transitioning from volume to value in health care.”

Meanwhile, OIG wrote, “Fraud schemes shift over time, but certain Medicare services have been consistent targets, “ and OIG continues to “uncover fraud schemes and questionable billing patterns by durable medical equipment (DME) suppliers, home health agencies, community mental health centers, clinical laboratories, ambulance transportation suppliers, and outpatient therapy providers.”