OIG Additions to February 2023 Work Plan

Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare

In-Depth Review of Nursing Home Citations Related to the Use of Antipsychotic Drugs

The potentially inappropriate use of antipsychotic drugs among nursing home residents remains concerning despite efforts to decrease their use over the last decade. Antipsychotic drugs were developed to treat schizophrenia—a serious mental disorder that is generally diagnosed before the age of 30. These powerful drugs are known to have severe side effects, particularly among elderly individuals with dementia. In 2008, the Food and Drug Administration issued a boxed warning against the use of all antipsychotic drugs among elderly individuals with dementia because of the increased risk of death. OIG has raised concerns about the high use of antipsychotic drugs among nursing home residents. In response, CMS took steps to discourage the use of these drugs by, for example, developing publicly reported quality measures related to the use of antipsychotic drugs among nursing home residents. More recently, OIG has raised concerns about the potential falsification of schizophrenia diagnoses to make the use of antipsychotic drugs appear appropriate and avoid Federal attention. We will conduct an in-depth review of survey reports to: (1) examine the nature of nursing home citations related to the use of antipsychotic drugs and (2) identify vulnerabilities that contribute to the inappropriate use of these drugs.

Securing Medicaid and Medicare Payments to Providers

Federal and State Governments reimburse health care providers and facilities electronically for providing health care services. Sometimes a provider or facility may change financial institutions to receive payment by using an electronic funds transfer (EFT) authorization request. However, since at least 2020 OIG has investigated schemes that have allegedly exploited vulnerabilities in EFT authorization forms to redirect provider reimbursements to their own bank accounts. Many State Medicaid agencies and Medicare Administrative Contractors (MACs) have been victims of this type of fraud over the past 3 years. We will collect information from States and MACs about EFT vulnerabilities and assess the feasibility of possible solutions to strengthen EFT fraud prevention efforts. In addition, we will collect information about any actions taken by CMS to address EFT fraud and assess the feasibility of CMS systems playing a role in fraud prevention efforts.