The Semiannual Report to Congress covers findings, recommendations and activities for the six month period from March 31 to September 30.The highlights of the Semiannual Report note that "for FY 2011, we reported expected recoveries of about $5.2 billion consisting of $627.8 million in audit receivables and $4.6 billion in investigative receivables.” The report outlines the OIG's role in recovery of stolen and misspent funds as well as outreach and training of providers to help them understand rules, statutes and regulations. It also emphasizes the importance of the OIG's continues work to reduce improper payment.

The Centers for Medicare & Medicaid Services’ (CMS) Office of E-Health Standards and Services (OESS) issued a statement on Nov. 17 clarifying their intentions with respect to enforcing compliance with Version 5010. The term Version 5010 refers to the new standards for electronic administrative transactions performed by HIPAA covered entities, such as claims submissions and receipt of remittance advice. The compliance date for use of the new standards continues to be January 1, 2012, as previously announced. However, the OESS indicates in the Nov. 17 statement that they will not initiate enforcement actions against non-compliant entities until March 31, 2012.

Effective Oct. 1, 2013, all Health Insurance Portability and Accountability Act (HIPAA) covered entities will be required to transition to the ICD-10 code sets. To help providers prepare for this transition, the Centers for Medicare & Medicaid Services (CMS) has developed a number of informational handbooks. The handbooks, which are specific to the type and size of the provider’s practice, include relevant timelines and templates to assist in the transition. 

In a Nov. 4 message, the Centers for Medicare & Medicaid Services (CMS) announced that it will extend the provider enrollment revalidation process for another 2 years. As a result, revalidation notices will be sent through Mar. 2015 (previously Mar. 2013). The provider enrollment revalidation process is required for all providers who enrolled prior to Mar. 25, 2011. Despite the extension of the overall revalidation timeline, providers who have been sent revalidation letters must respond to the request. Revalidation request letters will continue be sent to providers by their Medicare Administrative Contractors (MACs) between now and Mar. 2015. Providers must wait to complete the revalidation process until they receive a request letter from their MAC.

In a recent newsletter, National Government Services (NGS) reported on a recent prepayment medical review of claims for continuous positive airway pressure (CPAP) devices. NGS, the Durable Medical Equipment Medicare Administrative Contractor for Jurisdiction B, reported that the results of the review of 100 claims indicate a claims error rate of 81 percent. NGS reports that following a review of their findings, their Medical Review department will continue prepayment review of claims for CPAP. NGS encourages providers to review their local coverage determination (LCD) for Positive Airway Pressure (PAP) Devices for Treatment of Obstructive Sleep Apnea.

On Nov. 1 the Centers for Medicare & Medicaid Services (CMS) issued a final rule for services paid under the Medicare Physician Fee Schedule (MPFS) for the 2012 calendar year. Comments to the final rule are being accepted by CMS through Jan. 3, 2012.

The system, which was mandated in the Small Business Jobs Act of 2010 (SBJA), is designed to detect and flag potentially fraudulent claims in real time. Claims are streamed through the predictive modeling technology as they are submitted. Based on the data in the claims, the system builds profiles of providers, networks, billing patterns and beneficiary utilization. Based on these profiles, CMS can create estimates of fraud and flag potentially fraudulent claims. Though the predictive modeling system is designed to identify potential fraud, claims are not being denied exclusively based on alerts generated by the system at this time.

On Oct 5 the Department of Health & Human Services (HHS) Office of Inspector General (OIG) announced the publication of the Fiscal Year 2012 HHS OIG Work Plan. The work plan, which can be downloaded for review in its entirety on the OIG website, outlines the items to be addressed by the OIG in the next fiscal year. The 2011 OIG Work Plan highlighted a number of sleep-related projects for the OIG and sleep continues to be an important topic in the 2012 Work Plan.