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3 watchdog agency findings on PPACA implementation

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A federal health program watchdog agency — the Office of Inspector General at the U.S. Department of Health and Human Services (HHS OIG) — has given Congress a report on its own work.

HHS OIG inspectors are supposed to help Congress keep tabs on about $800 billion in annual federal spending, including Medicare, Medicaid, the new Patient Protection and Affordable Care Act (PPACA) exchange program, and other programs created by PPACA.

Daniel Levinson, the HHS OIG inspector general, says in a message at the front of the report that his agency produced about $440 million in investigative receivables for the period covered by the report.

His staff used the report to summarize PPACA implementation reports published earlier in the year, such as a report about the PPACA public exchanges’ difficulties with resolving PPACA exchange application inconsistencies.

See also: Watchdogs found ‘critical vulnerabilities’ at

But his staff also talks about matters that could affect future HHS OIG investigations.

For a look at some of the items in the report that relate to future investigations, read on.


1. HHS OIG is still working on PPACA implementation review projects related to a wide variety of PPACA programs

Officials say that, in addition to looking for risks and vulnerabilities in the PPACA public exchange program, they are looking at the PPACA Medicaid expansion program, use of state exchange establishment grants, and the use of PPACA loans to start the new nonprofit, member-owned Consumer Operated and Oriented Plan (CO-OP) carriers.


2. HHS OIG thinks HHS needs to update estimates of how much it could save by updating the way it calculates Medicare Advantage plan payments

Section 3201 of PPACA calls for the government to change the way Medicare program managers calculate the payments they make to the insurers that run the Medicare Advantage plans.

The Congressional Budget Office (CBO) estimated in 2010 that the change could save about $13.1 billion in fiscal year 2014.

Since then, HHS has made major changes in how it implements the provision, but neither the CBO nor HHS has come up with a new estimate of how much money PPACA Section 3201 changes in the Medicare Advantage plan payment level will or won’t save, officials say.

Someone in the corner in a dunce cap

3. PPACA gave HHS OIG new tools it can use to punish wrongdoers

HHS OIG created an appendix summarizing the statutory provisions authorizing it to impose sanctions.

Officials note that PPACA lets it exclude individuals or entities from participating in federal health care programs if they are found to have been “knowingly making, or causing to be made, any false statements or omissions in any application, bid, or contract to participate as a provider in a federal health care program, including managed care programs under Medicare and Medicaid, as well as Medicare’s prescription drug program.”

In a section on civil monetary penalties (CMPs), or fines, officials say PPACA added more grounds for imposing the penalties, including “knowingly making, or causing to be made, any false statements or omissions in any application, bid, or contract to participate as a provider in a federal health care program [including Medicare and Medicaid managed care programs and Medicare Part D].”

PPACA “authorizes a penalty of up to $50,000 for each such false statement,” officials say.

PPACA “also authorizes the imposition of CMPs for activities relating to fraudulent marketing by managed care organizations, their employees, or their agents,” officials say.

See also: What if you lie to a PPACA exchange?