HHS-OIG

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    The Prior Authorization Desk Needs Prior Authorization

    ByHugh Jass

    I have reviewed the federal audit, and the document coughed before I did: Health Share of Oregon’s prior-authorization denial process was not consistently meeting the rules that make those denials lawful, timely, understandable, and properly reviewed. The HHS Office of Inspector General examined 100 Medicaid denials and found that 21 failed to comply with at least one federal or state requirement. This is the bureaucratic equivalent of a courthouse discovering its front door requires a permit.

    The failures were not confined to one ceremonial checkbox. OIG identified problems involving the expertise used to make decisions, the content of denial notices, the timing of those notices, language access, and communication with providers. In other words, the system responsible for explaining why care was denied sometimes struggled with the basic administrative duties required to explain a denial. Exhibit A had a pulse, and it was asking where Exhibit B went.

    OIG estimated that the findings could represent 5,677 noncompliant denials during calendar year 2023. That estimate does not mean every denial was improper, and the audit does not decide whether particular treatments were medically necessary. It identifies something more elemental and, in its own way, more haunting: the gatekeeper enforcing authorization rules did not consistently satisfy the rules governing its own decisions.

    The agency issued four recommendations to Health Share of Oregon. Those recommendations are the usual institutional medicine: review procedures, improve oversight, train the machinery, and make sure the paperwork behaves before it is allowed near another human life. Necessary, presumably. But somewhere in the records room, a form is being prepared for the denial department itself.

    Therefore, as a matter of administrative justice, the prior-authorization desk should submit its own application for prior authorization. It should demonstrate expertise, deliver a timely and understandable notice, provide language access, and consult the people who actually know what is happening. Until then, patients and providers are being asked to trust a stack of paperwork that the stack could not consistently complete correctly. The filing blinked first.

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    Medicare Paid More Than the Bill, Because Apparently Even the Bill Needs Oversight

    ByHugh Jass

    I have spent the morning exhuming a HHS-OIG audit, and the document coughed. The review examined 801 selected Medicare Part B claim lines from payments made in 2022 and 2023. Among them were 138 incorrect lines that produced at least $140,182 in overpayments. Another 31 lines, totaling $76,640, lacked supporting documentation. This is not proof that every claim was improper; it is a selected sample with enough administrative thunder to make the filing cabinet nervous.

    The target here is not patients or an accusation that providers acted intentionally. The target is the payment-control machinery: the edits, reviews, and safeguards assigned to notice when Medicare money is headed somewhere it should not go. Wisconsin Physicians Service Insurance Corporation already had system edits and follow-up procedures intended to identify overpayments. HHS-OIG still found incorrect payments and unsupported claim lines in the reviewed sample, which suggests the controls were present in the same way a smoke detector is present during a very organized kitchen fire.

    Hugh Jass Serious Investigative Reporting has located the central contradiction: the claim was important enough to generate edits, reviews, and recommendations, but not important enough to stop the money first. The system had a process for checking the paperwork, a process for checking the checking, and apparently a later process for discovering that the first two processes had allowed the money to leave the building wearing sunglasses.

    HHS-OIG recommended corrective action, and WPS concurred with those recommendations. The audit does not establish a recovery outcome, so the responsible sentence ends there. That restraint is called evidence, a rare substance often found in the same room as a spreadsheet but never invited to the budget meeting.

    The invoice, in other words, survived quality control by becoming a payment. Before the money moved, the bill was suspicious. After the money moved, it appears to have received diplomatic immunity. Medicare oversight is supposed to catch mistakes; in this case, the auditors had to audit the audit trail, proving once again that paperwork is not useless. It is merely waiting for another layer of paperwork to explain why it failed.

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    The Stroke Code That Needed A Receipt

    ByHugh Jass

    The document coughed, and out came the familiar Medicare Advantage ghost story: CMS auditors looking at an HHS-OIG oversight item found overpayment concerns tied to serious diagnosis codes that were not supported by the medical records. Not patients. Not bedside judgment. The target here is the risk-coding machine, where a diagnosis can enter the payment bloodstream with federal seriousness, then become shy when someone asks where it lives in the folder.

    This is the bureaucracy’s finest magic trick: crisp enough to affect payment, foggy enough to need a lantern. In public-records terms, if a diagnosis code is sturdy enough to help bill the government, it should be sturdy enough to stand upright when the file drawer opens. Otherwise, we are not doing health oversight. We are conducting a séance for a receipt.

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