Summary of the OIG Work Plan 2010
posted 2/3/10

By Helen Hadley
VantagePoint HealthCare Advisors

The Office of the Inspector General/Department of Health and Human Services published the 2010 Work Plan that describes activities that will be initiated or continued by the department in this fiscal year (the plan was effective October 2009).

The OIG’s mission is to detect and prevent waste, fraud, and abuse and to hold accountable those who do not meet program requirements or who violate federal laws.

To report instances of waste, fraud, or abuse related to HHS’s programs, you may call the OIG Hotline at 1-800-HHS-TIPS or email HHSTips@oig.hhs.gov.

The summary below highlights that impact on private practice.

MEDICARE PART A and PART B

HOSPITALS

Provider-Based Status for Inpatient and Outpatient Facilities

· Will review cost reports of hospitals claiming provider-based status for inpatient and outpatient facilities.

· Will determine the appropriateness of the provider-based designation and the potential impact on the Medicare program and the beneficiaries of hospitals improperly claiming provider-based status for inpatient and outpatient facilities.

Provider Bad Debts

· Will review Medicare bad debt claims by acute care inpatient hospitals, LTAC’s, inpatient rehab facilities, inpatient psych facilities, and SNFs to determine whether they were reimbursable.

Medicare Secondary Payer

· Will evaluate procedures for identifying and resolving credit balance situations, which occur when payments from Medicare and other insurers exceed the providers’ charges or the allowed amounts.

Hospital Admissions with Conditions Coded as Present-on-Admission

· Will review Medicare claims to determine the number of inpatient hospital admissions for which certain diagnoses were coded as being present on admission.

Hospital Readmissions

· Will review Medicare claims to determine hospital readmission cases; if a same-day readmission occurs related to prior stay’s medical condition.

Payments for Diagnostic X-Rays in Hospital Emergency Departments

· Will review Medicare claims AND medical records for diagnostic x-rays performed in ERs to determine appropriateness of payments. There are concerns about the potential overuse of diagnostic imaging services and interpretations.

Observation Services During Outpatient Visits

· Will review Medicare payments for observation services provided during OP visits in hospitals.

Coding & Documentation Under the MS-DRG System

· Will examine coding patterns under the new system and determine whether specific MS-DRGs are vulnerable to potential upcoding.

OTHER PART A and PART B PROVIDERS PAYMENTS

Medicare Incentive Payments for E-Prescribing

· Will review incentive payments made in 2010 to eligible professionals for their 2009 e-prescribing activities. OIG will assess whether any payments for e-prescribing were made in error.

Place of Service Errors

· Will review physician coding of place of service on Medicare Part B claims for services performed in ASCs and hospital outpatient departments.

· Will determine whether physicians properly coded the POS for services provided in ASCs and hospital outpatient departments.

E&M Services During Global Surgery Periods

· Will review industry practices related to the number of E&M services provided by physicians and reimbursed as part of the global surgery fee.

Medicare Payments for Part B Imaging Services

· Will focus on the practice expense components, including the equipment utilization rate.

· Will determine whether payment reflects the actual expenses incurred and whether the utilization rate reflects current industry practices.

Services Performed by Clinical Social Workers

· Will reviewed services furnished by CSWs to inpatients of participating hospitals or SNFs.

· Will review PART A and PART B claims with overlapping dates of service.

OP PT Provided by Independent Therapists

· Will review OP PT services provided by independent therapists to determine compliance with Medicare regulations.

Appropriateness of Medicare Payments for Polysomnography

· Will examine appropriateness of payments for sleep studies.

· Will assess provider compliance with federal program requirements.

Medicare Billings with Modifier GY

· Will review appropriateness of use of modifier GY on claims for services that are not covered by Medicare.

Physician Reassignment of Benefits

· Will review extent to which physicians reassign their benefits to other entities.

· Will examine the extent to which physicians are aware of their reassignments.

Medicare Providers’ Compliance With Assignment Rules

· Will examine extent to which providers comply with assignment rules and determine if and to what extent beneficiaries are inappropriately billed in excess of amounts allowed by Medicare.

Medicare Payments for Transforaminal Epidural Injections

· Will review claims to determine appropriateness of payments for transforaminal epidural injections (used to diagnose or treat back problems and pain). Medicare will cover only services that are considered reasonable and necessary.

Accuracy and Completeness of the NPI

· Will determine whether providers are including NPIs on claims as required.

 

INVESTIGATIVE AND LEGAL ACTIVITIES RELATE TO CENTERS FOR MEDICARE & MEDICAID SERVICES PROGRAMS AND OPERATIONS

Health Care Fraud

· Will investigate individuals, facilities, or entities that bill or are alleged to have billed Medicare and/or Medicaid for services not rendered, claims that manipulate payment codes in an effort to inflate reimbursement amounts, and false claims submitted to obtain program funds.

· Will investigate business arrangements that allegedly violate the federal health care anti-kickback statute and the statutory limitation on self-referrals by physicians.

Provider Self-Disclosure

· Will continue to encourage providers to promptly self-disclose improper conduct.

HOW YOU SHOULD PREPARE

Look at where the OIG is focusing and how it might apply to your practice. It would be in your best interest to conduct an internal audit of services to ensure you are in compliance. If you have any concerns at all, contact your advisors to discuss what you should do to minimize risk.

 

Helen Hadley is President of VantagePoint HealthCare Advisors.
(203) 288-6860
www.vantagepointconsult.com