The United States Department of Health and Human Services Office of Inspector General (the "OIG") has released its Fiscal Year 2013 Work Plan (the "2013 Plan"). The OIG releases a Work Plan annually to identify the investigative, enforcement and compliance activities that it will undertake in the coming fiscal year. The Work Plan covers all aspects of the OIG's efforts, including state agencies, agencies within HHS, and health care providers. Providers may find the Work Plan to be a useful resource for focusing their compliance efforts and reviews.
The 2013 Plan includes many ongoing initiatives, continued from previous years. It also includes new initiatives set to begin in fiscal year 2013. The attorneys in von Briesen & Roper's Health Care Practice Group have reviewed the 2013 Plan to identify reviews set to begin for hospitals, physicians, and suppliers in 2013 and have highlighted a number of them below.
The 2013 Work Plan also includes initiatives for nursing homes, hospices, home health, and others, as well as reviews for Medicare Parts C and D. We encourage providers to review the 2013 Plan to identity new and ongoing areas of focus relevant to their organization. The entire 2013 Work Plan is available at: https://oig.hhs.gov/reports-and-publications/workplan/index.asp.
- DRG Window. The OIG will determine how much CMS could save if it bundled outpatient services performed up to 14 days (instead of three days) prior to an inpatient admission into the DRG payment.
- Readmissions. The OIG will review Medicare claims to identify trends in same-day readmissions.
- Non-Hospital Owned Practices Using Provider-Based Status. The OIG will determine the impact of non-hospital-owned physician practices billing Medicare as provider-based. The OIG will also review whether practices billing Medicare as provider-based satisfied Medicare billing requirements.
- Medicare's Transfer Policy. The OIG will review payments to hospitals for discharges that should have been coded as transfers and whether such claims were appropriately processed and paid.
- Discharges to Swing Beds in Other Hospitals. The OIG will review Medicare payments made to hospitals for discharges that were coded as discharges to a swing bed in another hospital.
- Canceled Surgical Procedures. The OIG will determine the costs to Medicare associated with inpatient claims for canceled surgical procedures. The OIG notes that in a preliminary analysis it identified significant occurrences of hospitals receiving two payments for cancelled surgical procedures (i.e. an initial IPPS payment followed by a second IPPS payment for the rescheduled procedure).
- Mechanical Ventilation. The OIG will review Medicare payments for mechanical ventilation to determine the appropriateness of the DRG assignments and the payments. The OIG will specifically review whether patients received fewer than 96 hours of mechanical ventilation.
- Graduate Medical Education Payments. The OIG will review data to identify whether providers have claimed duplicate or excessive graduate medical education payments.
- Acquisition of ASCs. The OIG will identify the extent to which hospitals acquire ambulatory surgery centers and the effect of such acquisitions on Medicare payments and beneficiary cost-sharing.
- Long-Term-Care Hospitals—Interrupted Stays. The OIG will assess the extent to which Medicare made improper payments for interrupted stays in LTCHs, identify readmission patterns and determine the extent to which LTCHs readmit patients directly following the interrupted stay period.
Medical Equipment and Supplies
- Quality Standards—Accreditation. The OIG will review the requirements and processes of accreditation organizations to ensure that suppliers satisfy each of Medicare's quality standards.
- Lower Limb Prosthetics. The OIG will review Part B payments for lower limb prosthetics to determine whether Medicare requirements were satisfied. Prior OIG work determined that suppliers submitted claims that did not satisfy Medicare requirements or had other questionable characteristics.
- Power Mobility Devices. The OIG will perform a series of reviews for power mobility devices to assess whether Medicare payments were made in accordance with Medicare rules.
Other Providers and Suppliers
- On-Site Visits for Enrollment and Reenrollment. The OIG will identify how frequently on-site visits occur for the Medicare enrollment and reenrollment process.
- Claims Submitted by Error Prone Providers. The OIG will determine the validity of claims submitted by error prone providers, project the results to the provider's population of claims, and recommend to CMS that it request refunds of projected overpayments.
- Use of Commercial Mailboxes. The OIG will review the extent to which the practice locations of Medicare Part B providers and suppliers matched commercial mailbox addresses in 2011.
- Providers Subject to Debt Collection. The OIG will review providers/suppliers that received Medicare payments after CMS referred them to the Treasury for failing to refund overpayments.
- High Cumulative Part B Payments. The OIG will assess controls that identify high cumulative Part B payments to physicians and suppliers and whether controls are in place to identify such payments.
- Independent Therapists. The OIG will determine whether outpatient physical therapy services provided by independent therapists complied with Medicare regulations.
- Anesthesia Services. The OIG will review Part B claims for personally performed anesthesia services to determine whether the claims satisfied Medicare requirements. The OIG will also review whether payments for services reported with the "AA" modifier satisfied Medicare requirements.
- Ophthalmological Services. The OIG will review Medicare claims data for ophthalmological services to identify questionable billing for services in 2011.
- Rural Health Clinics. The OIG will identity the extent to which rural health clinics do not satisfy basic location requirements.
- Electrodiagnostic Testing. The OIG will review claims data to identify questionable billing for electrodiagnostic testing and will determine the extent to which Medicare utilization rates for such testing differ by provider specialty, diagnosis and geographic area.
- High-Cost Diagnostic Radiology Tests. The OIG will review Medicare payments for high-cost diagnostic radiology tests for medical necessity. The OIG will also review the extent to which the same diagnostic tests are ordered by both a primary care physician and a specialist for a beneficiary.
- Incident-To Services Performed by Non-Physicians. The OIG will review billing for "incident to" services to identify whether payments for such services had a higher error rate than other services. The review stems from prior OIG findings regarding unqualified non-physicians performing such services.
- Modifiers During the Global Surgery Period. The OIG will review the use of certain modifiers during the global surgery period and determine compliance with Medicare requirements.
- Payments for Immunosuppressive Drugs. The OIG will determine whether Part B claims for immunosuppressive drugs billed with the KX modifier satisfied Medicare documentation requirements.