Highlights of the OIG’s 2011 Work Plan
The Office of Inspector General (the “OIG”) has released its Fiscal Year 2011 Work Plan (the “2011 Plan”). The OIG issues a Work Plan annually to describe the investigative, enforcement and compliance activities that it will undertake in the coming year. Specifically, the OIG conducts audits and evaluations with respect to various programs of the Department of Health and Human Services, including the Center for Medicare and Medicaid Service (“CMS”). Many of the initiatives are ongoing, others begin in 2011.
We have reviewed the 2011 Plan to identify areas of interest for providers. The OIG will continue its review of a number of quality-of-care issues, including the reliability of hospital-related quality data, trends in hospital readmissions, and reporting of adverse events. Several new projects exemplify the OIG’s focus on holding providers accountable for compliance and on recouping overpayments. The OIG, for example, intends to review a sample of claims from the top “error-prone” providers, project the results to the provider’s population of claims and request refunds of the projected overpayments.
Such projects highlight the need for an effective compliance program. The health reform legislation enacted in March 2010 requires health care providers to adopt compliance programs. Skilled nursing facilities and other nursing facilities must have a compliance and ethics plan in operation by March 2013. Other providers and suppliers will require a plan as of a date not yet identified by CMS.
This summary describes a few of the ongoing, and many of the new, activities set forth in the 2011 Plan. We encourage providers to review the Work Plan to identify areas to focus their compliance programs for 2011. The entire 2011 Work Plan is available at: http://oig.hhs.gov/publications/workplan/2011/.
• Medicare Secondary Payer Issues. The OIG will review Medicare payments to identify beneficiaries who had other insurance. The OIG will also assess the effectiveness of procedures to prevent inappropriate payment for beneficiaries with other coverage (e.g. procedures for identifying credit balance situations).
• Provider-Based Status. The OIG will continue to review the cost reports of hospitals asserting provider-based status for inpatient and outpatient facilities to determine the appropriateness of the designation.
• Payments for Non-Physician Outpatient Services. The OIG will review Medicare payments for non-physician outpatient services provided shortly before or during a hospital stay for compliance with federal law that prohibits separate payment for certain services. The OIG will review such payments for both Inpatient Prospective Payment System (“IPPS”) hospitals and non-IPPS hospitals.
• Medicare Excessive Payments. The OIG will review the appropriateness of Medicare claims with high payments and the effectiveness of the claims processing edits to identify excessive payments.
• Hospital Occupational Mix Data. The OIG will review whether hospitals reported occupational-mix data used to calculate inpatient wage indexes in compliance with Medicare regulations.
• Hospital-Acquired Conditions. The OIG will continue to review the implementation of CMS’s hospital-acquired conditions policy and will verify the accuracy of present on admission indicators.
• Adverse Events. The OIG will review the extent to which hospitals’ internal incident-reporting systems captured adverse events, the type of information the systems captured, and the extent to which hospitals reported the information to patient-safety oversight entities.
• Hospital Reporting for Restraint-and-Seclusion-Related Deaths. The OIG will review hospital-reported restraint-and-seclusion-related deaths to assess the volume and outcomes of reporting.
• Payments for Diagnostic Radiology Services in Hospital Emergency Departments. The OIG will review Part B claims and medical records for interpretations and reports of diagnostic radiology services performed in emergency departments to assess the appropriateness of the payments.
• Hospitals’ Compliance with Medicare Conditions of Participation for Intensity-Modulated and Image-Guided Radiation Therapy Services. The OIG will assess hospital compliance with Medicare safety and quality requirements for intensity modulated and image-guided radiation therapy.
• Medicare Hospital Claims for the Replacement of Medical Devices. The OIG will review inpatient and outpatient claims that included the insertion of replacement medical devices for compliance with Medicare regulations.
Other Providers and Suppliers
• Payments for Services Ordered or Referred by Excluded Providers. The OIG will assess the extent to which Medicare paid for services ordered or referred by excluded providers.
• Medicare Services Billed with Dates of Service After Beneficiaries’ Dates of Death. The OIG will continue to review claims with dates of service that occur after the beneficiary’s death.
• Payments for Evaluation and Management Services. The OIG will review the extent of inappropriate payments for E&M services and the consistency of E&M medical review determinations. The OIG will also review E&M services for the same providers and beneficiaries to identify electronic health records documentation practices associated with improper payments.
• Partial Hospitalization Program Services. The OIG will assess the appropriateness of Medicare payments for partial hospitalization psychiatric services and compliance with Medicare’s requirements (e.g. plans of care, physician supervision and certification requirements).
• Outpatient Physical Therapy Services Provided by Independent Therapists. The OIG will review outpatient therapy services provided by independent therapists to assess compliance with Medicare regulations, focusing on therapists with a high utilization rate for such services.
• Excessive Payments for Diagnostic Tests. The OIG will review Medicare payments for high-cost diagnostic tests for medical necessity. The OIG will also identify the extent that primary care physicians and specialists order duplicate tests for a beneficiary for the same treatment.
• Laboratory Test Unbundling by Clinical Laboratories. The OIG will assess the extent to which clinical laboratories inappropriately unbundled laboratory profile or panel tests.
• Medicare Part B Payments for Glycated Hemoglobin A1C Tests. The OIG will review the procedures of Medicare contractors for screening the frequency of clinical laboratory claims for glycated hemoglobin A1C tests and determine the appropriateness of Medicare payments.
• Independent Diagnostic Testing Facilities’ Compliance with Medicare Standards. The OIG will review Medicare-enrolled IDTFs to assess compliance with Medicare standards.
• Compliance with Medicare Assignment Rules. The OIG will continue to assess provider compliance with Medicare assignment rules. The OIG will also review whether beneficiaries were billed an amount greater than permitted by Medicare.
• Medicare Payments for End Stage Renal Disease Beneficiaries. The OIG will assess claims for ESRD beneficiaries entitled to coverage due to special circumstances in order to determine the extent to which such beneficiaries obtain Medicare benefits after their coverage should have ended.
• Error Prone Providers. The OIG will review the Medicare Part A and Part B claims of error-prone providers. The OIG will identify the top error-prone providers (using CMS’s Comprehensive Error Rate Testing Program data) and conduct a medical review of a sample of claims to assess the validity of the claims. The OIG will project the results of the medical review to the provider’s population of claims and request refunds from the provider on projected overpayments.
• Home Health Prospective Payment System Controls. The OIG will assess compliance with the home health PPS. The review will include the appropriateness of the location at which the services were provided.
• Frequency of Replacement Supplies for Durable Medical Equipment. The OIG will assess the compliance of DMEPOS suppliers with Medicare requirements for frequently replaced DME
• Medicaid Claims with Inactive or Invalid Physician Identifier Numbers. The OIG will review Medicaid claims to assess state agency controls for identifying claims with inactive or invalid unique physician identifiers (including claims with dates of services after the physician’s death).
• Medicaid Hospice Services. The OIG will review Medicaid payments for hospice services to assess compliance with reimbursement requirements. The OIG will also review a sample of claims for hospice care to assess whether the services were reasonable and necessary.
• Health Screenings of Medicaid Home Health Care Workers. The OIG will review the health-screening records of Medicaid home health care workers to identify whether the workers were appropriately screened in compliance with federal and state law.
• Rehabilitative Services. The OIG will review claims for rehabilitative services to assess whether the services complied with state and federal guidelines.
• Medicaid Medical Equipment. The OIG will review Medicaid payments for supplies and equipment to assess whether the supplies and equipment were authorized by physicians, received by beneficiaries, and paid for within Medicaid payment guidelines.