On Monday, the Office of Inspector General (OIG) published its 2016 Work Plan which outlines new, ongoing, and upcoming reviews/activities that they are currently working on or plans to pursue.
Below is a summary of new and revised activities for hospitals:
- Medical device credits for replaced medical devices – The OIG will determine whether Medicare payments for replaced medical devices were made in accordance with Medicare requirements.
- Medicare payments during MS-DRG payment window – The OIG will review payments to acute care hospitals to determine whether outpatient claims billed to Part B during inpatient stays were allowable and in accordance with the inpatient prospective payment system.
- Medicare oversight of provider-based status – The OIG will determine if provider-based facilities are meeting requirements and will also determine the number of facilities that hospitals own and the extent to which CMS has methods to oversee provider-based billing.
The OIG plans to continue the following activities for hospitals:
- Review of hospital wage data used to calculate Medicare payments – Review hospital controls over reporting of wage data used to calculate wage indexes for payments.
- Intensity-Modulated Radiation Therapy (IMRT) – Review Medicare outpatient payments for IMRT to ensure services were billed correctly.
- Hospital’s use of outpatient and inpatient stays under Medicare’s two-midnight rule – Review how hospital’s stays changed under this rule, and how Medicare and beneficiary payments also changed. The OIG will also compare how stays varied among hospitals.
- Medicare costs associated with defective medical devices – Review Medicare claims to identify the costs resulting from additional utilization of medical services associated with defective medical devices and determine the impact on the Medicare Trust Fund.
- Comparison of provider-based and free-standing clinics – Review and compare Medicare payments for physician office visits in provider-based and free-standing clinics to determine the difference in payments for similar procedures. The OIG will also assess the potential impact of hospitals’ claiming provider-based status on the Medicare program.
- Payments for patients diagnosed with Kwashiorkor – Review Medicare payments made to hospitals for claims that include a Kwashiorkor diagnosis to determine whether the diagnosis is adequately supported by medical record documentation.
- Bone marrow or stem cell transplants – Review Medicare payments made to hospitals for bone marrow or stem cell transplants to determine whether they were paid in accordance with Federal rules and regulations.
- Nationwide review of cardiac catheterization and heart biopsies – Review Medicare payments for right heart catheterizations (RHC) and heart biopsies billed during the same operative session, and determine if hospitals complied with Medicare billing requirements.
- Select inpatient and outpatient billing requirements– Review compliance with billing requirements for payments made to acute care hospitals.
- Duplicate Graduate Medical Education payments – Review data from CMS’s Intern and Resident Information System (IRIS) to determine whether duplicate or excessive Graduate Medical Education (GME) payments have been claimed.
- Indirect medical education payments – Review provider data to determine if payments made to hospitals were in accordance with regulations.
- Inpatient claims for mechanical ventilation – Review Medicare payments for inpatient hospital claims with certain Medicare Severity-Diagnosis Related Group (MS-DRG) assignments that require mechanical ventilation to determine whether hospitals’ DRG assignments, and resultant Medicare payments, were appropriate.
- Outpatient dental claims – Hospital outpatient dental payments will continue to be reviewed for compliance with Medicare requirements.
- Medicare’s reconciliations of outlier payments – The review of CMS’s timely reconciliation of outlier payments will continue.
Below is a summary of new and revised activities for physicians:
- Physicians-referring/ordering Medicare services and supplies – The OIG will review select Medicare services, supplies, and durable medical equipment (DME) referred/ordered to determine if payments were made in accordance with Medicare requirements. Certain services must be ordered/referred by a Medicare-enrolled physician/non-physician practitioner.
- Anesthesia services-non-covered services – Review Part B claims to determine if the beneficiary had a Medicare-related service and whether the service was supported in accordance with Medicare requirements.
- Physician home visits-reasonableness of services – Determine whether home visits were reasonable and made in accordance with Medicare requirements.
- Prolonged services-reasonableness of services – Determine whether payments made to physicians for prolonged evaluation and management services were appropriate and in accordance with Medicare requirements.
- Histocompatibility laboratories-supplier compliance with payment requirements – The OIG will determine if payments made to labs were in accordance with Medicare requirements.
The OIG plans to continue the following activities for physicians:
- Annual analysis of Medicare clinical laboratory payments – The OIG will analyze Medicare payments for clinical diagnostic laboratory tests, including the top 25 tests by expenditures in 2014. Previous analysis shows Medicare pays more for certain tests than other insurers. A new payment system for laboratory tests is slated for 2017.
- Inpatient Rehabilitation Facility (IRF) payment system requirements – Review compliance with IRF PPS, including documentation to support Medicare paid claims.
- Imaging services – Part B imaging services will continue to be reviewed to determine whether the services reflect expenses incurred, and whether the utilization rates reflect industry practices.
- Selected independent clinical laboratory billing requirements – Review payments to clinical laboratories to determine compliance with billing requirements.
- Physical therapists-high use of outpatient physical therapy services – Determine whether services provided by independent therapists are in compliance with Medicare reimbursement regulations.
- Portable x-ray equipment-supplier compliance with transportation and setup fee requirements – Determine if payments were appropriate and supported by documentation. They will also assess the qualifications of the performing technologists.
- Sleep disorder clinics-high use of sleep-testing procedures – Review Medicare payments to determine the appropriateness and compliance with requirements.
- Anesthesia services-payments for personally performed services – Review Part B claims to determine if they are supported by Medicare requirements, and review payments to determine if claims billed with modifier “AA” met requirements.
- Chiropractic services-Part B payments for non-covered services – Continue to review payments to ensure they were made in accordance with Medicare requirements.
- Chiropractic services-Portfolio report on Medicare Part B payments – Compile results of prior audits, investigations, and evaluations to identify trends in payments, compliance, and fraud vulnerabilities.
Durable Medical Equipment (DME) Suppliers
Below is a summary of new activities for DME suppliers:
- Orthotic braces-reasonableness of Medicare payments compared to amounts paid by other payers – The OIG will determine the reasonableness of fee schedule amounts for orthotic braces and compare to other payers to identify wasteful spending.
- Osteogenesis stimulators-lump-sum purchase versus rental – The OIG will determine if there is a savings by renting over a 13-month period rather than a lump-sum purchase.
- Orthotic braces-supplier compliance with payment requirements – The OIG will review payments to determine if claims were medically necessary and supported by Medicare requirements.
- Increased billing for ventilators – The OIG will describe billing trends for ventilators, Respiratory Assist Devices (RAD), and Continuous Positive Airway Pressure (CPAP) devices, and explore factors related to the increase in ventilator billing.
The OIG plans to continue the following activities for DME suppliers:
- Nebulizer machines and related drugs–supplier compliance with payment requirements – Review claims to determine if medical necessity is supported in accordance with Medicare requirements.
- Diabetes testing supplies effectiveness of system edits to prevent inappropriate payments for blood glucose test strips and lancets to multiple suppliers – Review effectiveness of system controls to prevent payments to multiple suppliers.
- Competitive billing for medical equipment items and services-mandatory post-award audit – Review the CMS process for competitive bidding and pricing determinations as required by Federal law.
- Access to DME in competitive bidding areas – Evaluate how the competitive bidding program has effected access for Medicare beneficiaries.
- Power mobility devices–lump-sum purchase versus rental – Determine if savings can be made through a 13-month rental rather than a lump-sum purchase.
- Power mobility devices-supplier compliance with payment requirements – Review Medicare Part B payments to determine if they were made in accordance with requirements.
We recommend Medicare providers review the Work Plan Update for FY 2016 in its entirety. We also recommend providers conduct proactive audits of the applicable areas identified in the update.
HC Healthcare Consulting staff includes certified coders, physicians, consultants certified in healthcare compliance, and statisticians that are available to provide expert assistance with your Medicare and Medicaid compliance programs.
To read the complete FY 2016 Work Plan Update, please click on the following link: http://oig.hhs.gov/reports-and-publications/archives/workplan/2016/oig-work-plan-2016.pdf.
DISCLAIMER: This post contains only summary information and highlights; it should be read in conjunction with the full article or document provided as a link. Any advice or recommendations given is general and specific questions should be directed to professional counsel.