It’s that time of year, when the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) releases its annual work plan.
This document always offers a valuable look into the key compliance initiatives and projects for the year. Providers and others should review this 165-page document, as it reflects some increased activity in fraud and abuse identification.
The OIG has some accomplishments listed in this work plan that show the results of its efforts, namely:
- $3.8 billion in court-ordered civil settlements resulting from cases developed by OIG investigators;
- $1.1 billion in audit receivables that were agreed to be pursued by HHS program managers as a result of OIG audit disallowance recommendations; and
- A ratio of $16.7 to $1 expected return on investment, a figure measuring the efficiency of the OIG’s healthcare oversight efforts.
Data Mining to Continue
Clinical data is so important, and it is a window into many aspects of healthcare compliance and finance. The OIG will continue to use data-mining techniques to help identify billing and coding variances as well as for other insights. The OIG also plans to review claims submitted by hospitals nationwide since October 2008 and to distinguish hospital-acquired conditions (HAC) from patient conditions present on admission (POA).
Seven Sections of Focus
The OIG work plan contains seven sections of focus, and within each are specific projects and areas of attention. These seven key sections include:
Part I: Medicare Part A and Part B
Part II: Medicare Part C and Part D
Part III: Medicaid Reviews
Part IV: Legal and Investigative Activities
Part V: Public Health Reviews
Part VI: Human Services Reviews
Part VII: Other HHS-Related Reviews
The work plan also contains several appendices:
Appendix A: Affordable Care Act Reviews
Appendix B: Recovery Act Reviews
Appendix C: Acronyms and Abbreviations
Appendix A covers reviews related to the Patient Protection and Affordable Care Act (PPACA) of 2010. Appendix B describes the OIG oversight of the funding HHS received under the American Recovery and Reinvestment Act of 2009. Appendix C lists selected acronyms and abbreviations used in the work plan.
Within “Part I” Medicare A and B focuses, there are a host of specific settings listed: Home Health, Hospital, Nursing Home, Hospice and Medical Equipment and Supply Providers.
For the hospital setting, the following are the focused areas and an indication of some new focused items:
- Hospital Reporting for Adverse Events;
- Reliability of Hospital-Reported Quality Measure Data;
- Hospital Admissions with Conditions Coded Present on Admission;
- Accuracy of Present-on-Admission Indicators Submitted on Medicare Claims (New Item);
- Medicare Inpatient and Outpatient Payments to Acute-Care Hospitals (New Item);
- Hospital Inpatient Outlier Payments: Trends and Hospital Characteristics;
- Medicare’s Reconciliations of Outlier Payments;
- Hospital Claims with High or Excessive Payments;
- Hospital Same-Day Readmissions;
- Acute-Care Hospital Inpatient Transfers to Inpatient Hospice Care (New Item);
- Medicare Payments for Beneficiaries with Other Insurance Coverage;
- Duplicate Graduate Medical Education Payments;
- Hospital Occupational-Mix Data Used To Calculate Inpatient Hospital Wage Indexes;
- Inpatient Prospective Payment System: Hospital Payments for Nonphysician
- Outpatient Services;
- Noninpatient Prospective Payment System: Hospital Payments for Nonphysician
- Outpatient Services;
- Medicare Brachytherapy Reimbursement;
- Medicare Outpatient Dental Claims (New Item);
- Medicare Inpatient and Outpatient Hospital Claims for the Replacement of Medical Devices;
- Observation Services During Outpatient Visits;
- Inpatient Rehabilitation Facility Transmission of Patient Assessment Instruments;
- In-Patient Rehabilitation Facilities (New Item);
- Critical Access Hospitals; and
- Critical Access Hospitals (New Item)
The OIG will continue to review hospitals’ internal incident-reporting systems and determine to what extent they are capturing adverse events (and to what extent the hospitals are reporting the events to external patient-safety oversight entities). In addition, the OIG will continue reviewing which types of facilities are transferring patients with POA conditions most frequently.
Nursing Homes and Hospice
The 2012 work plan contains several new OIG areas of focus that potentially will impact operating practices of nursing homes and hospices – and the relationships between these types of providers. Some areas of increased scrutiny are a) nursing home compliance plans; b) billing patterns of Part B provider services during non-Part A nursing-home stays; and c) hospice marketing practices and financial relationships with nursing facilities.
In all there are 349 current and planned reviews listed in this year’s document, 99 of which are new items on which to be focused.
Investigating Fraud and Abuse
It’s important to note that as part of the HITECH Act provisions in the American Recovery and Reinvestment Act, more resources are being made available to auditors and investigators to investigate fraud and abuse in the Medicare and Medicaid programs.
Compliance, revenue cycle, HIM and your RAC committee are a few of the key stakeholders that should review the work plan and put in place proactive defenses wherever there are vulnerabilities and opportunities to improve.
The full OIG 2012 work plan can be accessed online at http://oig.hhs.gov/reports-andpublications/
About the Author
Gloryanne Bryant, RHIA, RHIT, CCS, CCDS, is the Managing Director of HIM and Revenue Cycle Northern California Kaiser Permanent.
Contact the Author
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