2015 U.S. Department of Health and Human Services Office of Inspector General Work Plan is Published

As you may be aware, the 2015 U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) Work Plan was released on Oct. 31, 2014. This should be considered mandatory reading for all healthcare providers looking to avoid fraud charges.

From an institutional perspective, a very effective method to probe for compliance issues at your organization is to compare the projects listed in the 2015 Work Plan to your organization’s current practices. As the OIG does periodically update the document, plan on revisiting the website regularly to stay current throughout the year as part of your ongoing compliance activities. For instance, with the Ebola situation in the U.S., we suspect an update related to infectious disease control may be in the works.

Staying current on OIG and Centers for Medicare & Medicaid Services (CMS) rules is not only important for compliance reasons, but due to serious financial implications for providers as well. This new OIG Work Plan reports expected 2014 recoveries of over $4.9 billion, including nearly $834.7 million in audit receivables and about $4.1 billion in investigative receivables. The investigative receivables encompass about $1.1 billion in non-HHS investigations in areas such as the states’ shares of Medicaid restitution and $15.7 million in savings from OIG recommendations.

In this article, we will attempt to summarize the plan related to Medicare Part A and B. Future articles will summarize the plan related to Parts C and D. We do, however, strongly recommend you review all parts of the plan.

The OIG was created to protect the integrity of HHS programs and the wellbeing of beneficiaries by:

• Detecting fraud, waste and abuse;
• Identifying opportunities to improve program economy, efficiency, and effectiveness; and
• Holding accountable those who do not meet program requirements or who violate federal healthcare laws

This year’s work plan is 90 pages long, but the following are highlights associated with Medicare Part A and B.

2015 Projects for Hospitals: 

Policies and practices:

The OIG will compare payments across government programs and across hospitals to identify significantly different amounts for the same or similar services (outliers). It also will be looking at Medicare costs incurred because of deficiencies in services or defective medical devices, as well as non-compliance in areas with high payment error rates. Key focus areas will be:

• Additional medical services associated with a defective medical device
• Cost reports to identify impact on Medicare IF salaries and whether there were mandatory limits
• Provider-based facilities’ compliance with CMS criteria and payments to physicians at provider-based facilities versus a free-standing clinic
• Cost-effectiveness of payments for swing-bed services at a critical access hospital (CAH) versus the same level of care at a traditional skilled nursing facility (SNF)
• Medicare outlier payments compared to cost reports
• Billing variations across hospitals for short inpatient stays
• Review of new inpatient criteria (two-midnight policy) on hospital billing, Medicare payments, and beneficiary co-payments (and how billing varied among hospitals)
• Appropriate MS-DRGs for payments for those inpatients requiring mechanical ventilation for more than 96 hours
• “Selected inpatient and outpatient billing requirements” (the specifics for the review have not been published yet)
• Duplicate or excessive graduate medical education (GME) payments, for which an intern or resident may be counted as more than one full-time equivalent (FTE) employee
• Outpatient payments for dental services for non-covered services
• Outpatient evaluation and management services paid to hospitals and billed at new patient rate when the patient had been seen within the past three years as a registered inpatient OR outpatient of that hospital in the past three years
• Cardiac catheterization payments with a focus this year on endomyocardial biopsies and right heart catheterizations  billed during the same operative session
• Payments to hospitals for patients with a diagnosis of kwashiorkor, which is a form of severe protein malnutrition that generally affects children living in tropical and subtropical areas during famine or insufficient food supply (a disease not typically found in the U.S.)
• Payments to hospitals for bone marrow or stem cell transplants, with focus on appropriate diagnosis as well as documentation of all required steps of the process (mobilization, harvesting, and transplant of bone marrow or peripheral blood stem cells and the administration of high-dose chemotherapy or radiotherapy before the actual transplant)
• Hospital controls over the reporting of wage data used to calculate wage indexes, including deferred compensation costs
• Hospitals’ participation in projects through their quality improvement organizations (QIOs), as well as the extent of overlap of the QIO projects with projects offered by other entities
• Oversight on hospitals’ pharmaceutical compounding oversight as a result of the 2012 meningitis outbreak from contaminated injections of compounded drugs
• Hospital assessment of medical staff candidates before granting privileges
• Incidence of adverse and temporary harm events for Medicare beneficiaries receiving post-acute care in inpatient rehabilitation facilities (IRF) and in long-term care hospitals (LTACHs), including what factors contributed to those events, to what extent the events were preventable, and the average cost to Medicare
• Provider eligibility: The OIG will be introducing an enhanced enrollment screening process for Medicare providers related to the extent to which and the way in which CMS contractors have implemented enhanced screening procedures for Medicare providers pursuant to the PPACA 6401. This will include site visits, fingerprinting, and background checks, in addition to automated provider screening.
• New models: The OIG will be performing a risk assessment of CMS’s administration of the pioneer accountable care organization (ACO), to include internal controls over administration of the ACO model.

Billing and payments:

The OIG will be examining the transition from volume-based to value-based payments. Key focus areas will include:

Quality of care and safety:

As new projects, the OIG will focus on medical necessity, patient safety, and quality of care. It is planning to continue its focus on access to care, including access to durable medical equipment (DME), prosthetics, orthotics, and supplies involving competitive bidding. Key focus areas will include:

• Hospitals’ participation in projects through their quality improvement organizations (QIOs), as well as the extent of overlap of the QIO projects with projects offered by other entities
• Oversight on hospitals’ pharmaceutical compounding oversight as a result of the 2012 meningitis outbreak from contaminated injections of compounded drugs
• Hospital assessment of medical staff candidates before granting privileges
• Incidence of adverse and temporary harm events for Medicare beneficiaries receiving post-acute care in inpatient rehabilitation facilities (IRF) and in long-term care hospitals (LTACHs), including what factors contributed to those events, to what extent the events were preventable, and the average cost to Medicare

Other Part A and Part B Program Management Issues:

• Provider eligibility: The OIG will be introducing an enhanced enrollment screening process for Medicare providers related to the extent to which and the way in which CMS contractors have implemented enhanced screening procedures for Medicare providers pursuant to the PPACA 6401. This will include site visits, fingerprinting, and background checks, in addition to automated provider screening.
• New models: The OIG will be performing a risk assessment of CMS’s administration of the pioneer accountable care organization (ACO), to include internal controls over administration of the ACO model.

2015 Projects for Non-Hospital Providers:

The OIG will continue to monitor billings from SNFs for medical necessity and for its three-day inpatient stay requirement, but will also focus on excessive claims for foot care. It also will be auditing state agencies for their verification of a SNF’s successful completion of a corrective action plan generated from deficiencies found during survey. Claims for hospice care delivered in an assisted living facility will be reviewed for length of stay, level of care, and common terminal illnesses. For new home health agencies, the OIG will monitor for documentation to justify billing.

The OIG also will be looking for payment efficiencies across the healthcare continuum. Payment disparities between outpatient and ambulatory surgery centers will be reviewed, as well as increases in acquisition costs for high-dollar drugs as part of review of prospective payment systems (PPS) for end-stage renal disease facilities. Medical necessity for ambulance services also will be under review, as will coverage of billed chiropractic services. Claims for “personally performed” anesthesia services must have supportive documentation.

OIG will be closely watching diagnostic services, including medical necessity of physical therapy, sleep-testing procedures, high-cost diagnostic radiology (such as MRIs), compliance with CMS billing requirements for independent clinical laboratories, and place-of-service codes on bills for services at ambulatory service centers and hospital outpatient departments.

DME providers and prescription drugs also will continue to be a high priority as they pertain to OIG activities in 2015. Approval of powered mobility devices now will include face-to-face evaluation by a physician. Market share among providers for diabetic testing strips will be evaluated as part of examination of claims for mail order supply services, and the OIG will look at CMS’s internal controls to prevent concurrent bills from multiple providers of diabetic test strips for the same time frame and the same beneficiaries. Refills for test strips and drugs for nebulizer machines must be ordered by the physician as medically necessary, and not automatically refilled by the DME provider.

This next year will not see the same intensity of review for medications as had been seen in previous years. The OIG will be auditing for appropriate outpatient billings for certain drugs billed by unit of service (the number of times a service was performed) versus those billed by unit of administered dose. The OIG is reviewing for conflicts of interest for publishers of authoritative prescription drug compendia as well.

By far the most interesting 2015 project the OIG will undertake is a harder look at information systems and their impact on protected health information (PHI). One other interesting OIG project is an evaluation of security programs in information systems for Medicare fiscal intermediaries, carriers, and Medicare Administrative Contractors (MACs). The OIG also is reviewing controls over networked medical devices at hospitals for the security of PHI.

Summary:

So, to reiterate the importance of this work plan, for the 2014 fiscal year the OIG expects to recover over $4.9 billion. In addition, it excluded 4,017 individuals and entities from federal healthcare programs and filed 971 criminal actions and 533 civil actions, including actions against false claims.

By publishing their work plan early in the fiscal year, the OIG hopes to educate healthcare providers, limit fraud, and protect the interests of beneficiaries. This includes parts of the work plan we did not cover that lay out oversight of Medicaid programs and legal and investigative activities such as self-disclosure, whistleblower reporting, and other fraud and abuse prevention information vital to all providers.

While the work plan is not an easy read, the time invested in scrutinizing and comparing planned OIG work projects against your organization’s current work processes may increase potential reimbursement, reduce denials, limit re-work, and prevent fraud investigations.

The report is available for review online at the OIG’s website, http://oig.hhs.gov.

About the Authors

Elizabeth Lamkin, MHA, is CEO of PACE Healthcare Consulting, LLC in Hilton Head S.C. After 20 years as a highly innovative hospital CEO, she now brings effective solutions to all types of hospitals and healthcare providers. She is a nationally known speaker and author on billing compliance including CMS Recovery Auditors. She has two books on RAC published in 2011 through.  The RAC Toolkit for Hospitals and Health Systems and The RAC Toolkit for Physician Practices are available at Amazon books.

Patricia Hildebrand is a seasoned healthcare professional with more than 25 years in the industry.  She consults on regulatory compliance, risk, QAPI, and physician performance Patricia is a Lean Six Sigma Black Belt, a certified coder and ICD10 trainer, a CPHQ, CPHRM, HACP and a fellow in the ACHE.  She is a national speaker on ICD-10 and patient centered medical homes, and a publisher author for nurse practitioners.

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