By John H. Fisher II
October 10, 2012
The Office of Inspector General of the Department of Health of Health and Human Services (“OIG”) has published their annual work plan for the 2013 fiscal year (“2013 Work Plan”). The Work Plan focuses on areas where OIG plans to focus significant resources during the 2013 fiscal year. The 2013 Work Plan creates opportunities for providers to get a glimpse of what the OIG feels is important and to integrate these areas into their ongoing compliance activities.
This update will briefly summarize some of the new issues that were added this year. It is not a comprehensive description of all items that are on the OIG’s radar. Providers are advised to review the entire 2013 Work Plan plus the work plans from the past several years to get a more complete picture of issues that the OIG feels are important.
Expansion of DRG Payment Window. OIG states its intent is to analyze claims data to determine whether any savings could be achieved by bundling outpatient services that are delivered up to 14 days before a hospital inpatient admission. Current Medicare policy bundles outpatient services that are delivered three days prior to inpatient admission into the DRG window.
Provider-Based Status of Hospital on Physician Practices. There is currently an incentive for a physician group to bill as a provider-based physician practice where there are ties to a hospital. The OIG will be reviewing the appropriateness of physician practices who are billing as “provider-based” groups without meeting all of the necessary criteria.
Medicare Transfer Policy. The OIG will review Medicare payments made to hospitals for beneficiary discharges that should more appropriately have been coded as transfers. Hospitals that transfer beneficiaries to another facility are not entitled to the full DRG payment that is due when a patient is properly discharged. This creates an incentive for hospitals to code for a discharge when the patient is actually being transferred to another facility. The OIG will be reviewing hospital billings to look for inappropriate “discharge” classifications. Hospitals should audit their discharge and transfer practices to be certain that they are properly coding transfers where applicable.
Payment for Discharges to Swing Beds and Other Hospitals. Currently, Medicare does not reduce the DRG amount that is paid when a patient transfer is made into a “swing bed,” even when the “swing bed” is located in a separate facility. The OIG will be reviewing this practice to determine whether any savings can come from reducing DRG payments when the swing bed transfer is made to another facility.
Hospital Payments for Canceled Surgical Procedures. The OIG will be reviewing payments that are made for canceled surgical procedures which are then followed by a second payment for a rescheduled procedure. Current Medicare policy does not preclude payments for claims when there is an inpatient stay followed by canceled surgical procedure. CMS will be reviewing this policy to determine whether savings can be made in this area.
Payments from the Mechanical Ventilation. CMS will be reviewing Medicare payments for mechanical ventilation. Patients are required to receive 96 hours of mechanical ventilation in order to be eligible for payments under the DRG system.
Improve An Organization Work With Hospital. OIG will be reviewing the extent that Quality Improvement Organizations have worked with hospitals to conduct quality improvement projects and to provide technical assistance.
Hospital Acquisition of Ambulatory Surgery Centers. OIG will be reviewing hospital acquisitions of ambulatory surgery centers to determine whether these centers are being acquired as a method to increase reimbursement. ASC services that are provided as in an outpatient department of the hospital are reimbursed at higher rates than independently owned an ambulatory surgery centers.
Critical Access Hospital Payments for Swing Bed Services. Critical access hospitals are able to designate a portion of the 25 bed allotment for use as acute care or swing bed services with CMS’s approval. There is no limitation on the length of stay that is permitted for swing bed utilization. The OIG will be reviewing this policy to determine whether reimbursement changes are required in this area.
Long Term Care Issues
Long-Term Care Hospital Interrupted Stay Payments. The OIG will be reviewing Medicare payments for interrupted stays in long-term care hospitals for the year 2011. They will be identifying readmission patterns to determine whether the long-term care hospital s re-admittance policies are in compliance with rules.
Nursing Home Verification of State Agency Deficiency Corrections. The OIG will be determining whether state survey agencies properly followed up and verified fulfillment of corrective action plans for deficiencies and identified during nursing home recertification surveys. The OIG is concerned that state survey agencies may not always be verifying that identified deficiencies were properly corrected.
Nursing Home Use of Atypical Antipsychotic Drugs. The OIG will be reviewing administration of atypical antipsychotic drugs to nursing home residents. The OIG will describe characteristics associated with nursing homes that frequently administer atypical antipsychotic drugs.
Nursing Home Minimum Data Set Submissions. OIG will determine whether CMS and state agencies oversee the accuracy and completion of minimum data sets that are submitted for nursing facilities.
Home Health Care
Home Health Agency Face-To-Face Requirements. OIG will be reviewing Medicare eligible home health services to be certain that face-to-face encounters are taking place as required under the Patient Protection and Affordable Care Act. Previous studies indicated that only 30% of beneficiaries had at least one face-to-face visit with the physician who ordered the home health.
Criminal Background Checks By Home Health Agencies. The OIG will be reviewing home health agencies to determine whether they are complying with state requirements that require criminal background checks to be conducted on home health applicants and employees. Federal law requires compliance with state and local laws regarding criminal background checks. In previous OIG reviews, 92% of nursing homes employed at least one individual with criminal convictions.
Medical Equipment Suppliers
Accreditation of Medical Equipment Suppliers. OIG will be reviewing CMS procedures for conducting validation surveys of medical equipment suppliers. CMS is required to conduct validation surveys regarding beneficiary safety and quality of care that may place Medicare beneficiaries at risk.
Payments for Power Mobility Devices. A series of reviews will be conducted relative to power mobility devices. Reviews will focus on whether Medicare payments made to suppliers were made in accordance with federal regulations and were “reasonable and necessary.” OIG will also be reviewing payment methods to determine whether savings can be achieved by eliminating the option of a lump sum purchase and requiring leasing of some power mobility devices.
Continuous Positive Airway Pressure Supplies. CMS will be reviewing whether scheduling of replacement supplies is appropriate and whether changing the scheduling could avoid possible wasteful spending. There is currently no national requirement for CPAP replacement schedules.
Diabetes Testing Supplies. There are a number of new areas identified for examination relating to diabetes testing supplies. Providers involved in these areas should carefully review the new items that relate to diabetes management and testing.
Onsite Visits for Medical Providers in Supplier Enrollment and Reenrollment. CMS has the right as it deems necessary to perform onsite inspections of providers who are enrolling in the Medicare program. CMS is authorized to expand the role of unannounced pre-enrollment visits. Reviews found that some 33% of medical equipment suppliers in South Florida do not maintain physical facilities. OIG will be examining these requirements to determine whether additional site visits are appropriate.
Improper Use of Commercial Mailboxes. Medicare providers are required to establish a physical business location with a permanent visible sign and a specific street addresses. Mailboxes alone or not permitted. Recent evidence suggests that individuals attempting to defraud Medicare may be using commercial mailbox addresses for this purpose. OIG will be reviewing providers and suppliers to determine whether their listed addresses match commercial mailbox addresses.
Provider Subject To Debt Collection. CMS will be determining whether payment should be rechanneled relative to providers who have been reported to the Department of Treasury for collection of overpayment refunds.
Payment for Personally Performed Anesthesia Services. OIG will be reviewing anesthesia claims to determine whether they are supported in accordance with Medicare requirements. In order for a provider to be reimbursed as a personally performed anesthesia service, proper information must be included on the claim and in the medical chart to verify the claim. Service modifier “AA” is used in connection with anesthesia services that are personally perform. QK modifiers are used for medical direction of two, three, four concurrent anesthesia services. Providers using “AA” modifiers must be able to support the requirement for receiving 100% of the personally performed services.
Questionable Ophthalmological Service Billings for 2011. OIG will be reviewing claims data to identify questionable billings for ophthalmologic services during 2011. They will review geographic locations and provider patterns where questionable billings are located. The types of billing that will be examined were not identified.
Electrodiagnostic Testing. OIG will be reviewing questionable billing for electrodiagnostic testing and will be attempting to identify Medicare utilization rates and get different rates by provider specialty, diagnosis, and geographic areas. OIG identifies electrodiagnostic testing as an area of potential inappropriate financial gain posing significant vulnerabilities to the Medicare program.
Location Requirements for Rural Health Clinics. Rural health clinics are required to meet basic location requirements. CMS has not promulgated final regulations allowing removal of rural health clinics that did not meet location requirements. OIG will be reviewing this procedure.
Claims Processing Areas “G” Modifiers. The OIG will determine the extent to which Medicare improperly paid claims from 2002 to 2011 where certain “G” modifiers were used. “G” modifiers are used to indicate that Medicare denial is expected by the provider. It has been identified that some payments were made to providers in spite of the use of these modifier codes.
Analysis of Drug Shortage in Patient Safety Concerns. The OIG will be examining the recent trend of drug shortages to determine whether there has been an effect on pricing of pharmaceuticals. Suspicion of industry price manipulation appears to be the motivation behind this system.
This is a brief summary of some of the areas that were described in the recent 2013 Work Plan. For a more comprehensive discussion of these items, visit the website for the Office of Inspector General and download the complete fiscal year 2013 annual work plan. It is highly advisable for compliance officers to examine the document in its entirety to determine what impact, if any, it will have on their compliance efforts for fiscal year 2013. It is also good practice to review annual work plans for several previous years as part of the risk identification process.
If there are any questions regarding these requirements or how they impact compliance programs and detailed requirements that are generally described in this document, please do not hesitate to contact John Fisher, CHC, CCEP, the author of this article, or any of the attorneys on the Health Care Focus Team of Ruder Ware.
This document provides information of a general nature regarding legislative or other legal developments, and is based on the state of the law at the time of the original publication of this article. None of the information contained herein is intended as legal advice or opinion relative to specific matters, facts, situations, or issues, and additional facts and information or future developments may affect the subjects addressed. You should not act upon the information in this document without discussing your specific situation with legal counsel.
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