By Michele McDonald
On October 2, 2012 the Office of Inspector General (“OIG”) released its Fiscal Year 2013 Work Plan. The Work Plan is published at the beginning of each Fiscal Year (“FY”) and sets forth new and ongoing targets of focus for OIG audit and compliance activity of healthcare providers, suppliers, and payers in the coming year. The 2013 Work Plan identifies a significant number of new areas of focus that healthcare providers, suppliers and payers will want to add to audit and compliance plans in their own organizations. Important new targets for hospitals, providers and suppliers include:
· Analysis of Medicare inpatient billing compliance and payment through the Inpatient Prospective Payment System (IPPS).
· Financial impact to Medicare of the expansion of the Diagnosis Related Group (DRG) payment window for outpatient services from 3 days to 14 days.
· Review of physician practices that are billing Medicare as though they are hospital owned, commonly referred to as “provider-based”, in order to receive higher reimbursement.
· Review of Medicare beneficiary hospital stays that should have been coded as transfers instead of discharges. Medicare pays the full DRG payment to a hospital for discharge of a beneficiary, but pays only a graduated amount for a beneficiary who has been transferred.
· Review of Medicare beneficiary hospital stays that were coded as discharges to a swing bed in another hospital. Swing beds are inpatient beds that can be used either for acute care or skilled nursing care. Medicare pays a reduced rate to hospitals for a beneficiary that is transferred to another acute care setting, while it pays the full amount to hospitals for a discharge of a patient to a swing bed.
· Costs to Medicare for canceled surgical procedures. Current Medicare policy allows for payment of services provided when a surgery has been canceled and then rescheduled on a separate day, resulting in two payments to the hospital.
· Review of payments made to hospitals for Medicare beneficiaries who received mechanical ventilation. Certain DRG payments require a minimum of 96 hours of mechanical ventilation. OIG will verify that mechanical ventilation DRG assignments and payments were appropriate.
· Review of supplier compliance with payment and billing requirements for diabetic testing supplies.
· Review frequency of onsite visits as part of the Medicare provider and supplier enrollment or re-enrollment process. CMS requires on-site inspection of premises for providers deemed at moderate or high risk and OIG will confirm the occurrence of these inspections.
· Analysis of the extent that Medicare Part B providers and suppliers establish locations of commercial mailboxes. All Medicare providers and suppliers must establish physical business facilities for the provision of services and supplies. OIG has evidence that attempts to defraud Medicare have been through providers or suppliers with only the location of a commercial mailbox.
OIG frequently overlaps target areas from year to year as order of importance is reassigned or further review is deemed necessary. Continuing targets in 2013 include:
· Hospital Same Day Readmissions
· Acute Care Inpatient Transfers to Inpatient Hospice
· Admissions with Conditions Coded Present on Admission
· Frequently Replaced Supplies-Supplier Compliance with Medical Necessity, Frequency and Other Requirements
· Review of Part A and Part B Claims Submitted by Top Error-Prone Providers
· Ambulance Company Compliance With Medical Necessity and Level-of-Transport Requirements
Through the Work Plan, OIG has given healthcare organizations compliance audit and review priorities for 2013. A complete copy of the 2013 OIG Work Plan is available here.
For questions about the 2013 OIG Work Plan, please contact James C. Foresman.