Executive Summary

On November 10, 2016, the Office of the Inspector General ("OIG") published its Work Plan for Fiscal Year ("FY") 2017 ("Work Plan"). The Work Plan, published annually, describes OIG's new and continuing audit and enforcement priorities for the upcoming year. The Work Plan is also useful in identifying corporate compliance risk areas and providing focused areas for ongoing efforts related to compliance program activities, audits and policy development. Compliance Officers should carefully review the Work Plan when preparing their organization's annual compliance audit priorities to ensure they include the pertinent risk areas identified by OIG.

Although there is significant overlap between the FY 2017 Work Plan and OIG's previous work plan activities, there are several new areas of focus. In particular, some of the significant new hospital focus areas include, but are not limited to: payment for hyperbaric oxygen therapy services; disproportionate share hospital payments; outlier payments for inpatient psychiatric facilities; and outpatient payments for intensity-modulated radiation therapy services. Significant new focus areas for other types of providers/suppliers include, but are not limited to: levels of billing for skilled nursing facilities; hospice billing; ambulance billing; and billing for inpatient rehabilitation facilities.

A complete copy of the Work Plan is available here.

A summary of OIG's key FY 2017 hospital audit areas and other activities is provided below.

Medicare Hospital Audit Activities

Significant new and revised hospital risk areas that OIG plans to pursue during FY 2017 include the following:

  • Hyperbaric Oxygen ("HBO") Therapy Services - Provider Reimbursement in Compliance with Federal Regulations (New). OIG will determine whether Medicare payments related to HBO therapy outpatient claims were reimbursed in accordance with federal requirements. Prior OIG reviews expressed concern that beneficiaries received treatment for noncovered conditions, documentation did not adequately support HBO treatments and beneficiaries received more treatments than were considered medically necessary.
  • Incorrect Medical Assistance Days Claimed by Hospitals (New). OIG will review whether, with respect to Medicaid patient days, Medicare administrative contractors ("MACs") properly settled Medicare cost reports for Medicare disproportionate share hospital ("DSH") payments in accordance with federal requirements. Medicare DSH payments include many complex variables that may create risk of overpayment for claims submitted by DSH hospitals, based on Medicaid patient days counted on Medicare cost reports.
  • Inpatient Psychiatric Facility Outlier Payments (New). OIG will determine whether Inpatient Psychiatric Facilities complied with Medicare documentation, coverage and coding requirements for stays that resulted in outlier payments. OIG noted significant increases in the number of claims with outlier payments and the total amount of outlier payments.
  • Intensity-Modulated Radiation Therapy ("IMRT") (Revised). OIG will review whether Medicare outpatient payments for IMRT, an advanced mode of high-precision radiotherapy, were made in accordance with federal requirements. Prior OIG reviews concluded that some hospitals incorrectly billed for IMRT services performed as part of developing an IMRT plan.

Other Continuing Medicare Hospital Audit Activities

In FY 2017, OIG will also continue to examine several compliance risk areas that have been the focus of previous years' work plans, including the following:

  • Outpatient Outlier Payments for Short-Stay Claims
  • Comparison of Provider-Based and Freestanding Clinics
  • Reconciliations of Outlier Payments
  • Hospitals' Use of Outpatient and Inpatient Stays Under Medicare's Two-Midnight Rule
  • Medicare Costs Associated with Defective Medical Devices
  • Payment Credits for Replaced Medical Devices That Were Implanted
  • Medicare Payments for Overlapping Part A Inpatient Claims and Part B Outpatient Claims
  • Selected Inpatient and Outpatient Billing Requirements
  • Duplicate Graduate Medical Education Payments
  • Indirect Medical Education Payments
  • Outpatient Dental Claims
  • Nationwide Review of Cardiac Catheterizations and Endomyocardial Biopsies
  • Payments for Patients Diagnosed with Kwashiorkor
  • Review of Hospital Wage Data Used to Calculate Medicare Payments
  • CMS Validation of Hospital-Submitted Quality Reporting Data
  • Long-Term Care ("LTC") Hospitals - Adverse Events in Post-Acute Care for Medicare Beneficiaries
  • Hospital Preparedness and Response to Emerging Infectious Diseases

Other Provider/Supplier Audit Activities

The Work Plan identifies enforcement priorities not only for hospitals, but also for other types of providers/suppliers, including skilled nursing facilities ("SNFs"), hospices, ambulance suppliers and individual practitioners, including chiropractors and mental health providers. Some of the significant new focus areas that OIG identified for these providers/suppliers during FY 2017 include the following:

  • Nursing Home Complaint Investigation Data Brief (New). OIG will examine the extent to which state agencies investigate nursing home complaints categorized as immediate jeopardy and actual harm within the required timeframes.
  • Unreported Incidents of Potential Abuse and Neglect in SNFs (New). OIG will assess the incidence of abuse and neglect of Medicare beneficiaries receiving treatment in SNFs to determine whether incidents were properly reported and investigated pursuant to state and federal requirements.
  • SNF Reimbursement (New). OIG will review documentation for SNFs to assess their compliance with particular resource utilization group requirements. Previously, OIG investigations found that SNFs billed for higher levels of therapy than were provided or were reasonable or necessary.
  • National Background Checks for Long-Term Care Employees (Revised). OIG will determine the outcomes and consequences of state procedures implemented for LTC facilities and providers to conduct background checks on prospective employees who would have direct contact with patients.
  • Review of Hospices' Compliance with Medicare Requirements (New). OIG will review hospice medical records and billing documentation to determine whether Medicare payments for hospice services were made in accordance with Medicare requirements.
  • Comparing Home Health Agency ("HHA") Survey Documents to Medicare Claims Data (New). OIG will assess whether HHAs are accurately providing patient information to state agencies for recertification surveys to avoid scrutiny of potentially unqualified or fraudulent providers.
  • Part B Services During Non-Part A Nursing Home Stays: Durable Medical Equipment (New). OIG will study the extent of inappropriate Medicare Part B payments for durable medical equipment, prosthetics, orthotics and supplies ("DMEPOS") provided during non-Part A stays. Also, OIG will examine if CMS has a system to identify and recoup inappropriate payments for DMEPOS from suppliers.
  • Supplier Compliance with Documentation Requirements for Positive Airway Pressure ("PAP") Device Supplies (New). OIG will review claims for frequently replaced PAP device supplies to determine compliance with documentation requirements for medical necessity, frequency of replacement and other Medicare requirements.
  • Medicare Payments for Transitional Care Management ("TCM") (New). OIG will determine whether payments for TCM services were made in accordance with Medicare requirements. TCM services cannot be billed during the same service period as chronic care management, end-stage renal disease and prolonged services without direct patient contact.
  • Medicare Payments for Chronic Care Management ("CCM") (New). OIG will review payments made for CCM services to determine whether payments were made in accordance with Medicare requirements. CCM services cannot be billed during the same service period as TCM, home health care supervision/hospice care or certain end-stage renal disease services.
  • Ambulance Services - Supplier Compliance with Payment Requirements (Revised). OIG will assess whether Medicare payments for ambulance services were made in accordance with Medicare requirements. Prior OIG work identified inappropriate payments for advanced life support emergency transports.
  • Inpatient Rehabilitation Facility ("IRF") Payment System Requirements (Revised). OIG will determine whether IRFs billed claims in accordance with Medicare documentation and coverage requirements. Medical record documentation must support a reasonable expectation that the patient needs multiple intensive therapies, is able to actively participate and demonstrate measurable improvement and requires supervision by a rehabilitation physician to maximize benefit from the rehabilitation process. Prior reviews have identified substantial Medicare overpayments related to IRF admissions.

Other New and Continuing Provider/Supplier Audit Activities

OIG will also focus on the following areas in FY 2017:

  • SNF Prospective Payment System Requirements
  • Potentially Avoidable Hospitalizations of Medicare- and Medicaid- Eligible Nursing Facility Residents
  • Home Health Compliance with Medicare Requirements
  • Orthotic Braces - Reasonableness of Medicare Payments Compared to Amounts Paid by Other Payers
  • Osteogenesis Stimulators - Lump-Sum Purchase Versus Rental
  • Power Mobility Devices - Lump-Sum Purchase Versus Rental
  • Competitive Bidding for Medical Equipment Items and Services - Mandatory Review
  • Orthotic Braces - Supplier Compliance with Payment Requirements
  • Nebulizer Machines and Related Drugs - Supplier Compliance with Payment Requirements
  • Access to Durable Medical Equipment in Competitive Bidding Areas
  • Review of Financial Interests Reported Under the Open Payments Program
  • Ambulatory Surgical Centers - Quality Oversight
  • Payments for Medicare Services, Supplies and DMEPOS Referred or Ordered by Physicians - Compliance
  • Anesthesia Services - Noncovered Services
  • Anesthesia Services - Payments for Personally Performed Services
  • Physician Home Visits - Reasonableness of Services
  • Prolonged Services - Reasonableness of Services
  • Chiropractic Services - Part B Payments for Noncovered Services
  • Chiropractic Services - Portfolio on Medicare Part B Payments
  • Selected Independent Clinical Laboratory Billing Requirements
  • Physical Therapists - High Use of Outpatient Physical Therapy Services
  • Portable X-Ray Equipment - Supplier Compliance with Transportation and Setup Fee Requirements
  • Sleep Disorder Clinics - High Use of Sleep-Testing Procedures

Practical Takeaway

The Work Plan offers providers a preview of many of OIG's enforcement priorities for 2017. Providers should familiarize themselves with the Work Plan and use it to help identify potential risk areas in their organizations. The Work Plan is a critical tool in maintaining an effective compliance program and may help prevent government scrutiny and enforcement activity at your organization.