On October 5, 2011 the Department of Health and Human Services, Office of Inspector General (OIG) posted its 2012 Work Plan. The OIG’s Work Plan sets forth the initiatives and priorities of the OIG for the 2012 federal fiscal year, which the OIG will pursue through audits, investigations, inspections, industry guidance (including advisory opinions), and enforcement actions (including actions to impose civil monetary penalties, assessments, and administrative sanctions, such as exclusions).

In addition to the audits begun in years past that will continue, some of the key OIG audits and inspections scheduled to begin in 2012 that will affect hospitals, physicians and other healthcare providers, nursing homes and Medicaid managed care organizations include:

Key Hospital Initiatives

Reliability of Hospital-Reported Quality Measure Data. Review hospitals’ controls for ensuring the accuracy and validity of data related to quality of care they submit to CMS, which is used to determine Medicare reimbursement since reimbursement to hospitals that don’t report quality measures for the 10 required indicators is reduced by 0.4 percent.

Medicare Inpatient and Outpatient Payments. Review Medicare payments to hospital to determine compliance with selected (not specified) billing requirements. The areas to be reviewed will be selected based on prior audits, inspections and investigations. This review will use data mining and computer matching techniques to select hospitals whose claims may be at risk for overpayment. Then the OIG will use the same data analysis to identify hospitals at both high and low risk for compliance issues and will compare their policies and procedures to compare the compliance practices of these two groups of hospitals. The OIG will also interview/survey hospital leadership and compliance officers about their compliance programs.

Medicare’s Reconciliation of Outlier Payments. Determine whether CMS performed the necessary reconciliations for Medicare outlier payments so that Medicare contractors could perform final settlement of cost reports submitted by providers, and whether MACs referred all providers that met the criteria for reconciliations to CMS.

Acute Hospital Inpatient Transfers to Inpatient Hospice Care. Review Medicare claims for inpatient stays where the beneficiary was transferred to hospice care, and examine the relationships between the hospitals and the hospice providers to identify financial relationships or common ownership, if any. Review how Medicare treats reimbursement for similar transfers from the acute-care setting to other settings.

Medicare Payments for Beneficiaries with Other Insurance Coverage. Review Medicare payment for services provided to beneficiaries with certain other types of insurance coverage to assess the effectiveness of procedures to prevent inappropriate Medicare payments, including review of procedures for identifying and resolving credit balances (where payments from Medicare and other insurers exceed the providers; charges or the allowed amounts).

Hospitals Occupational-Mix Data Used to calculate Inpatient Hospital Wage Indexes. Determine whether hospitals reported occupational-mix data accurately and evaluate the effect on Medicare of inaccurate reporting of such data.

Hospital Payments for Nonphysician Outpatient Services. Review the appropriateness of payments for nonphysician outpatient services provided to Medicare beneficiaries shortly before or during Medicare Part A-covered stays at non-IPPS hospitals.

Medicare Outpatient Dental Claims. Review Medicare payments for outpatient dental services to determine compliance with Medicare requirements since Medicare only pays for dental services in a few circumstances.

Observation Services during Outpatient Visits. Review Medicare payments for observation services during outpatient visits to assess the appropriateness of the services and their effect on beneficiaries’ out of pocket expenses.

Inpatient Rehabilitation Facilities. Review appropriateness of IRF admissions and the level of therapy provided in IRFs as well as how much concurrent and group therapy IRFs are providing.

Critical Access Hospitals. A general review of critical access hospitals to learn more about their structure and the type of services they provide. The OIG will review CAHs to profile the variations in size, services, and distance from other hospitals as well as the numbers and types of patients they treat.

Key Initiatives for Physicians and Other Health Care Practitioners and Entities

Ambulances: Comparison of Medicare Fee Schedule Amounts to Other Payers. Comparison of Medicare reimbursement to reimbursement by Medicare Advantage, State Medicaid programs, and the Federal Employees Health Benefits Plan to determine whether Medicare reimbursement exceeds the other programs’ reimbursement for ambulance services.

Physicians and Suppliers: Compliance with Assignment Rules. Review of the extent to which providers comply with assignment rules and determine to what extent beneficiaries are billed in excess of amounts allowed by Medicare. The OIG will also assess beneficiaries’ awareness of their rights and responsibilities regarding potential billing violations and Medicare coverage guidelines.

Providers and Suppliers: High Cumulative Part B Payments. Review what controls are in place to identify high cumulative Medicare Part B payments to individual physicians and suppliers, or on behalf of an individual beneficiary, over a specified time period.

Physicians: Incident-To Services. Review physician billing for incident-to services to determine whether payment for such services had a higher error rate than non-incident-to services. Assess CMS’s ability to monitor incident-to services.

Chiropractors: Part B Payment for Services. Review Medicare Part B payments for chiropractic services to determine whether payments were in accordance with Medicare rules.

Ambulatory Surgical Centers and Hospital Outpatient Departments: Safety and Quality of Surgery and Procedures. Review the safety and quality of care for Medicare beneficiaries in ASCs and hospital outpatient departments, including assessment of care in preparation for and provided during surgeries and procedures in both settings and identification of adverse events in both settings.

Evaluation and Management Services: Use of Modifiers During the Global Surgery Period. Review the appropriateness of the use of certain modifier codes during the global surgery period and whether Medicare payments for claims with such modifiers used during the global surgery period were in accordance with Medicare requirements.

Part B Imaging Services: Medicare Payments. Review Medicare payments for Part B imaging services to determine whether they reflect the expenses incurred and whether the utilization rates reflect industry practices, with a particular focus on certain practice expenses, including the equipment utilization rate. (This review was included in the 2011 Work Plan but apparently delayed until 2012.)

Clinical Social Workers: Part B Billing for Services to Hospital Inpatients. Review services furnished by clinical social workers to inpatients of Medicare participating hospitals and SNFs to determine whether the services were inappropriately separately billed to Medicare Part B.

Partial Hospitalization Program Services in Hospital Outpatient Departments and Community Mental Health Centers. Review of the appropriateness of Medicare payments for PHO psychiatric services in hospital outpatient departments and freestanding community mental health centers to determine whether payments met program requirements; in particular, whether payments met Medicare requirements based on documentation supporting the services, including patient plans of care and physician supervision and certification requirements.

Independent Therapists: Outpatient Physical Therapy Services. Review of outpatient physical therapy services provided by independent therapists to determine compliance with Medicare requirements, focusing on independent therapists with a high utilization rate for outpatient physical therapy services.

Sleep Testing: Appropriateness of Medicare Payments for Polysomnography. Again this year, sleep testing is on the OIG’s Work Plan, this year with a focus on the factors contributing to the rise in Medicare payments for sleep studies and to assess provider compliance with Medicare requirements.

Diagnostic Radiology: Excessive Payments. Review of Medicare payments for high-cost diagnostic radiology tests to determine whether they were medically necessary and to determine the extent to which the same tests were ordered for a beneficiary by both a primary care physician and a specialist.

Payments for ESRD Beneficiaries Entitled to Medicare Under Special Provisions. Review claims for end state renal disease (ESRD) beneficiaries entitled to Medicare coverage only because of special circumstances. The OIG will determine the extent to which beneficiaries who are eligible for Medicare benefits because of special provisions continue to obtain Medicare benefits after their coverage should have ended. (This review was also included in the 2011 Work Plan but must have been delayed since it is listed as a new start for 2012.)

Payments for Services Ordered or Rendered by Excluded Providers. Review of the nature and extent of Medicare payments for services ordered or rendered by excluded providers and examine CMS’s oversight mechanisms to identify and prevent payments for such services.

Medical Claims Review at Selected Providers. Review Medicare Part A and Part B claims submitted by error-prone providers. The OIG will select the top error-prone providers based on expected dollar error amounts and match selected providers against the National Claims History file to determine the total dollar amount of claims paid. The OIG will then conduct a medical review on a sample of claims to determine their validity, project their results to each provider’s population of claims, and request refunds on projected overpayments. (This review was included in the 2011 Work Plan, but apparently delayed until 2012).

Hospice Services: Compliance with Reimbursement Requirements. Review of whether Medicaid payments for hospice services complied with federal reimbursement regulations. Durable Medical Equipment. Determine whether Medicaid payments for medical supplies and equipment were properly authorized by physicians, actually received by beneficiaries, and whether the amounts paid were within Medicaid payment guidelines.

Payments for Health-Care-Acquired Conditions. Determine whether selected State Medicaid agencies made Medicaid payments for health-care-acquired conditions and provider-preventable conditions (for which federal funding is prohibited as of July 1, 2011) and quantify the amount of Medicaid payments for such conditions.

Key Nursing Home Initiatives

Nursing Home Compliance Plans. Review of Medicare- and Medicaid-certified nursing homes’ implementation of the Affordable Care Act requirement that nursing homes have compliance and ethics programs that include 8 specific components on or after 2013. Specifically, the OIG will evaluate how the compliance plans have been implemented as part of nursing homes’ day-to-day operations and whether the plans contain the elements identified in the OIG’s compliance program guidance for nursing homes. (Since the requirement doesn’t go into effect until 2013, it’s not clear what the OIG’s intent is in doing the review prior to 2013.)

Oversight of Poorly Performing Nursing Homes. Review of CMS’s and States’ use of enforcement measures to determine the effect on the quality of care beneficiaries receive in poorly performing nursing homes. Determine the extent to which CMS and States follow up to ensure that poorly performing nursing homes implement corrective action plans. (This review was included in the 2011 OIG Work Plan but must not have gotten underway as it is listed in the 2012 Work Plan as a new start.)

Key Home Health Agency Initiatives

Missing or Incorrect Patient Outcome and Assessment Data. Review of HHA OASIS data to identify payments for episodes for which OASIS data was not submitted or for which the billing code on the claim is inconsistent with OASIS data.

Wage Indexes Used to Calculate Home Health Payments. Determine whether Medicare home health payments were calculated using incorrect wage indexes and evaluate the adequacy of controls to prevent such inaccuracies.

Home Health PPS Requirements. Review compliance with home health prospective payment system, including the documentation that supports the claims for home health services.

Screenings of Health Care Workers. Review health screening records of Medicaid home health workers to determine whether the workers were screened in accordance with federal and State laws, including vaccinations for hepatitis and influenza.

Key Medicaid Managed Care Initiatives

Completeness and Accuracy of Managed Care Encounter Data. Review the extent to which Medicaid managed care encounter data included in MSIS submissions to CMS accurately represent all services provided to beneficiaries and the extent to which CMS acted to enforce federal requirements that such encounter data be included in MSIS.

Managed Care Entities’ Marketing Practices. Review State Medicaid agencies’ oversight policies, procedures and activities to determine the extent to which States monitor Medicaid managed care entities’ marketing practices and compliance with federal and State contractual marketing requirements as well as the extent to which CMS ensures States comply with these same federal requirements regarding managed care marketing practices.

Use of Prepayment Review to Detect and Deter Fraud and Abuse. Review the extent to which Medicaid managed care entities use prepayment reviews to detect and deter fraud and abuse as well as examine the results of such reviews, the challenges in developing and implementing the prepayment program, and lessons the managed care organizations learned about the programs.