The Office of the Inspector General (OIG) for the U.S. Department of Health & Human Services recently published its Fiscal Year 2016 Work Plan, which summarizes OIG’s priorities over the coming year. Notably, the 2016 Work Plan demonstrates the OIG’s expanded focus on delivery system reform and the effectiveness of alternate payment models, coordinated care programs, and value-based purchasing.
There were also noteworthy areas of new focus for several provider types, including skilled nursing facilities, hospice organizations, ambulatory surgical centers, and physician practices. Below we have highlighted a few key areas from the FY 2016 Work Plan that will likely impact these providers. Please note this is not intended to be a comprehensive summary of the 2016 Work Plan and is focused only on the new OIG focal areas for these certain providers.
Skilled Nursing Facilities (SNF) – The OIG will review SNF compliance with the prospective payment system, with a special focus on whether documentation supports Medicare claims. Specifically, the Work Plan notes that prior OIG reviews revealed Medicare payments for therapy services that greatly exceeded the facility’s cost for therapy and an increasing pattern of facilities that bill for the highest level of therapy without regard for the beneficiary’s actual needs. In light of this, SNFs should review their documentation and therapy billing policies to ensure required documentation is in place demonstrating that care is reasonable and necessary, including: (1) a physician order at the time of admission for the resident’s immediate care; (2) a comprehensive assessment; and (3) a comprehensive care plan prepared by an interdisciplinary team, comprised of the attending physician, a registered nurse, and other appropriate staff.
Hospices – Although the OIG identified the general inpatient care level of the Medicare hospice benefit as an area subject to review in prior Work Plans, this year the OIG announced it will examine medical records to address concerns that the general inpatient care level of hospice care is not medically necessary. Additionally, OIG will review whether Medicare payments for hospice services were made in accordance with Medicare requirements. Thus, hospices providing this level of care should ensure all hospice care provided is palliative, rather than curative in nature; that documentation supports the medical need for inpatient hospice care; and that claims are submitted in accordance with federal regulations.
Ambulatory Surgical Centers (ASC) – This year’s Work Plan states the OIG will review Medicare’s quality oversight of ASCs. In particular, previous OIG work identified issues with Medicare’s oversight system, including gaps of five years or more between certification surveys for some ASCs, weak CMS oversight of state survey agencies and ASC accreditors, and little public transparency on the quality of ASCs. Accordingly, ASCs should prepare for an increased frequency of stricter certification surveys and the release of more facility quality data for public consumption.
Physicians and Physicians’ Practices – The OIG will review Medicare payments to physicians for evaluation and management home visits to determine whether the visits were reasonable and necessary and made in accordance with Medicare requirements. Moreover, the OIG considers the necessity of prolonged evaluation and management (E/M) services, where more than one hour of additional, direct face-to-face care is provided to a beneficiary beyond the usual service after a companion E/M service has been performed, to be rare and unusual. Under the CY 2016 Work Plan, the OIG will also analyze whether Medicare payments to physicians for prolonged E/M services were reasonable and made in accordance with Medicare requirements. Consequently, physicians providing home visits will be subject to increased scrutiny and must consistently confirm and document the medical necessity of a home visit in lieu of an office or outpatient visit. Providers should also consult the Medicare Claims Processing Manual to determine whether services provided meet the prolonged E/M service code billing requirements.
All Providers – New this year, the OIG included an oversight function that is reminiscent of CMS’s Stark Law oversight. Namely, the OIG reports it will review select Medicare services, supplies, and durable medical equipment (DME) referred and/or ordered by physicians and non-physician practitioners to determine whether payments were made in compliance with Medicare requirements. The OIG expressly noted CMS will only pay for certain services, supplies, and/or DME ordered or referred by Medicare-enrolled physicians or legally eligible non-physician practitioners. For this reason, providers should review their ordering practices and referral relationships to ascertain whether beneficiaries are referred by Medicare-enrolled practitioners.
Another new area of OIG focus relevant to all providers is OIG’s review of the adequacy of the Office for Civil Rights’ (OCR) oversight over the security of electronic protected health information (ePHI). The OIG notes that OCR has not assessed the risks, established priorities, or implemented controls for its HITECH Act requirements to provide for periodic security audits of covered entities and business associates, and therefore, has limited assurance that ePHI is adequately protected. Providers can expect OCR to ramp up its security audits in order to gain the OIG’s confidence that ePHI is adequately safeguarded by providers. Accordingly, providers should ensure they have HIPAA and HITECH Act compliant privacy and security programs in place.
In summary, it is important for all healthcare providers to understand the specific areas within their practice that will be subject to increased OIG surveillance over the next year and beyond. Take these areas into consideration and correct any issues before your practices are called into question.