On October 1, 2008, the Department of Health and Human Services Office of Inspector General (OIG) posted its 2009 Work Plan. The OIG's Work Plan sets forth the initiatives and priorities of the OIG for the 2009 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 (CMPs), assessments, and administrative sanctions (such as exclusions)). Some of the key 2009 OIG initiatives for hospitals, physicians, and nursing homes include:
Key Hospital Initiatives:
- Additional Part A Medicare Capital Payments for Extraordinary Circumstances -- to determine whether the additional Medicare capital payments made to hospitals for extraordinary circumstances (such as floods, fires, earthquakes) complied with Federal requirements.
- Provider-Based Status for Inpatient and Outpatient Facilities -- to determine the potential impact on the Medicare program and Medicare beneficiaries of hospitals improperly claiming provider-based status for inpatient and outpatient facilities.
- Hospital Ownership of Physician Practices -- to determine whether hospitals have met the Federal requirements to obtain provider-based designation for purchased physician practices and assess the impact of the increased cost to Medicare as a result of reimbursement as an outpatient hospital service for physician services in provider-based practices; also to determine the extent to which hospital-owned physician practices without provider-based designation improperly received reimbursement as an outpatient hospital service.
- Payments to Inpatient Rehabilitation Facilities -- to determine the extent to which coding errors for claims that should have been paid as transfers have resulted in IRFs submitting improper claims for Medicare payment.
- Inpatient Psychiatric Facility Emergency Department Adjustments -- to determine whether appropriate adjustments were made for inpatient psychiatric facilities that operate emergency departments.
- Reliability of Hospital-Reported Quality Measurement Data -- to determine whether hospitals have implemented sufficient controls to ensure that their quality measurement data are valid.
- Oversight of Compliance with EMTALA -- a review of CMS's oversight of hospitals' compliance with EMTALA to determine whether required peer reviews have been conducted prior to CMS's determination about whether to terminate a noncompliant provider from the Medicare program.
- Coding and Documentation Changes under the Medicare Severity Diagnosis Related Group (MS-DRG) System -- to determine whether specific MS-DRGs are vulnerable to potential upcoding.
- Serious Medical Errors ("Never Events") -- to review the incidences of and payments for serious medical errors ("never events") in the Medicare population; review of policies and practices regarding never events in hospitals; and review of hospitals' compliance with CMS requirements by identifying hospital-acquired conditions using the Present on Admission coding system.
- Supplemental (Upper Payment Limit, or UPL) Payments to Private Hospitals -- a review of Medicaid supplemental payments made by States to private hospitals to determine if errors exist in the calculation of the UPL.
- Potentially Excessive Medicaid Payments for Inpatient and Outpatient Hospital Services -- to determine whether vulnerabilities exits in State agencies' controls for detecting potentially excessive Medicaid payments for inpatient and outpatient hospital service.
Key Initiatives for Physicians and Other Health Care Practitioners:
- Medicare Practice Expenses Incurred by Selected Physician Specialties -- to determine whether Medicare payments for physician services performed by selected specialties are comparable to the actual expenses incurred by the physicians in providing services and operating their practices.
- Services Performed by Clinical Social Workers -- to determine whether services performed by clinical social workers in inpatient facilities were separately billed to Medicare Part B.
- Outpatient Physical Therapy Performed by Independent Therapists -- to determine whether the services billed to Medicare by independent physical therapists complied with Medicare requirements.
- Medicare Payment for Colonoscopy Services -- to determine whether Medicare payments for colonoscopy services were properly supported, billed, and paid in accordance with Medicare requirements.
- Appropriateness of Medicare Payments for Polysomnography (Sleep Studies) -- to examine the appropriateness of Medicare payments for sleep studies and the factors contributing to the rise in edicare payments for sleep studies as well as provider compliance with Federal program requirements.
- Medicare Payment for Unlisted Procedure Codes -- a review of the accuracy of Medicare payments for services billed using unlisted procedure codes.
- Laboratory Test Unbundling by Clinical Laboratories -- to determine whether clinical laboratories have unbundled profile or panel tests by submitting claims for multiple dates of service or by drawing specimens on sequential days.
- Clotting Factor Furnishing Fee -- a review of the appropriateness of the furnishing fee that Medicare pays to providers of blood clotting factor and to determine whether providers performed all of the services covered by the furnishing fee.
- Use of the Modifier GY on Medicare Claims -- to examine patterns and trends for physicians' and suppliers' use of modifier GY (used to code services that are statutorily excluded or do not meet the definition of a covered service).
Key Nursing Home Initiatives:
- Accuracy of Coding for Medicare SNF Resource Utilization Groups' (RUGs) Claims -- to determine the extent to which RUGs included in SNF claims for Medicare reimbursement are accurate and supported by the residents' medical records.
- Calculation of Medicare Benefit Days -- to determine whether SNFs submit no-pay bills as required in order to track beneficiaries' benefit periods and to determine whether failure to submit no-pay bills contributes to inappropriate calculations of SNF eligibility periods.
- Oversight of Nursing Home Minimum Data Set (MDS) Data -- review of CMS's processes for ensuring that nursing homes submit accurate and complete MDS data.
- Medicaid Payments to Nursing Homes while Dual-Eligible Beneficiaries Received Part A Covered Services -- to determine whether nursing home per diem payments from Medicaid overlap with a covered Medicare Part A service.
- Transparency of Nursing Facility Ownership -- to review ownership structures at investor-owned nursing homes to determine which entities are benefiting from the Medicaid reimbursement and to study the effects of ownership changes on the care received by Medicaid beneficiaries in nursing homes.
- Medicaid Payments for "Bed Holds" -- to determine whether CMS has effectively provided oversight of States' compliance with their bed hold policies and to assess the adequacy of States' oversight of facilities' compliance with temporary-absence-reporting requirements.
The 2009 Work Plan also includes initiatives for Home Health, Hospice, Durable Medical Equipment Suppliers, Medicare Part B Drug Claims, and the Medicare Part D Prescription Drug program.
In addition to the specific initiatives outlined in the 2009 Work Plan, the OIG reiterated its concern about fraud and abuse in the Medicare and Medicaid programs and reaffirmed its commitment of significant resources to the investigation of false claims and anti-kickback violations as well as patient abuse and neglect allegations.