On October 2, 2012, the U.S. Department of Health and Human Services (HHS), Office of Inspector General (OIG) released its annual Work Plan for the coming fiscal year (FY 2013 Work Plan). There are new activities and areas of interest to the OIG outlined in the FY 2013 Work Plan, in addition to the main areas of focus which have remained unchanged from year to year. Notably, the OIG is focusing on implementation of the Affordable Care Act (ACA) and hospital billing issues. Akerman provides this brief summary of the highlights of the Work Plan for your information. 

The OIG plans to continue devoting significant resources to investigating and prosecuting Medicare and Medicaid fraud. Shortly after the release of the OIG's 2013 Work Plan, the Medicare Strike Force announced the arrest of 91 individuals, including doctors, nurses and other licensed medical professionals, who were charged for their alleged participation in Medicare fraud schemes involving approximately $429.2 million in false billing. In Miami alone, a total of 33 defendants were charged for their alleged participation in various fraud schemes involving a total of $204.5 million in false billings.

The 2013 Work Plan notes that the OIG remains committed to making available a Self-Disclosure Protocol that offers providers the opportunity to possibly minimize the potential costs and disruption that a full-scale OIG audit or investigation might entail if fraud is uncovered.  In June 2012, the OIG published a Solicitation for Information and Recommendations in the Federal Register and expects to publish a revised Protocol in 2013 after considering the comments received.

Regarding the ACA, the OIG outlines the following:

• Review of possible savings regarding bundling into a diagnosis related group payment any outpatient services delivered up to 14 days before an inpatient hospital admission. Prior to the ACA, it had been a 3 day look-back;

• Review of home health agencies to verify compliance with ACA requirement that doctors have had true face-to-face encounters with beneficiaries;

• Establish frequency of on-site visits, required in certain situations, as part of the Medicare enrollment process.

Regarding Medicare, the OIG added, among others, the following items to its 'standard' Work Plan:

• Review of physician practices billing Medicare as 'provider-based' physician practices. such a practice could result in both higher Medicare payments for services and increased beneficiary costs;

• Review of inpatient hospital claims for canceled surgical procedures;

• Review of Medicare spending from the conversion of ambulatory surgical centers (ASCs) to hospital outpatient departments following the acquisition of an ASC by a hospital;

• Review of cost savings resulting from new payment methodologies for swing-bed services at critical access hospitals, as opposed to skilled nursing facilities;

• Review of the requirements and processes employed by accreditation organizations in reviewing and granting accreditation to durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) suppliers;

• Review potential savings continuous positive airway pressure machines and supplies.

Additionally, the OIG proposes to review potential Medicare savings for infused Part B-covered drugs. The OIG plans to compare the provider's acquisition cost for the infused drugs, with payments for the drugs had they been based on average sale price. Also, the OIG plans to continue to focus on prescription drugs within the Medicaid program as well.  This year the OIG is shifting its attention to reimbursement for home blood-glucose test strips. The OIG previously found that state negotiated rebates allowed state Medicaid programs to reduce payments for blood-glucose test strips. Centers for Medicaid & Medicare Services reduced Part B rates in selected areas through the DMEPOS competitive bidding program.