On October 1, 2009, the Department of Health and Human Services, Office of Inspector General (OIG) posted its 2010 Work Plan. The OIG’s Work Plan sets forth the initiatives and priorities of the OIG for the 2010 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). Some of the key 2010 OIG audits and inspections scheduled to begin in 2010 that will affect hospitals, physicians and other healthcare practitioners, nursing homes, and Medicaid managed care organizations include:
Key Hospital Initiatives:
- Hospital Payments for Nonphysician Outpatient Services Under the IPPS – review of the appropriateness of outpatient services rendered within 3 days of an inpatient hospital stay (including services rendered by entities "under arrangements" with hospitals)
- Inpatient Rehabilitation Facility Submission of Patient Assessment Instruments – to determine whether CMS properly reduced payments to IRFs when the IRF transmitted a patient assessment after the defined time limit (42 CFR 412.614(d)(2)).
- Reliability of Hospital-Reported Quality Measure Data – review of the accuracy of data submitted by hospitals to CMS related to quality of care as required by section 1886(b)(3)(vii) of the Social Security Act in order to avoid a payment reduction.
- Hospital Admissions with Conditions Coded Present-on-Admission – to determine the number of inpatient hospital admissions for which certain diagnoses were coded as present on admission and to determine which diagnoses were most frequently coded as POA. The OIG will also determine which types of facilities most frequently transfer patients with POA diagnoses to hospitals and whether specific providers transferred a particularly high number of patients with POA diagnoses.
- Hospital Readmissions – to test the effectiveness of a CMS edit intended to prevent hospitals from receiving two DRG payments if a same-day readmission occurred for symptoms related to or for evaluation or management of the prior stay's medical condition. The OIG will also review the oversight of hospital readmissions to determine whether the hospital services (presumably in the first stay) met professional standards of care.
- Oversight of Compliance with EMTALA – a review of CMS's oversight of hospitals' compliance with EMTALA to determine whether there are variations among CMS regional offices in evaluating EMTALA complains and referring cases requiring investigation to State licensing agencies. In addition, the OIG will continue with an initiative identified in the 2009 Work Plan 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.
- Observation Services During Outpatient Visits – review of hospitals' use of observation services and how that affects beneficiaries' care and ability to pay for out of pocket expenses.
- Coding and Documentation Changes Under the MS-DRG System – to review the MS-DRGs in order to identify any that are particularly vulnerable to upcoding.
Key Initiatives for Physicians and Other Health Care Practitioners:
- Trends in Medicare Hospice Utilization – review of Part A hospice claims in order to identify trends in hospice utilization, including the characteristics of hospice beneficiaries, geographical variations in utilization, and differences between for-profit and not-for-profit providers.
- Medicare Incentive Payments for E-Prescribing – review of Medicare incentive payments made in 2010 to eligible health care professionals for their 2009 e-prescribing activities to determine whether incentive payments were made in error, and if so, to assess CMS's actions to remedy erroneous payments.
- Medicare Payments for Part B imaging Services – review of payments for certain Part B imaging services with a focus on the practice expense component included in the payment for such services, including equipment utilization rate, in order to determine whether the Medicare payment for such services reflects actual expenses incurred and whether the utilization rate reflects current industry 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 (listed in 2009 OIG Work Plan but apparently the start date was delayed to 2010).
- Outpatient Physical Therapy Performed by Independent Therapists – to determine whether the services billed to Medicare by independent physical therapists complied with Medicare requirements (listed in 2009 OIG Work Plan but apparently the start date was delayed to 2010).
- 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) (listed in 2009 OIG Work Plan but apparently the start date was delayed to 2010).
- 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 Medicare payments for sleep studies as well as provider compliance with Federal program requirements (listed in 2009 OIG Work Plan but apparently the start date was delayed to 2010).
- Geographic Areas with a High Density of IDTFs – a review of billing patters, provider and beneficiary profiles, and services billed in areas with high concentrations of IDTFs.
- Enrollment Standards for IDTFs – to determine whether IDTFs are in compliance with the 14 standards that IDTFs certify compliance with in the enrollment application.
- Medicare Providers' Compliance with Assignment Rules – a review of provider compliance with assignment rules, in particular, whether providers treat the Medicare payment as payment in full, and to determine beneficiary awareness with their rights and responsibilities related to Medicare billing violations and Medicare coverage guidelines.
- Payments for Services Ordered or Referred by Excluded Providers – a review of Medicare payments for services ordered or referred by excluded providers with a focus on the referring/ordering providers; a review of oversight mechanisms CMS has in place to identify and prevent improper payment for services based orders or referrals by excluded individuals.
- Ambulance Services Used to Transport ESRD Beneficiaries – a review of the extent to which ambulance services are used to transport ESRD beneficiaries to and from dialysis facilities.
- Physician Self-Referral for DME Services – This is a review for compliance with the Stark Law. The OIG will review DME payments to DME suppliers in which physicians held an ownership interest.
- Appropriateness of DME Categorization – a review of the appropriateness of DME categorization in the Medicare fee schedule in light of current costs, expected duration of beneficiary use, or extent of servicing involved to maintain the equipment, in order to determine whether DME are properly classified.
- Medicare Pricing for Parenteral Nutrition – a review of the Medicare fee schedule in comparison to fees paid by other payors.
- Medicaid Payments for Personal Emergency Response Systems – review of one state's payments to providers of personal emergent response systems to determine allow-ability for federal matching funds.
- Medicaid Physician and Occupational Therapy Services: Appropriateness of Payments – review of the medical necessity, billing, and qualification of providers of physical therapy and occupational therapy to Medicaid beneficiaries.
Key Nursing Home Initiatives:
- Oversight of Poorly Performing Nursing Homes – review of CMS/State use of enforcement measures (such as survey and certification reviews) for poorly performing nursing homes in order to determine their impact on improving quality of care.
- Oversight of Nursing Home MDS – a review of CMS's processes for ensuring that nursing homes submit accurate and complete MDS data.
- Medicaid Nursing Home Patients: Quality of Care – review of certain nursing facilities who may have provided substandard care based on conditions present in patients admitted to hospital (pressure sores, infections, or both).
- Medicaid Incentive Payments for Nursing Facility Quality-of-Care Performance Measures – review of incentive payments made by Medicaid agencies to nursing facilities based on the nursing facility's performance on quality of care measures to determine if the States have sufficient controls in place to assess quality of care performance and whether the incentive payments were made in accordance with program requirements.
Key Medicaid Managed Care Initiatives:
- Medicaid Managed Care Fraud and Abuse Safeguards – review of State monitoring of managed care organizations' fraud and abuse program safeguards.
- Medicaid Managed Care Marketing Practices – review of State oversight and monitoring of managed care organization marketing practices.
Key Recovery Act Initiatives:
- Breach Notification and Medical Identity Theft in Medicare – examination of CMS's compliance with the new breach notification requirements under the HIPAA Privacy and Security Rules.
- Medicare Incentive Payments for Electronic Health Records – review of Medicare incentive payments made to eligible health care professionals and hospitals for adopting electronic health records (payments begin in 2011).
The 2010 OIG Work Plan also includes initiatives for Home Health, Medicare Part B Drug Claims, Medicare Advantage, and the Medicare Part D Prescription Drug program and well as a number of additional planned reviews related to the American Recovery and Reinvestment Act of 2009 (the Recovery Act).
In addition to the specific initiatives outlined in the 2010 Work Plan, as in years past, the OIG again 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.