On October 5, 2011, the Department of Health and Human Services Office of Inspector General (OIG) issued its work plan for 2012, which outlines specific focus areas for the OIG next year.

Focus Areas

The 2012 OIG Work Plan includes increased focus on hospital quality measures, “present-on-admission” data, same-day readmissions, payment for outpatient services performed in the 72-hour window of an inpatient admission, hospice and home health care services, billing and payment for durable medical equipment (DME) and the professional component billing of evaluation and management (E/M) services. In addition, there will be renewed interest in whether services billed under the “incident-to” guidelines meet the Centers for Medicare & Medicaid Services (CMS) criteria.

The Medicaid program also will be elevating its audit activities to include focus on home health billed and paid services, hospice billed and paid services, DME, transportation services, i.e., ambulance, and family planning services.

A list of some focus areas by facility, provider and supplier type is provided below.

All Hospitals

• Reliability of hospital-reported quality measures data
• Hospital admissions with conditions coded as “present-on-admission” as well as accuracy of present-on-admission indicators submitted on Medicare claims; although critical access hospitals (CAHs) are not as affected because these facilities are not reimbursed through the DRG system, some state Medicaid programs as well as state Blue Cross Blue Shield insurers reimburse on a DRG system, so CAHs also are responsible for collecting this data
• Medicare inpatient and outpatient payments to acute care hospitals
• Hospital outlier payments and reconciliation of outlier payments
• Hospital claims with high or excessive payments
• Hospital same-day readmissions
• Acute-care inpatient transfers to inpatient hospice care
• Duplicate Graduate Medical Education (GME) payments
• Hospital occupational mix data used to calculate inpatient hospital wage indexes
• IPPS and non-IPPS payments for nonphysician outpatient services, i.e., 72-hour rule

Critical Access Hospitals

• Appropriateness of payments to CAH, i.e., meeting designation criteria and conditions of participation, as well as review of profile variations in size, services and distance from other hospitals

Nursing Facility

• Quality of care, safety of residents and quality of post-acute care
• Review of whether Medicare and/or Medicaid certified nursing homes have implemented compliance plans and whether those plans meet criteria set forth in the OIG compliance program guidelines
• Medicare Part A payments to skilled nursing facilities
• Trends of hospitalizations and repeat hospitalizations of residents
• Questionable billing patterns during non-Part A nursing home stays

Hospice

• Marketing practices and associated financial relationships with nursing facilities
• Inpatient hospice care claims from 2005–2010, specifically inpatient claims and drug claims billed under Part D

Durable Medical Equipment Suppliers

• Payment for replacement DME supplies, home blood glucose testing supplies and effectiveness of contractor edits to prevent payments to multiple suppliers of home glucose testing supplies as well as questionable testing supply billing
• Compliance with the competitive bidding process

Physicians/Medical Practice and Other Services

• Billing for ambulance services
• Compliance with Medicare assignment rules
• Trends of billing for high levels of service or high complexity services resulting in high Part B payments
• Place of service errors, i.e., reporting place of service office instead of hospital outpatient, resulting in inaccurate reimbursement
• Services billed under the incident-to criteria that have been performed by unqualified staff and/or resulted in incorrect billing
• Consistent billing of high E/M service levels without supporting documentation and billing in error for related E/M services within an operative global period
• Payment for Part B imaging services
• Services billed by independent physical therapy providers
• Payment for polysomnography, i.e., sleep studies
• Part B payments for Hemoglobin A1C testing and increased lab service utilization
• Physician-administered drugs and biologicals

Conclusion

The annual OIG Work Plan should be part of your compliance library and should serve as a vital reference for your compliance officer and committee. Compliance officers and committees should evaluate the OIG’s focus areas and consider them as part of an annual risk assessment and development of an annual compliance work plan. This offers the ability to develop internal or external compliance review processes around the focus areas, identify potential areas of risk and develop a course of action related to the evaluation. This can help improve charge capture and billing processes, facilitate staff education and improve the overall compliance program.

For more information on the 2012 Work Plan, contact your BKD advisor or email Joe Watt at jwatt@bkd.com.