On October 1, 2008, the Department of Health and Human Services, Office of Inspector General (OIG) released its 2009 Work Plan. The OIG’s Work Plan describes the initiatives and priorities of the OIG for the 2009 fiscal year. The OIG will address these initiatives through audits, investigations, inspections, and health care industry guidance documents, as well as enforcement action under federal, civil and criminal statutes. The following are some of the important 2009 OIG initiatives for hospitals, physicians, and other health care providers:
2009 Hospital Initiatives:
• Provider-Based Status for Inpatient and Outpatient Facilities: The OIG will determine the potential impact on both the Medicare program and its beneficiaries of hospitals improperly claiming provider-based status for inpatient and outpatient facilities.
• Hospital Ownership of Physician Practices: The OIG will determine whether hospitals have met the Federal requirements to obtain the provider-based designation and access the impact of the increased cost of Medicare as a result of reimbursement under the Hospital Outpatient Prospective Payment System for physician services and provider-based practices. The OIG will also determine the extent to which hospital-owned physician practices without provider-based designation were improperly received reimbursement under the Hospital Outpatient Prospective Payment System.
• Inpatient Rehabilitation Facility Payments: The OIG will determine the extent to which coding errors for claims that should have been paid as transfers have resulted in inpatient rehabilitation facilities submitted improper claims under the Medicare payment system for inpatient rehabilitation facilities.
• Critical Access Hospitals: The OIG will determine whether critical access hospitals have met the critical access hospital designation criteria in the Social Security Act and Medicare Conditions of Participation, and whether payments made to critical access hospitals were made in accordance with Medicare requirements.
• Medicare Secondary Payor: The OIG will access the effectiveness of current procedures in preventing inappropriate Medicare payments for beneficiaries with other insurance coverage. For example, the OIG will evaluate procedures for identifying and resolving credit balance situations, which occur when payments from Medicare and other insurers exceed the provider’s charges or the allowed amount.
• Reliability of Hospital-Reported Quality Measure Data: The OIG will determine whether hospitals have implemented sufficient controls to ensure that their quality measurement data are valid.
• Payments for Diagnostic X-rays in Hospital Emergency Departments: The OIG will determine the appropriateness of payments for diagnostic x-rays and interpretations paid by Medicare Part B for diagnostic x-rays performed in hospital emergency departments.
• Serious Medical Errors (“Never Events”): The OIG will review the incidences of and payments for serious medical errors, known as “Never Events,” in the Medicare population. The Tax Relief and Health Care Act of 2006 requires the OIG to conduct a study of Never Events, examining types of events and payments by any party; the extent that which the Medicare Program paid, denied payment, or recouped payment for services furnished in connection with such events; and the extent to which beneficiaries paid for such services.
• Financial Status of Hospitals in the New Orleans Area: The OIG will review the financial status of hospitals in the New Orleans area in the aftermath of Hurricane Katrina to access the needs of hospitals and options for policymakers as the area rebuilds its health care infrastructure.
The following are some significant areas for physicians:
• Place of Service Errors: The OIG will determine whether physicians properly coded the places of service on claims for services provided in ambulatory surgical centers and hospital outpatient departments, as compared to services provided in a physician’s office.
• Evaluation in Management Services During Global Surgery Periods: The OIG will determine whether industry practices related to the number of evaluation and management services provided during the global surgery period have changed since the global surgery fee concept was developed in 1992. Under the global surgery fee concept, physicians bill a single fee for all of their services usually associated with a surgical procedure and related E&M services provided during the global surgery period.
• Outpatient Physical Therapy Services Provided by Independent Therapists: The OIG will review outpatient physical therapy services provided by independent therapists to determine if they are in compliance with Medicare reimbursement regulations.
• Medicare Payments for Colonoscopy Services: The OIG will determine whether Medicare payments to physicians for colonoscopy services were properly supported, billed, and paid in accordance with Medicare requirements.
• Physicians Medicare Services Performed by Non-Physicians: The OIG will examine the qualifications of non-physician staff in physician offices that perform “incident to” services and access whether these qualifications are consistent with professionally recognized standards of care.
• Appropriateness of Medicare Payments for Polysomnography: The OIG will examine the appropriateness of Medicare payments for sleep studies. The OIG will also examine the factors contributing to the rise in Medicare payments for sleep studies and access provider compliance with Federal program requirements.
• Geographic Areas with a High Density of Independent Diagnostic Testing Facilities: The OIG will review services and billing patterns in geographic areas with high concentrations of independent diagnostic testing facilities. The IDTF is a facility that performs diagnostic procedures and is independent of a physician’s office or hospital.
• Patterns Related to High Utilization of Ultrasound Services: The OIG will review services and billing patterns in geographic areas with high utilization of ultrasound services paid by Medicare.
• Medicare Billings with Modifier GUI: The OIG will review the appropriateness of provider’s use of Modifier GUI on claims for services that are not covered by Medicare.
The following are some of the OIG investigative initiatives involving other types of providers:
• Medicare Payments for Continuous Positive Airway Pressure Devices: The OIG will review the appropriateness of Medicare Part B payments for continuous positive airway pressure (CPAP) devices.
• Medicare Payments for Chemotherapy Drug Administration Services: The OIG will review Medicare payments for chemotherapy drug administration services pursuant to the Social Security Act, § 1832, that occur without corresponding chemotherapy administration drug claims.
• Ambulatory Surgical Center Payment System: The OIG will examine changes to the revised ambulatory surgical center payment system and the rate-setting methodology used to calculate ASC payment rates.
• Physician Referrals for Home Health Agency Services: The OIG will review Medicare payments for home health claims to identify potential aberrant billing by referring physicians.
• Skilled Nursing Facility Consolidated Billing: The OIG will review Medicare Part B claims submitted by suppliers for items, supplies, or services provided to beneficiaries during Part A Medicare-Covered skilled nursing facility stays.
A copy of the OIG Work Plan can be downloaded here.