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Highlights of the OIG 2015 Work Plan

on Monday, 8 December 2014 in Health Law Advisory: Zachary J. Buxton, Editor

On October 31, 2014, the U.S. Department of Health and Human Services (“HHS”) Office of Inspector General (“OIG”) released its Work Plan for fiscal year 2015. The Work Plan identifies key areas of review and activities that the OIG plans to pursue in the upcoming year, in an effort to detect and prevent fraud, waste, and abuse in HHS programs; improve program economy, efficiency, and effectiveness; and hold those accountable who violate program rules and health care laws.

In the 2015 Work Plan, the OIG states that “[i]n FY 2015 and beyond, we will continue to focus on emerging payment, eligibility, management, and IT system security vulnerabilities in health care reform programs, such as the health insurance marketplaces.” Because oversight of Medicare and Medicaid programs constitute the majority of the OIG’s total funding, this continues to be a significant area of focus in the 2015 Work Plan. The OIG notes a particular emphasis for Medicare Part A and Part B on quality of care, appropriate payments, and oversight of payment of delivery reforms; these concerns are reflected in the specific objectives listed in the Work Plan.

Highlights of the 2015 Work Plan, as applicable to specific providers, include the following:

  • Hospitals: Hospitals continue to be a main area of focus, with 22 areas of review, including two new categories for this year. First, the OIG will review hospital controls over the reporting of wage data used to calculate wage indexes for Medicare payment, since prior OIG work identified millions of dollars in incorrectly reported wage data. In addition, the OIG will review the incidence, costs and factors contributing to adverse events for Medicare beneficiaries receiving care in long-term-care hospitals. Other notable areas of review include: the impact of new inpatient admission criteria (i.e., the “two midnight rule”) on hospital billing, Medicare payments, and beneficiary copayments and how billing varied among hospitals in FY 2014; payments for specific procedures and diagnoses, such as cardiac catheterizations and endomyocardial biopsies, bone marrow or stem cell transplants, and kwashiorkor (a form of malnutrition), which have been previously noted for improper payments; and oversight of hospital privileging, due to the relationship to patient safety.
  • Nursing Facilities, Hospice, Home Health: The focus remains on billing (i.e., Medicare Part A billing by skilled nursing facilities; questionable billing patterns for services during nursing home stays not paid under Part A; home health PPS requirements), quality of care (i.e., hospitalization for manageable and preventable conditions; employing individuals with criminal convictions in home health agencies), and appropriateness of services rendered (i.e., hospice in assisted living facilities; hospice general inpatient care). There is also a new category of review related to the rate and reasons for Medicaid beneficiary transfers from group homes and nursing facilities to hospital emergency rooms. This is an item of congressional interest based on concerns about the quality of care in some nursing facilities.
  • Provider-Based Facilities: The OIG will continue to determine the extent to which provider-based facilities meet CMS criteria, and review and compare payments for physician office visits in various locations (provider-based clinics v. free-standing clinics) to identify disparities in payment for similar procedures.
  • Laboratories: There is new area of focus on Medicare payments to independent clinical laboratories to determine laboratories’ compliance with certain billing requirements. The OIG will focus on independent clinical laboratories with claims that may be at risk for overpayments, to identify those entities that routinely submit improper claims and recommend recovery of such overpayments.
  • Other Providers: The OIG continues to examine questionable billing and payments in the areas of ambulance services, anesthesia services, chiropractic services, diagnostic radiology, imaging services, ophthalmologists, physical therapists, portable x-ray equipment, and sleep disorder clinics. Particular areas of concern are compliance with Medicare billing requirements, medical necessity and proper documentation and coding.

The 2015 Work Plan addresses several other substantive areas of interest to providers, including the risk and payment adjustments in the Part C – Medicare Advantage Program, and prescribing policies and program safeguards in the Part D – Prescription Drug Program. The 340B Program is a continued target area—the OIG plans to perform analysis regarding potential reductions in Part B spending if Medicare were able to share in the savings for 340B-purchased drugs and there is a new focus on assessing duplicate discounts for 340B-purchased drugs paid through Medicaid managed care organizations. The OIG will also review incentive payments for adopting electronic health records and CMS efforts to prevent improper payments, and will perform audits to determine the security of certified electronic health record technology under meaningful use. In addition, new for FY 2015, the OIG will conduct a risk assessment of the administration of the Pioneer ACO model.

The OIG Work Plan is a valuable resource to identify areas of heightened risk to be targeted by a facility’s compliance program. Compliance officers should carefully review the 2015 Work Plan and use the information contained therein to shape risk assessment as well as monitoring and auditing activities. The full 2015 Work Plan is available here.

Laura A. Feldman

1700 Farnam Street | Suite 1500 | Omaha, NE 68102 | 402.344.0500