News: OIG Work Plan Released

Every October, the Office of the Inspector General (OIG) hands the public a cheat sheet of sorts—its annual Work Plan—releasing its list of audit targets for the coming calendar year. Sometimes its priorities echo those from previous years, other times they highlight problematic shifts warranting additional investigations. Typically, these focus areas are based on the results of OIG risk assessments, or have been significant management and performance challenges for the Department of Health and Human Services.

In 2015, the OIG plans to continue its focus on emerging payment, eligibility, management, and IT systems security vulnerabilities in healthcare reform programs, as well as quality and access in Medicare and Medicaid.

“The OIG’s examination of the appropriateness of Medicare and Medicaid payments will continue, with possible additional work on the efficiency and effectiveness of payment policies and practices in inpatient and outpatient settings, for prescription drugs, and in managed care,” the report states.

Of particular interest for CDI programs at short-term acute care inpatient facilities include the following items:

• Inpatient claims for mechanical ventilation: The OIG will review Medicare payments for certain MS-DRG assignments that require mechanical ventilation to determine whether hospitals’ DRG assignments and resultant Medicare payments were appropriate.
• Cardiac catheterizations and endomyocardial biopsies: Previous OIG reviews have identified inappropriate payments when hospitals were paid for separate for right heart catheterizations (RHC) and endomyocardial biopsies billed during the same operative session. The new reviews will determine whether hospitals complied with Medicare billing requirements.
• Kwashiorkor: Kwashiorkor is a form of severe protein malnutrition that generally affects children living in tropical and subtropical parts of the world during periods of famine or insufficient food supply, typically not found in the United States. Since the diagnosis substantially increases reimbursement, the OIG review medical records to determine whether the diagnosis is adequately supported by physician documentation. The OIG recently compiled reports of inappropriate coding and billing of kwashiorkor at three different facilities—Overlook Medical Center, in Summit, New Jersey; Providence Portland Medical Center, in Portland, Oregon; and Mother Frances Hospital, in Tyler, Texas—totaling $880,000 in appropriate reimbursement.

Of additional interest, OIG will review Medicare outpatient payments made to hospitals for evaluation and management (E/M) services billed at the “new-patient” rate to determine whether they were appropriate, and will recommend recovery of overpayments. According to Federal regulations, the meaning of “new” and “established’ pertains to whether the patient has been seen as a registered inpatient or outpatient of the hospital within the past three years.

The OIG will also take a look at the “extent and nature of hospitals' participation in quality improvement projects with Quality Improvement Organizations (QIOs)” and determine how such efforts may overlap with other hospital projects or quality improvement efforts by other government agencies. According to the Work Plan, Medicare spent $1.6 billion on QIO-related efforts over the past three-years.

CDI programs at inpatient rehabilitation facilities or long-term care hospitals may want to take a look at any adverse or temporary harm events within their patient populations to ensure documentation accurately reflects the circumstances of the patient encounter. With the national incidence of such events on the rise in these settings, the OIG hopes to identify factors contributing to these events and “determine the extent to which the events were preventable and estimate the cost to Medicare.”