The Office of Inspector General (“OIG”) within the federal Department of Health and Human Services (“HHS”) is charged with protecting the integrity of HHS programs by combating fraud, abuse and waste.  On October 31, 2014, the OIG released its Work Plan for fiscal year 2015.  The Work Plan highlights the projects and issues that OIG intends to prioritize in 2015.

According to the Work Plan, the OIG will continue to emphasize oversight of Medicare and Medicaid payments, emerging payment models, IT systems security vulnerabilities (particularly in health insurance marketplaces), quality of care and access in Medicare and Medicaid, and public health and human services programs.  The Work Plan indicates that the OIG is also considering new work in the areas of food, drug and medical device supply chain integrity, electronic data security, health information technology and emergency preparedness and response.

Within these broad categories of focus, the Work Plan highlights many specific initiatives.  Many of these are ongoing projects, while others are new to this year’s Work Plan.

Some notable new initiatives include review of:

• Hospital wage data used to calculate Medicare payments
• Factors contributing to adverse and temporary harm events for Medicare beneficiaries receiving care in long-term care hospitals, determination of preventability of those events, and estimation of the costs to Medicare
• Medicare payments to independent clinical laboratories to determine labs’ compliance with selected billing requirements, with the goal of identifying those that routinely submit improper claims and recovering overpayments
• Medicaid beneficiary transfers from group homes and nursing facilities to hospital emergency rooms, with a particular focus on potential quality issues raised by high transfer rates
• Managed care organization payments for services after beneficiaries’ deaths and for ineligible beneficiaries

The Work Plan also continues a number of initiatives from prior years.  These focus areas span the healthcare provider industry – including hospitals, nursing homes, physician practices and other providers, hospices, long-term care providers, home health, ambulatory surgery centers, end-stage renal disease facilities, ambulance providers and others.  The following are a few notable initiatives relevant to various industry segments:

Hospitals

• Impact of the “two midnight” rule on inpatient and outpatient billing
• Compliance with provider-based status criteria
• Provider-based versus free-standing clinic payment rates
• Reimbursement for swing-bed services at critical access hospitals, as compared to the same level of care provided at traditional skilled nursing facilities
• Duplicate or excessive graduate medical education payments
• Outpatient evaluation and management services billed at the new patient rate, rather than the established patient rate
• Oversight of pharmaceutical compounding
• Review of medical staff candidate credentialing

Nursing Homes

• Billing for high level therapy when beneficiary characteristics remain largely unchanged
• Questionable billing patterns for Part B services during stays not paid under Part A
• Oversight of state agency verification of correction plans for deficiencies identified during recertification surveys
• Hospitalization of residents for conditions manageable or preventable in the nursing home setting

Hospices

• Review of extent of hospice services rendered to beneficiaries resident in assisted living facilities, including length of stay, levels of care and common terminal illnesses
• Appropriateness of hospice general inpatient care

Home Health

• Compliance with prospective payment system requirements, including documentation requirements
• Employment of individuals with criminal convictions

Medical Equipment

• Competitive bidding and post-award audit
• Power Mobility Devices, including rental v. lump sum payments, medical necessity and face-to-face examination requirements
• Lower limb prosthetic billing practices
• Medical necessity of nebulizer machines and related drugs
• Diabetic testing supplies, including medical necessity, frequency and other requirements

Ambulatory Surgery Centers (“ASC”)

• Review of Medicare’s methodology for ASC payment rates
• Review of disparity between payments to ASCs and hospital outpatient departments for similar surgical procedures

End-Stage Renal Disease Facilities

• Medicare payments under prospective payment system

Ambulance Providers

• Questionable billing, including medical necessity, level of transport and transports billed but not conducted
• Analysis of Part B data to identify vulnerabilities, inefficiencies and fraud trends

Physicians and Other Providers

• Place-of-service coding errors by physicians
• Payments for personally performed anesthesia services (and incorrect service code modifiers)
• Questionable billing for chiropractic services
• Inappropriate billing by opthalmologists
• Medical necessity of high-cost diagnostic radiology tests
• Documentation and medical necessity of outpatient physical therapy services
• High utilization of sleep testing procedures

The foregoing are just a few of the many initiatives outlined in the Work Plan.  Download the full Work Plan here: http://oig.hhs.gov/reports-and-publications/workplan/index.asp