The Department of Health and Human Services Office of Inspector General (OIG) conducts audits, investigations and evaluations to ensure compliance with laws and regulations for Medicare, Medicaid and more than 300 other HHS programs.
The OIG issues its work plan each year, and the work plan provides significant signs about OIG activity and investigations over the coming year. Its fiscal year 2013 work plan was issued on October 2.
The work plan details several new areas of focus related to hospitals including inpatient billing for Medicare beneficiaries, same day readmissions, and Medicare payments made to hospitals for beneficiary discharges that should have been coded as transfers, along with other initiatives.
Although many of OIG’s focus areas continue previous years’ initiatives, the fiscal year 2013 work plan “includes many new and notable reviews and activities that could affect accreditation and payment matters under Medicare and Medicaid,” noted Stephen Bentfield and Karen Lovitch in an October 3 article from American Health Lawyers Association. Two areas of particular focus in the upcoming year relate to billing and payment issues and also the ongoing implementation of the Affordable Care Act (ACA) requirements. (S. Bentfield, Esq., K. S. Lovitch, Esq., “HHS OIG Issues FY 2013 Work Plan,” Regulation, Accreditation and Payment Practice Group Leadership, AHLA, October 3, 2012)
Areas for review and investigation include:
- When hospitals acquire ambulatory surgery centers and convert them to hospital outpatient departments, OIG will determine the effect of such acquisitions on Medicare payments and beneficiary cost sharing.
- Medicare issues in other care setting such as nursing homes, hospices and home health agencies.
- Reviewing the impact on Medicare costs associated with inpatient hospital claims for canceled surgical procedures.
- Identifying potential cost savings resulting from new payment methodologies for swing-bed services at critical access hospitals (as compared to the same level of care obtained at a skilled nursing facility).
- Medicaid reviews of manufacturer rebates, Medicaid waivers, state management of Medicaid, dual-eligible issues and Medicaid managed care.
(“DHHS OIG Releases FY 2013 Work Plan,” Health Lawyers Weekly, October 05, 2012)
OIG’s review of the ongoing implementation of the ACA covers several new focus areas. Notably, it will analyze possible savings associated with bundling outpatient services delivered up to fourteen days prior to inpatient hospital admissions into the DRG payment for the inpatient stay (compared to the three-day window that currently applies). Under the so-called DRG window policy, Medicare does not pay separately for preadmission services when they are delivered in a setting owned or operated by the admitting hospital. (S. Bentfield, Esq., K. S. Lovitch, Esq., “HHS OIG Issues FY 2013 Work Plan”)
The OIG has posted its work plan here.
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