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Focus on Healthcare: An Overview of the 2012 Office of Inspector General Work Plan on Healthcare Providers

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The U.S. Department of Health and Human Services Office of Inspector General (OIG) recently published its 2012 Work Plan.
January 5, 2012

The U.S. Department of Health and Human Services Office of Inspector General (OIG) recently published its 2012 Work Plan. Below are some highlighted areas by healthcare provider type:


Trending of Evaluation and Management (E/M) Coding of Claims

E/M claims will be reviewed to identify trends in coding of E/M services from 2000-2009. The OIG will also identify providers that exhibited questionable billing for E/M services in 2009. The E/M codes represent the type, setting and complexity of services provided and the patient status, such as new or established.

Compliance with Assignment Rules

The extent to which providers comply with assignment rules and beneficiaries are inappropriately billed in excess of amounts allowed by Medicare will be reviewed. In addition, the OIG will assess beneficiaries’ awareness of their rights and responsibilities regarding Medicare coverage guidelines. The “assignment” is defined as a written agreement between the patient and provider that allows a provider to request direct payment from Medicare and that the provider will accept Medicare payment for services rendered.

High Cumulative Part B Payments

Payment system controls will be reviewed to identify high cumulative Part B payments. In addition, the OIG will determine whether payment system controls are in place to identify such payments and assess the effectiveness of those controls. A “high cumulative payment” is an usually high payment made to an individual physician or supplier, or on behalf of an individual beneficiary, over a specific period.

Home Health Agencies (HHAs)

Questionable Billing Characteristics of Home Health Services

Home health agency claims will be reviewed to identify agencies that exhibit questionable billing in 2010. Questionable billing refers to claims that exhibit certain characteristics that may indicate potential fraud.

Home Health Prospective Payment System (PPS) Requirements

Compliance with various aspects of the home health PPS will be reviewed, including the documentation required in support of the claims paid by Medicare.

Home Health Agency Claims’ Compliance with Coverage and Coding Requirements

Claims submitted by HHAs will be reviewed to determine the extent to which claims meet Medicare coverage requirements. The accuracy of resource group codes submitted for Medicare home health claims in 2008 will be reviewed to identify characteristics of miscoding.

Nursing Homes

Nursing Home Compliance Plans

Medicare and Medicaid certified nursing homes’ implementation of compliance plans as a part of their day-to-day operations will be reviewed and whether the plans contain elements identified in OIGs compliance program guidance. The Affordable Care Act requires the Center for Medicare and Medicaid Services to issue compliance program regulations by March, 2012 and for skilled nursing facilities to have plans implemented that meet such requirements by March, 2013.

Questionable Billing Patterns during Non-Part A Nursing Home Stay

Questionable billing patterns associated with Part B services provided to nursing home residents whose stay was not paid for under Medicare Part A benefit will be reviewed. Certain areas of interest to the OIG are podiatry, ambulance, laboratory and imaging services.


Medicare Inpatient and Outpatient Payments to Acute Care Hospitals

Medicare payments to hospitals to determine compliance with selected billing requirements will be reviewed. The results of the reviews will be used to recommend recovery of overpayments and identify providers that routinely submit improper claims. The hospitals selected for the reviews will be based on computer matching and data mining techniques.

Medicare Payments for Beneficiaries with Other Insurance Coverage

Medicare payment for services to beneficiaries who have certain types of other insurance coverage will be reviewed to assess the effectiveness of procedures in preventing inappropriate Medicare payments. In addition, the review will evaluate procedures for resolving credit balance situations, which occur when payments from Medicare and other insurers exceed the provider’s charges or the allowed amount.

The full text of the OIG Work Plan can be found here.

While the Work Plan does not provide details on which specific providers will be reviewed, it does provide some insight on the OIG’s areas of concern. Like with any regulatory requirement, providers should ensure that appropriate controls are in place to reduce the risk on non-compliance.


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