November 18, 2016
The United States Health and Human Services (HHS) Office of Inspector General (OIG) recently released its Fiscal Year 2017 Work Plan, which summarizes new and ongoing reviews and activities of HHS programs and operations that the OIG plans to pursue in 2017. The OIG Work Plan provides valuable insights into government regulation and enforcement areas. Providers can use the Work Plan to steer compliance activities and reduce risk associated with preventable compliance shortcomings.
In determining which projects it will undertake, the OIG considers factors including mandatory requirements for OIG review, requests made or concerns raised by Congress or the Office of Management and Budget, top management and performance challenges faced by HHS, and potential for positive impact. HHS oversees a significant portion of the national budget, with 2016 Medicare spending amounting to $595 billion. Below is a sampling of new OIG review activities announced in the 2017 Work Plan.
Activities Affecting Hospitals
- Determine whether inpatient psychiatric facilities (freestanding or hospital-based units) complied with Medicare documentation, coverage, and coding requirements for stays that resulted in outlier payments.
- Assess a sample of inpatient rehabilitation hospital admissions to determine whether patients participated in and benefited from intensive therapy.
- Determine whether Medicare payments related to Hyperbaric Oxygen Therapy outpatient claims were reimbursed in accordance with federal requirements.
- Determine whether Medicare Administrative Contractors (MACs) properly settled Medicare cost reports for Medicare disproportionate share hospital (DSH) payments in accordance with federal requirements.
Activities Affecting Physician Groups
- Review financial interests reported to CMS under the Open Payments program pursuant to Affordable Care Act § 6002 and determine the number and nature of financial interests.
- Review Open Payments data to quantify Medicare payments for drugs and DMEPOS ordered by physicians who had a financial relationship with manufacturers and group purchasing organizations.
- Review CMS’ implementation of the Quality Payment Program as required by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and its attendant regulations.
- Determine whether payments for Chronic Care Management (CCM) and Transitional Care Management (TCM) were in accordance with Medicare requirements.
Activities Affecting Skilled Nursing Facilities (SNFs)
- Review SNF reimbursements with a special focus on documentation of therapy in the Minimum Data Set tool. This activity is in response to previous OIG findings that SNFs bill for higher levels of therapy than were provided or were reasonable and necessary.
- Review state agencies’ processes for investigating complaints of abuse and neglect, and whether abuse and neglect incidents are being properly reported by SNFs.
Activities Affecting Hospices
- Review Hospice benefit vulnerabilities and draft recommendations for improvement. This is in response to identified vulnerabilities in payment, compliance, and oversight, as well as quality of care concerns.
- Review medical records and billing documentation to determine whether Hospices met Medicare conditions of payment and limitations on payment found at 42 C.F.R. Part 418 Subpart G.
- Review frequency of nurse on-site visits to assess quality of care and services. Medicare requires a registered nurse visit to Hospice patient homes at least once every 14 days to assess quality of care and services provided by the hospice aide and to ensure the services meet patient need.
Activities Affecting Home Health Agencies (HHAs)
- Compare HHA survey documentation to Medicare claims data to ensure HHAs are accurately providing patient information to State agencies during recertification surveys.
- Continue to assess HHA compliance with Medicare requirements, and work to address what the OIG perceives as an unjustifiably high improper payment error rate for HHA claims.
Activities Affecting Pharmacies
- Analyze potential government savings from drug manufacturers offering rebates for Part D prescriptions filled at 340B covered entities and contract pharmacies.
- Determine whether prospective payments made after a Part D beneficiary’s date of death were in accordance with Medicare requirements, including whether payments were associated with service dates after the beneficiary’s death.
The above list is a small sampling of the new reviews and activities that the OIG will undertake in 2017. We recommend that providers review the Work Plan closely to identify additional areas of focus for compliance teams. For more information, please contact Mary Malone at firstname.lastname@example.org or (866) 967-9604.
The information contained in this advisory is for general educational purposes only. It is presented with the understanding that neither the author nor Hancock, Daniel & Johnson, P.C., PC, is offering any legal or other professional services. Since the law in many areas is complex and can change rapidly, this information may not apply to a given factual situation and can become outdated. Individuals desiring legal advice should consult legal counsel for up-to-date and fact-specific advice. Under no circumstances will the author or Hancock, Daniel & Johnson, P.C., PC be liable for any direct, indirect, or consequential damages resulting from the use of this material.