We warned you.
Download the 2013 OIG Work Plan
That could easily be the motto for the U.S. Department of Health and Human Services’ Office of Inspector General. Each fall, the OIG rolls out its Work Plan for the fiscal year … and each year the document outlines the OIG’s plans and enforcement priorities for HHS programs, particularly Medicare and Medicaid… and each year a number of providers, suppliers, and insurers ignore the nuances of that plan to their own detriment.
Gloria Jarmon, deputy inspector general for Audit Services, oversees a stable of more than 600 auditors. She noted, “Just in FY 2011, the estimated improper payments to the federal government were $115.3 billion dollars.” She went on to say HHS programs made up over half of those improper payments … about $65 billion … and that the majority of those were from Medicare fee-for-service and Medicaid programming.
As a result of FY 2011 audits and investigations, 2,662 individuals and entities were banned from participation in federal healthcare programs, 723 criminal actions were brought, and 382 civil actions were taken, including suits for false claims, civil monetary penalty settlements and administrative recoveries related to provider self-disclosure matters.
The OIG’s work, however, isn’t done under the cover of darkness … no cloak and dagger intrigue. Instead, the federal entity outlines its priorities in print, on YouTube, through podcasts, emails and tweets. Available for anyone to download, the 2013 Work Plan continues a large number of initiatives launched in prior years and adds more than 75 new ones for the 2013 fiscal year.
Areas of continued emphasis include fraud and abuse prevention, implementation of the Affordable Care Act (ACA), and hospital billing issues. The OIG has made it clear the group plans to vigorously investigate and prosecute cases of fraud and abuse as it pertains to Medicare and Medicaid. The ACA work includes oversight of funding grants designated for the deployment of electronic health records, health information systems and data security.
Hospital billings offer a wide range of targets for the OIG. A few new projects under Medicare Part A & B include: inpatient billing for Medicare beneficiaries, diagnosis related group window, non-hospital-owned physician practices using provider-based status, compliance with Medicare’s transfer policy, payments for discharges to swing beds in other hospitals, payments for mechanical ventilation, payments for cancelled surgical procedures, and payments for interrupted stays in long-term care hospitals. Ongoing areas of concern include same-day readmissions, acute-care inpatient transfers to inpatient hospice care, inpatient and outpatient payments to acute care hospitals, proper coding of conditions present upon admission, and appropriateness of admission and level of therapy in inpatient rehab facilities.
There appears to be an increasing scrutiny of post-acute care providers, as well. In addition to new and continuing programs impacting long-term care hospitals and inpatient rehab units, the OIG has outlined a number of initiatives geared toward home health agencies (HHA). Two new areas of interest are ensuring HHAs are complying with the face-to-face requirement and that appropriate background checks are conducted to forestall hiring home health aides with exclusionary criminal convictions. An earlier OIG review found that 92 percent of nursing homes employed at least one individual with one or more criminal convictions. Continuing programs include the timeliness, outcomes and follow-up of HHA recertification and complaints and scrutiny of improper billing and payments.
There are six new initiatives pertaining to medical equipment and supplies including an emphasis on supplier compliance with payment requirements for lower limb prosthesis and power mobility devices. Competitive bidding also continues to be an area of focus. High utilization or appropriateness of services is also tagged for Medicare beneficiaries in the areas of outpatient rehab, sleep disorder clinics and testing, and orthopaedic implant devices used in spinal fusion procedures.
Prescription drugs are also on the radar for both the Medicare and Medicaid programs. Safety and quality initiatives in the Medicare program include off-label use of drugs and supply shortages of certain drugs. A new program on the Medicare side looks at the potential savings that could be gained from using manufacturer rebates for Part B drug coverage. In 2010, federal and state governments recouped approximately $11 billion of the $29 billion Medicaid spent on prescription drugs because of statutorily-mandated rebates. That same year, more than $16 billion was spent on covered prescriptions under Part B, but a comparable program doesn’t currently exist for Medicare. Price and rebates will also come under scrutiny on the Medicaid side looking at states’ collection of physician-administered drug rebates and on supplemental rebates (both new), as well as ongoing efforts focused on the calculation of average manufacturer prices, use of generics, the federal share of collected rebates and states’ efforts with resolving rebate disputes.
A few other areas of new focus that might take some by surprise include the OIG’s scrutiny of hospitals acquiring ambulatory surgery centers and then converting them into hospital outpatient departments, payments for personally performed anesthesia, and payments to providers based on debt collection activities. The last item is a review of providers and suppliers that received Medicare payments after CMS referred them to the Department of the Treasury for failing to refund overpayments. OIG officials will look to determine the extent to which a supplier or provider ceased billing under one Medicare provider number and instead billed under a different number.
With healthcare expenditures accounting for almost a quarter of the federal budget, Roberta Baskin, OIG director of media communications, pointed out maintaining effective oversight of HHS programs is crucial. “Any one investigation can result in millions … even billions … of dollars returned to taxpayers.”