The topics discussed in this article are but a small sampling of the broad array of areas that OIG will be focusing on in the coming year when implementing its audit and enforcement programs. Not surprisingly, all medical providers, including hospitals, physicians, nursing facilities, hospice providers, durable medical equipment suppliers, home health providers, and ambulance service companies are also targets for OIG audit programs. As a result, the OIG Work Plan continues to be a must read for all administrators and compliance officers. For a complete list, go to http://oig.hhs.gov/reports-and-publications/archives/workplan/2012/Work-Plan-2012.pdf.
The Usual Suspects
The Work Plan includes many “work in progress” areas of interest. Consistent with prior Work Plans, the OIG continues to focus on areas that tend to consume large quantities of Medicare funds. For that reason, these audit targets are favorites of the OIG and include: (1) evaluation and management services, with a focus on identifying providers with questionable billing and examining potentially inappropriate payments for E/M services; (2) diagnostic radiology, specifically focusing on excessive payments for high-cost diagnostic radiology tests to determine medical necessity; (3) Medicare payments to durable medical equipment providers, looking at providers who specialize in “scooters” for otherwise immobile Medicare beneficiaries and providers who supply blood glucose testing; and (4) hospital same day readmissions, continuing to focus on ensuring that hospitals are not benefiting from improper coding during these stays.
Hospital, Hospice Program and Nursing Home Relationships
Additionally, the Work Plan indicates that the OIG will take a closer look at relationships between hospitals, hospice programs and nursing homes. OIG is emphasizing compliance review of the ownership structures and referrals between these providers.
Part of this new emphasis includes an examination of the financial relationships hospice programs maintain with nursing homes and hospitals. OIG notes that a recent report indicated that 82% of hospice claims for beneficiaries in nursing facilities did not meet Medicare coverage requirements. As a result, OIG will be reviewing hospices’ marketing materials and practices and their financial relationships with nursing facilities and hospitals. More specifically, OIG has expressly indicated that they “. . . will focus [their] review on hospices that have a high percentage of their beneficiaries in nursing facilities.” Relatedly, the OIG has targeted acute-care hospital inpatient transfers to inpatient hospice programs focusing on the financial and ownership relationships between and the proper reporting of these divergent inpatient programs.
Additionally, for the first time, the OIG will review the safety and quality of Medicare beneficiaries transferred from acute-care hospitals to nursing homes, long-term-care hospitals, and inpatient rehabilitation facilities due to rises in increased transfers of Medicare beneficiaries from acute-care hospitals to nursing homes, long-term-care hospitals and IRFs.
A Sampling of the OIG’s Newest Targets
For FY 2012, the Work Plan includes several new areas of focus, which OIG will be taking a look at for the first time, including: (1) critical access hospitals, specifically examining whether hospitals are properly classified as such, i.e. ensuring that the hospital is located in a rural area, furnishes 24-hour emergency care services, provides no more than 25 inpatient beds, and has an average annual length of stay of 96 hours or less; (2) organ procurement organization payments, focusing on a determination of whether payments to such providers are correct and supported by proper documentation; and (3) the impact of physicians opting out of Medicare, appearing to target physicians involved in concierge medical practices.
Statistics Indicate a Continued Zeal for Enforcement
Based on the OIG’s reported successes from FY 2010, one can expect that the OIG will remain zealous in its pursuit of audit and enforcement priorities set forth in the current Work Plan. Some of OIG’s proudly announced successes for FY 2010 include the recoupment of more than $3 Billion and a 1600%! return on investment for dollars spent toward audit initiatives and enforcement priorities in the FY 2010.
Neah Mitchell is an associate with Balch & Bingham in the Montgomery, Alabama office. A litigator, Mitchell’s practice includes the representation of hospitals and other health care providers. Philip Sprinkle is head of the Firm’s Health Law Practice Group and is in the Atlanta office.
