2014 U.S. Department of Health and Human Services Office of Inspector General Work Plan

By Baker Newman Noyes March 9, 2014

The 2014 Office of Inspector General (OIG) health care work plan was recently issued. This plan summarizes new and ongoing reviews and activities to be conducted by the OIG to ensure that health care providers are working consistently with known laws and regulations and to ensure that tax payer dollars, as well as other scarce resources, are spent prudently.

The OIG program was developed to protect the integrity of the U.S. Department of Health and Human Services (HHS) programs and operations and the well-being of beneficiaries by detecting and preventing fraud, waste and abuse. The program seeks to gain efficiencies and effectiveness in program economy and hold those accountable who do not meet its requirements or violate federal laws. Its mission extends to over 300 Medicare and Medicaid programs in addition to programming by the National Institutes of Health, Food and Drug Administration, the Centers for Disease Control and the Administration for Children and Families.

OIG officials conduct audits, evaluations, and investigations and provide guidance to health care providers regarding the implementation and maintenance of national and state health care programming. When appropriate, providers may be imposed civil monetary penalties, assessments and other administrative sanctions. A branch of HHS collaborates with The Office of Audit Services, The Office of Evaluation and Inspections, The Office of Investigations and The Office of Counsel to the Inspector General.

The OIG and its collaborative partners take their mission seriously! In 2013, the OIG reported expected recoveries of over $5.8 billion which includes over $1 billion attributed to non-HHS investigative receivables resulting from audit work in areas such as the state’s shares of Medicare restitution.

The 2014 OIG work plan outlines the office’s current thinking, focus areas and primary objectives for each project by provider type. Selected projects are reported in this article by provider. For a full listing of OIG projects or to download the entire work plan please visit the Department of Health and Human Services website.

Medicare Part A and Part B

Hospitals-Related Policies and Practices

• Reconciliation of outlier payments
• New inpatient admission criteria
• Medicare costs associated with defective medical devices
• Analysis of salaries included in hospital cost reports
• Impact of provider-based status on Medicare billing
• Comparison of provider-based and free-standing clinics
• Critical Access Hospital – Payment policy for swing beds
• Critical Access Hospital – Beneficiary costs for outpatient services
• Long-term-care hospitals’ billing patterns associated with interrupted stays
• Outpatient evaluation and management services billed at the new patient rate

Nursing Homes

• SNF Part A billing practices as compared to beneficiary characteristics
• SNF Part B billing practices associated with unqualified resident stays
• Test state agency verification of deficiency corrections in Nursing Homes
• Program for national background checks for long-term care employees
• Hospitalizations of nursing home residents for manageable and preventable conditions

Hospice

• Hospice in assisted living facilities
• Hospice general inpatient care

Home Health Services

• Home health prospective payment system requirements
• Employment of individuals with criminal convictions

Prescription Drugs

• Part B payments for 340b drug purchases
• Manufacturer reporting of average sales prices for Part B drugs
• Covered uses for Medicare Part B drugs
• Payment for compounded drugs under Medicare Part B

Other Providers

• Ambulance Services   Portfolio report on Medicare Part B payments
• Ambulance Services – Questionable billing, medical necessity, level of transport
• Ambulatory Surgical Centers – Payment system
• Rural Health Clinics – Compliance with location requirements
• Diagnostic Radiology – Medical necessity of high-cost tests
• Imaging Services – Payments for practice expenses
• Physicians and Suppliers – Noncompliance with assignment rules and excessive billing of beneficiaries
• Physicians – Place of service coding errors

We recommend that all health care providers read the OIG Work Plan annually. It not only informs you what OIG will be focusing on during the upcoming year, it assists in gaining perspective of the overall health care audit plans and problems they foresee in other industries. Many times there is a focused project review in an exclusive provider type in one year and the next year the same review is conducted in another industry. Paying attention to these projects and review patterns will allow you to strengthen your compliance program and avoid major issues with the OIG.

In 2013 there were 3,214 individuals and entities excluded from participation in the federal health care program, along with 960 criminal actions against individuals or entities that engaged in crimes against HHS programs. This is in addition to over 470 civil actions, false claims and unjust-enrichment lawsuits, civil monetary penalties settlements and administrative recoveries related to provider self-disclosure matters.

That said, staying up to date on federal and state health care regulations pays dividends beyond those remittance advices we look forward to seeing. Ensuring that your compliance and internal audit programs are in sync, your billing practices adhere to all known regulations and your quality care review type is focused on new health care reform standards and measure will go a long way in ensuring that the OIG keeps a long distance from your doorway.

For more information, please contact your BNN advisor at 1.800.244.7444.