Highlights of the OIG 2013 Work Plan

The Office of Inspector General, a component of the Health and Human Services Department of the United States Government, releases an annual work plan that hospitals, equipment manufacturers, and other entities related to the healthcare industry can use to help ensure they are in compliance with applicable laws and regulations.  The following are the highlights from the 2013 plan.

Hospitals and other Care Providers

The 2013 plan will review same day hospital readmissions for patients after their initial discharge to assure that only one DRG code is used.  In addition, they will be looking at the discharge of patients who are readmitted for treatment of the same problem or are admitted to a lower level of care facility that may be coded inappropriately as a transfer instead of a discharge.

Also on the schedule is a review of the impact of extending the pre-admission time frame for out-patient services used for DRG bundled payments from three to fourteen days prior to admission.  The OIG will be taking into consideration the effects that this would have and determine whether or not any further changes are appropriate.  They will also be looking at payments for cancelled surgeries with subsequent higher billing for the same surgery as well as payments for 96 hours or more of mechanical ventilation for patients.

The Office of Inspector General will also be examining claims of medical education payments to check for duplicate or excessive claims as well as billing by non-hospital owned doctor’s offices as provider-based physician practices to obtain higher reimbursements when they do not qualify.

Manufacturing and Supplies

The 2013 plan’s focus on equipment places an emphasis on the requirements for and the process used for companies to qualify as a Medicare supplier.  In particular, the Office of Inspector General will be examining the level of quality in supplies to ensure that they are in full compliance with Medicare regulations.

Outside of quality concerns, the impact on manufacturers and suppliers is limited, save for an examination of certain prosthetics and mobility devices.  Previous work by the Office of Inspector General uncovered certain questionable elements in claims, and the current plan is to follow up on this investigation during 2013.

Miscellaneous Tasks

A large number of other tasks are included in the Work Plan for 2013. These items include, but are not limited to:

• An examination of the frequency with which enrollment visits for Medicare occur
• A more thorough review of claims submitted by providers that have been detected as frequently erroneous in some fashion
• A study of the extent to which mailing addresses are connected to physical locations claimed on forms
• A consideration of debt collection for practices that refuse to issue refunds for detected overpayment
• A finding on the extent to which independent therapists and healthcare providers that patients are referred to are in compliance with the regulations set out by Medicare
• A determination of whether or not certain anesthesia procedures are eligible for reimbursement under applicable Medicare requirements
• A review of questionable billing practices for Ophthalmological care during 2011
• A study of the extent to which certain outlying (i.e. especially rural) practices meet zoning and location regulations for their type of practice
• Various tests on diagnostic services in many different categories, including billing and multiple instances of the same test on a patient
• A study of the extent to which non-physicians are performing certain services, particularly in regards to “incident to” care
• An overview of how certain immunosuppressive claims billed with the modifier ‘KX’ satisfy documentation requirements
• Initiatives designed to promote non-hospital or specialty care in areas such as hospice, nursing homes, and at-home health support

The above highlights are not a comprehensive list of all changes and plans that the Office of Inspector General has for the year 2013 and should not be regarded as such.  All practices are encouraged to review the full work plan published by the Office of Inspector General and study the areas of the plan that are relevant to their business.

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