Lobbying Affiliate: MML&K Government Solutions

On the Enforcement Radar: The 2012 OIG Work Plan, Kentuckydoc, Feb-March 2012, Volume 3, Issue 6

March 10, 2012

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Medical News, The Legislative Edition

Authored By Christopher J. Shaughnessy

On October 1, 2010, the Office of Inspector General of the United States Department of Health and Human Services (OIG) released its Work Plan for fiscal year 2011. At the beginning of each fiscal year, the OIG issues its annual Work Plan, which describes current audit, enforcement and evaluation activities and those the agency plans to initiate in the upcoming year. The Work Plan also provides a general view of the OIG's investigative, enforcement and compliance activities. Basically, the Work Plan informs health care providers what is on the OIG's enforcement radar in the coming year. Health care providers, their compliance officers and their legal counsel should review the Work Plan and review their own practices to ensure compliance with regulatory requirements. The following are some of the highlights from the FY 2011 Work Plan.

Provider-Based Status for Inpatient and Outpatient Facilities

The OIG plans to review cost reports of hospitals claiming provider-based status for in-patient and out-patient facilities. Hospitals claiming provider-based status often receive higher reimbursement when they include the costs of a provider-based entity in their cost reports. The OIG intends to determine the appropriateness of a provider-based designation to ensure that the facility meets all requirements of regulations governing provider-based status.

Payments for Diagnostic Radiology Services in Hospital Emergency Departments

The OIG plans to review Medicare Part B paid claims and medical records for interpretations and reports of diagnostic radiology services (x-rays, CTs and MRI's) performed in hospital emergency departments to determine the appropriateness of payments. Interpretations and reports furnished by physicians are reimbursed according to the Medicare Physicians Fee Schedule provided certain regulatory requirements are met.

Medicare Part B Payments for Home Health Beneficiaries

The OIG intends to review Medicare Part B payments for services and medical supplies provided to Medicare beneficiaries in home health settings. Most services and non-routine medical supplies furnished to Medicare beneficiaries in home health settings are included in the home health agency prospective payments. OIG plans to examine Part B payments to outside suppliers for services and medical supplies that are included in the home health agency prospective payment and examine the adequacy of controls to prevent inappropriate Medicare Part B payments for services and medical supplies.

Medicare Requirements for Quality Care in Skilled Nursing Facilities

The OIG plans to review how skilled nursing facilities have addressed certain legal requirements related to quality of care. Specifically, the OIG intends to examine the extent to which skilled nursing facilities developed plans of care based on assessments of beneficiaries, provided services to beneficiaries in accordance with plans of care, and planned for beneficiaries' discharge. The OIG will also review skilled nursing facilities' use of the required Resident Assessment Instrument to develop nursing home residents' plans of care.

Place-of-Service Errors

The OIG plans to review physician coding of place of service on Medicare Part B claims for services performed in ambulatory surgical centers and hospital outpatient departments. Medicare regulations provide for different levels of payments to physicians depending on the location where the services were performed, with Medicare paying a higher amount when a service is performed in a non-clinical setting, such as a physician's office, than when a service is performed in a hospital outpatient department or, with certain exceptions, in an ambulatory surgical center.

Coding of Evaluation and Management Services

The OIG plans to review evaluation and management (E & M) claims to identify trends in the coding of these services and to ensure that providers providing these services submit codes that accurately reflect the services provided.

All health care providers should review the Work Plan to be prepared for potential audits and other enforcement activities in the coming year.

A complete copy of the OIG FY 2011 Work Plan can be downloaded from the OIG website at www.oig.hhs.gov and clicking on the link to publications.

Christopher J. Shaughnessy is a member at McBrayer Law. Mr. Shaughnessy concentrates his practice area in healthcare law and is located in the firm's Lexington office. He can be reached at cshaughnessy@mcbrayerfirm.com or at 859-231-8780, ext. 1251.

This article is intended as a summary of federal law enforcement activities and does not constitute legal advice.

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