Simplifying Your Approach to the OIG Work Plan

January 18th, 2013 / By Camille Cohen

When you first viewed the U.S. Department of Health and Human Services Office of Inspector General (OIG) Work Plan for FY 2013, were you almost paralyzed by the amount of reviews underway which could have implications for the way you do business? By now, many of you may have a system for ranking the most important areas of focus on the OIG’s radar for this year.  What helps me is to segment the targeted areas into a few simple themes. I find it easier to handle the large volume of data by categorizing the topics into easy-to-understand groupings that address how the OIG measures its success. Based on what the OIG publicizes as its accomplishments, success is measured by large recoveries from audits and investigations and estimated savings for U.S. Department of Health and Human Services (HHS) programs.

Taking this approach with the Work Plan, I grouped the topic areas for Medicare Parts A and B, throwing in a couple of the “Other Part A and Part B Management and Systems Issues,” and came up with the following top themes:

  • Looking for overpayments
  • Correct coding
  • Testing Medicare policies
  • Testing HHS programs

Most health care organizations rank looking for overpayments and correct coding as high priorities within their own audit plans, so let’s start by tackling these areas first.

Looking for Overpayments

Healthcare providers should be testing their systems for any potential overpayments and promptly returning monies paid in error. With the knowledge that various Recovery Auditors are also testing the accuracy of claims for payment, it makes sense to conduct your typical audits while adding the reviews from  the OIG Work Plan that makes sense for your organization. Looking for overpayments include:

  • Hospitals – Payments for Mechanical Ventilation (new audit) – OIG will review to determine if the DRG assignment and payments were appropriate looking for the 96 hours of mechanical ventilation required for the DRG payment.
  • Hospitals – Payments with Conditions Coded Present on Admission (POA) – OIG will review claims to determine if specific acute care hospitals are frequently transferring patient with certain diagnoses coded as POA to another acute care hospital.
  • Hospitals – Inpatient and Outpatient Payments to Acute Care Hospitals – OIG to review payments to hospitals to determine compliance with selected billing requirements. Using these reviews, the OIG will recommend recovery of overpayments and identify providers that routinely submit improper claims. The data mining and computer matching techniques will be a part of this review.
  • Hospitals – Duplicate Graduate Medical Education Payments – OIG to determine if duplicate or excessive graduate medical education (GME) payments have been claimed.
  • Hospitals – Inpatient and Outpatient Hospital Claims for the Replacement of Medical Devices – OIG to determine if hospitals submitted claims that included procedures for the insertion of replacement medical devices in compliance with Medicare regulations.
  • Hospitals – Outpatient Dental Claims – OIG to review Medicare hospital outpatient payments for dental services to ensure they are made in accordance with Medicare requirements.
  • Inpatient Rehabilitation Facilities (IRFs) – Transmission of Patient Assessment Instruments (PAIs) – OIG will determine if IRFs received reduced payments for claims with PAIs transmitted more than 27 days following the beneficiary’s discharge.
  • Medicare as Secondary Payer Improper Medicare Payments for Beneficiaries with Other Insurance Coverage – OIG will identify improper Medicare payments made for services to beneficiaries who have other insurance coverage.

Correct Coding

Incorrect coding can lead to overpayments and is typically reviewed by most healthcare providers. Based upon the two targets for this year, it appears that identifying and coding the correct status of patients for readmission or discharge may be an issue for some providers. Correct coding reviews include:

  • Hospitals – Same-Day Readmissions – OIG will review Medicare claims for same-day readmissions and test the effectiveness of the edit to reject subsequent claims when beneficiaries were readmitted to the same hospital on the same day.
  • Hospitals – Compliance with Medicare’s Transfer Policy (new audit) – OIG to review Medicare payments made to hospitals as discharges that should have been coded as transfers.

We’ve touched on the audit topics to address first, and the next post will discuss how the OIG will test Medicare policy and HHS Programs. These reviews are important as the resulting recommendations can impact future laws and regulations.

Questions? Comments? Leave a message below with your thoughts and opinions!

Camillle Cohen is the Compliance Officer for 3M Health Information Systems.