Wednesday, 04 March 2015 18:03

2015 HHS OIG Work Plan Focuses on Quality and Safety

Written by Elizabeth Lamkin, MHA and Patricia Hildebrand


Original publication date of the article was November 2014

As you may be aware, the 2015 U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) Work Plan was released on Oct. 31, 2014. This should be considered mandatory reading for all healthcare providers looking to avoid fraud charges.

From an institutional perspective, a very effective method to probe for compliance issues at your organization is to compare the projects listed in the 2015 Work Plan to your organization’s current practices. As the OIG does periodically update the document, plan on revisiting the website regularly to stay current throughout the year as part of your ongoing compliance activities. For instance, with the Ebola situation in the U.S., we suspect an update related to infectious disease control may be in the works.

Staying current on OIG and Centers for Medicare & Medicaid Services (CMS) rules is not only important for compliance reasons, but due to serious financial implications for providers as well. This new OIG Work Plan reports expected 2014 recoveries of over $4.9 billion, including nearly $834.7 million in audit receivables and about $4.1 billion in investigative receivables. The investigative receivables encompass about $1.1 billion in non-HHS investigations in areas such as the states’ shares of Medicaid restitution and $15.7 million in savings from OIG recommendations.

In this article, we will attempt to summarize the plan related to Medicare Part A and B. Future articles will summarize the plan related to Parts C and D. We do, however, strongly recommend you review all parts of the plan.

The OIG was created to protect the integrity of HHS programs and the wellbeing of beneficiaries by:

  • Detecting fraud, waste and abuse;
  • Identifying opportunities to improve program economy, efficiency, and effectiveness; and
  • Holding accountable those who do not meet program requirements or who violate federal healthcare laws

This year’s work plan is 90 pages long, but the following are highlights associated with Medicare Part A and B.

2015 Projects for Hospitals: 

Policies and practices:

The OIG will compare payments across government programs and across hospitals to identify significantly different amounts for the same or similar services (outliers). It also will be looking at Medicare costs incurred because of deficiencies in services or defective medical devices, as well as non-compliance in areas with high payment error rates. Key focus areas will be:

  • Additional medical services associated with a defective medical device
  • Cost reports to identify impact on Medicare IF salaries and whether there were mandatory limits 
  • Provider-based facilities’ compliance with CMS criteria and payments to physicians at provider-based facilities versus a free-standing clinic
  • Cost-effectiveness of payments for swing-bed services at a critical access hospital (CAH) versus the same level of care at a traditional skilled nursing facility (SNF)
  • Medicare outlier payments compared to cost reports
  • Billing variations across hospitals for short inpatient stays
  • Review of new inpatient criteria (two-midnight policy) on hospital billing, Medicare payments, and beneficiary co-payments (and how billing varied among hospitals)
  • Appropriate MS-DRGs for payments for those inpatients requiring mechanical ventilation for more than 96 hours
  • “Selected inpatient and outpatient billing requirements” (the specifics for the review have not been published yet)
  • Duplicate or excessive graduate medical education (GME) payments, for which an intern or resident may be counted as more than one full-time equivalent (FTE) employee
  • Outpatient payments for dental services for non-covered services
  • Outpatient evaluation and management services paid to hospitals and billed at new patient rate when the patient had been seen within the past three years as a registered inpatient OR outpatient of that hospital in the past three years
  • Cardiac catheterization payments with a focus this year on endomyocardial biopsies and right heart catheterizations  billed during the same operative session
  • Payments to hospitals for patients with a diagnosis of kwashiorkor, which is a form of severe protein malnutrition that generally affects children living in tropical and subtropical areas during famine or insufficient food supply (a disease not typically found in the U.S.)
  • Payments to hospitals for bone marrow or stem cell transplants, with focus on appropriate diagnosis as well as documentation of all required steps of the process (mobilization, harvesting, and transplant of bone marrow or peripheral blood stem cells and the administration of high-dose chemotherapy or radiotherapy before the actual transplant) 
  • Hospital controls over the reporting of wage data used to calculate wage indexes, including deferred compensation costs
  • Hospitals’ participation in projects through their quality improvement organizations (QIOs), as well as the extent of overlap of the QIO projects with projects offered by other entities 
  • Oversight on hospitals’ pharmaceutical compounding oversight as a result of the 2012 meningitis outbreak from contaminated injections of compounded drugs
  • Hospital assessment of medical staff candidates before granting privileges
  • Incidence of adverse and temporary harm events for Medicare beneficiaries receiving post-acute care in inpatient rehabilitation facilities (IRF) and in long-term care hospitals (LTACHs), including what factors contributed to those events, to what extent the events were preventable, and the average cost to Medicare
  • Provider eligibility: The OIG will be introducing an enhanced enrollment screening process for Medicare providers related to the extent to which and the way in which CMS contractors have implemented enhanced screening procedures for Medicare providers pursuant to the PPACA 6401. This will include site visits, fingerprinting, and background checks, in addition to automated provider screening.
  • New models: The OIG will be performing a risk assessment of CMS’s administration of the pioneer accountable care organization (ACO), to include internal controls over administration of the ACO model.


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Last modified on Wednesday, 18 March 2015 22:36