6 Takeaways from 2016 OIG Mid-Year Work Plan

The U.S. Department of Health and Human Services Office of Inspector General (OIG) released an updated Mid-Year Work Plan for FY 2016.The updated Work Plan summarizes new and ongoing reviews and activities that OIG plans to pursue in the current year and beyond. Specifically, this edition of the Work Plan removes items that have been completed, postponed, or canceled, and includes new items that have been started since October 2015.

Here’s are 6 NEW takeaways from the 2016 OIG Mid-Year Work Plan:

1. Outpatient Outlier Payments for Short-Stay Claims

Prior OIG reports have concluded that a hospital’s high charges, unrelated to cost, lead to excessive inpatient outlier payments. The mid-year OIG work plan will determine the extent of potential Medicare savings if hospital outpatient stays were ineligible for an outlier payment. CMS makes an additional payment (an outlier payment) for hospital outpatient services when a hospital’s charges, adjusted to cost, exceed a fixed multiple of the normal Medicare payment (Social Security Act (SSA) § 1833(t)(5)). The purpose of the outlier payment is to ensure beneficiary access to services by having the Medicare program share in the financial loss incurred by a provider associated with individual, extraordinarily expensive cases.

2. Intensity-Modulated Radiation Therapy

OIG will now review Medicare outpatient payments for intensity-modulated radiation therapy (IMRT) to determine whether the payments were made in accordance with Federal requirements. IMRT is an advanced mode of high-precision radiotherapy that uses computer-controlled linear accelerators to deliver precise radiation doses to a malignant tumor or specific areas within the tumor. Prior OIG reviews have identified hospitals that have incorrectly billed for IMRT services.

3. Skilled Nursing Facility Prospective Payment System Requirements

OIG will now review compliance with the skilled nursing facility (SNF) prospective payment system requirement related to a 3-day qualifying inpatient hospital stay. Medicare requires a beneficiary to be an inpatient of a hospital for at least 3 consecutive days before being discharged from the hospital, in order to be eligible for SNF services (SSA § 1861(i)). If the beneficiary is subsequently admitted to a SNF, the beneficiary is required to be admitted either within 30 days after discharge from the hospital or within such time as it would be medically appropriate to begin an active course of treatment. Prior OIG reviews found that Medicare payments for SNF services were not compliant with the requirement of a 3-day inpatient hospital stay within 30 days of an SNF admission.

4. Potentially Avoidable Hospitalizations of Medicare and Medicaid Eligible Nursing Home Residents for UTI

OIG will review nursing home records for residents hospitalized for urinary tract infections (UTI) to determine if the nursing homes provided services to prevent or detect UTIs in accordance with their care plans before they were hospitalized.

5. National Background Check Program for Long-Term-Care Employees

OIG will review the procedures implemented by participating States for long-term-care facilities or providers to conduct background checks on prospective employees and providers who would have direct access to patients and determine the costs of conducting background checks. This mandated work will be issued at the program’s conclusion as required, which is expected to be 2018 or later. (ACA, § 6201.)

6. Medicare Home Health Fraud Indicators

The Medicare home health benefit has long been recognized as a program area vulnerable to fraud, waste, and abuse. According to the Work Plan, OIG will describe the extent that potential indicators associated with home health fraud are present in home health billing for 2014 and 2015. OIG will analyze Medicare claims data to identify the prevalence of potential indicators of home health fraud.

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