OIG Workplan: What Can Providers Expect

by: Andrew Wachler

On October 1, 2007, the Department of Health and Human Services (HHS) Office of Inspector General (OIG) issued its 2008 annual Work Plan, which outlines the key focus areas and projects the OIG intends to pursue during the 2008 fiscal year (FY 2008). The OIG Work Plan is available in its entirety from the OIG website. Approximately 80 percent of the OIG’s resources are devoted to projects within the Medicare and Medicaid programs. These projects include audits, evaluations, investigations, and legal activities. This article will highlight a few of the areas within the Medicare and Medicaid programs that the OIG identified as focus areas for FY 2008. Physicians and other healthcare providers and suppliers providing services billed to Medicare and Medicaid are well-advised to review the sections of the Work Plan applicable to the services they provide, and review their existing compliance efforts, in the context of anticipated OIG activity for the upcoming year. Although the 2008 Work Plan outlines the OIG’s intended areas of activity for the fiscal year ahead, the OIG also has noted that work planning is a dynamic process that continues after the publication of its annual Work Plan. Thus, after analyzing current events and emerging issues as they arise, the OIG may add new activities or cancel or delay planned activities, as it deems appropriate. At the time of the Work Plan’s publication in October 2007, the OIG announced that it would focus on the following issues related to Medicare and Medicaid, among others, during FY 2008: A. Medicare 1. Hospitals As in previous annual Work Plans, the OIG outlined several areas of focus and initiatives it has planned for FY 2008 regarding Medicare payments made to hospitals. New in the 2008 Work Plan, the OIG articulated heightened interest in Medicare payments made to long-term care hospitals. Accordingly, long-term care hospitals may see increased investigations and audit activity during FY 2008. The OIG enumerated multiple areas of focus with respect to these hospitals. Also in FY 2008, the OIG will review physician-owned specialty hospitals for indicators of patient care and safety. The OIG cited concerns raised about the appropriateness of care and about whether staffing levels were appropriate at specialty hospitals. 2. Home Health Agencies The OIG will review national data collected regarding home health agencies’ survey and certification findings, particularly with respect to any findings of deficiency. The OIG will consider whether agencies with a history of noncompliance with certification standards perform differently during cyclical survey and certification than agencies without a history of noncompliance with certification standards. This analysis will be conducted in an effort to determine whether sanctions are effective when placed upon agencies with findings of deficiencies. The OIG will also consider whether services billed by home health agencies were appropriately coded, fully documented, and properly billed. 3. Nursing Homes and Hospice The OIG plans to review hospice services provided to Medicare beneficiaries who reside in nursing facilities and assess the appropriateness of payments for hospice care for these services. 4. Physicians and Other Health Professionals The 2008 Work Plan includes several areas of focus regarding Medicare services billed by physicians and other health professionals. These areas of focus include, but are not limited to, the areas listed below. Notably, diagnostic testing is a significant area of focus for the OIG in FY 2008, as evidenced by numerous projects identified in these areas: Place of service billing errors E/M services billed during global surgery periods Selected physician services Services billed “incident to” Psychiatric services Services performed by clinical social workers Polysomnography services Pain Management services High-frequency chiropractic treatments Business relationships and MRI Geographic areas with a high-frequency of ultrasound services Geographic areas with a high-density of IDTFs Medicare reassignment rules 5. Durable Medical Equipment As in previous years, the OIG identified multiple focus areas regarding Medicare payments for durable medical equipment supplies. The multiple areas of focus outlined by the 2008 OIG Work Plan demonstrate that durable medical equipment suppliers remain subject to high-scrutiny by the OIG, and thus these suppliers must be highly vigilant about compliance with Medicare and Medicaid regulations and policy. 6. Part B Drug Reimbursement The OIG will review Medicare Part B drug reimbursement. Among other topics, the OIG will review drug manufacturers’ methodologies for computing the average sales price for Part B medications, and will assess manufacturers’ compliance with the statutory requirements for determining the average sales price of these medications. 7. Medicare Part D Administration The OIG will continue to monitor the administration of the Medicare prescription drug benefit in 2008. Among other areas of focus, the OIG will consider the following: * Whether duplicative claims have been made for medications (e.g. whether claims submitted under Medicare Part D were also submitted under Part A or B); * Whether employer controls for the Retirement Drug Subsidy (RDS) program are sufficient; * Whether CMS’ methodology for reviewing and approving Medicare Part D sponsor bids is appropriate; and * Whether sponsors’ compliance programs are effective and compliant with federal regulations. The OIG cited a previous report finding that some sponsors’ compliance plans did not address all of the required elements concerning fraud. 8. Medicare Cross-Cutting Issues As mandated by the Tax Relief and Health Care Act of 2006, section 203, the OIG plans to conduct a series of studies of serious medical errors, known as “never events.” The OIG will study the incidence, facility response, and payments associated with these events. The studies will include an evaluation of medical error reporting and provider response, as well as other targeted studies. B. Medicaid In FY 2008, the OIG will also focus its attention upon various aspects of Medicaid payments. Among other areas of focus, the OIG will consider all of the following: Medicaid payments made to hospitals Medicaid long-term and community care Medicaid mental health services Other Medicaid services Medicaid State Children’s Health Insurance Program (SCHIP) Medicaid administration TOP MANAGEMENT AND PERFORMANCE CHALLENGES Recently, the OIG acknowledged that many projects on which it intends to focus in FY 2008 pose management and performance challenges that must be addressed with novel strategies, in addition to the current management strategies the Department of Health and Human Services (HHS) has implemented. The OIG published a publication, “Top Management and Performance Challenges,” which is available from OIG’s website, and outlines these management challenges and the steps the OIG is taking to address these challenges. The management challenges specified by the OIG include all of the following: Oversight of Medicare Part D Integrity of Medicare Payments Appropriateness of Medicaid and SCHIP Payments Medicaid Administration Quality of Care Public Health Emergency Preparedness and Response Oversight of Food, Drug, and Medical Device Safety Grants Management Integrity of Information Technology Systems and Infrastructure; and Ethics Program Oversight and Management Notably, Medicare providers and suppliers practicing in the areas listed above should be aware that there is even more governmental scrutiny on these areas than on other areas outlined in the 2008 Work Plan. The OIG is actively taking steps to address these perceived risk and management challenges.

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