Office of Inspector General Work Plan Fiscal Year 2007 The Office - PDF document

Shipman & Goodwin LLP November 8, 2006 Office of Inspector General Work Plan – Fiscal Year 2007 The Office of Inspector General (“OIG”) of the U.S. Department of Health and Human Services (“HHS”) has published its Work Plan for the fiscal year 2007 (see http://oig.hhs.gov/publications/docs/workplan/2007/Work%20Plan%202007.pdf). The OIG Work Plan is a compilation of the various project areas that the OIG perceives as critical to maintaining the integrity and effectiveness of HHS programs. We have created for your review our own annotated summary of some of the key areas the OIG will be focusing on in the next year. If you identify an area below that may be applicable to your operations, you should consider including it in the audit and monitoring component of your corporate compliance plan. HOSPITALS The following areas have been identified as areas of focus for hospitals: • Medicare inpatient capital payments , including the accuracy and appropriateness of the current methodology used to update the capital rates. • Whether hospitals use capital payments for their intended purposes. • Whether payments were made for inpatient admissions for dialysis services when the physicians’ orders stated the level of care as admission to observation status . • Whether hospital and Medicare controls are adequate to ensure the accuracy of the hospital wage data used for calculating wage indices for the inpatient PPS .

Sh i pm a n & Goo dwi n LLP November 2006 • Payments to psychiatric facilities under the inpatient psychiatric facility PPS to determine the extent to which they were made in accordance with Medicare laws and regulations. • Whether Medicare payments are appropriately denied for “inpatient only” and related services performed in an outpatient setting and the extent to which Medicare beneficiaries are held liable for denied inpatient claims for these services. • Review inpatient hospital claims to identify providers who exhibit high or unusual patterns for selected DRGs . • Whether the audit adjustments for direct and indirect graduate medical education that fiscal intermediaries make while settling Medicare cost reports were properly reflected in the revised Medicare reimbursement. • Payments made to organ procurement organizations, and controls and cost containment practices used by organ procurement organizations to acquire organs for transplant. • Payments made to hospitals for new services and technologies and the costs associated with the new devices and technologies to determine whether reimbursement is appropriate. • Whether outlier payments to hospital outpatient departments and community health centers were in accordance with Medicare laws and regulations. • Whether Medicaid State agencies’ methods of computing inpatient hospital outlier payments result in reasonable payments. • Payments made to hospital outpatient departments under the outpatient hospital PPS to determine the extent to which they were made in accordance with Medicare laws and regulations. • Extent to which hospitals and other providers have been submitting claims for services that should be bundled into outpatient services . • Review payments under the long term care hospital (LTCH) PPS to determine the extent to which they were made in accordance with Medicare laws and regulations. 2

Sh i pm a n & Goo dwi n LLP November 2006 • Extent to which LTCHs admit patients from a sole acute-care hospital . • Whether hospitals currently reimbursed as LTCHs are in compliance with the a verage length of stay criteria . • Whether hospitals are properly identifying purchase credits rebates as a separate line item in their Medicare cost reports. • Extent of inappropriate payments for the interpretation of diagnostic x-rays performed in emergency departments . • Extent to which admissions to inpatient rehabilitation facilities (IRF) met specific regulatory requirements and whether the facilities billed for services in compliance with Medicare regulations. • Review payments to IRF’s under the PPS to determine the extent to which they were made in accordance with Medicare requirements. • Review several States’ disproportionate share hospital (DSH) payments to selected hospitals to verify that the States calculated the payments according to their approved State plans and that the payments to individual hospitals did not exceed the limits imposed by the Omnibus Budget Reconciliation Act of 1993. • Whether States are appropriately determining hospitals’ eligibility for Medicaid DSH payments . HOME HEALTH The following areas have been identified as areas of focus for home health agencies: • Whether outlier payments to home health agencies (HHAs) were in compliance with Medicare laws and regulations. • Whether HHAs’ therapy services met the Medicare regulations threshold for higher payments. • Trends and patterns in HHA survey and certification deficiencies . • Extent to which the Home Health Compare Website includes accurate and complete information on Medicare-certified home health agencies. 3

Sh i pm a n & Goo dwi n LLP November 2006 • Extent to which Medicare HHAs accurately code the Home Health Resource Group (HHRG) in the Outcome and Assessments Information Set . • Extent to which rehabilitation therapy services provided by HHAs were provided by appropriate staff and were medically necessary. • Appropriateness of Medicaid payments for Medicare-covered home health services . NURSING HOMES The following areas have been identified as areas of focus for nursing homes: • Whether rehabilitation and infusion therapy services provided to Medicare beneficiaries in skilled nursing facilities (SNF) were medically necessary, adequately supported, and actually provided as ordered. • Whether SNF care provided to Medicare beneficiaries with consecutive inpatient stays was medically reasonable and necessary. Focus will be on beneficiaries who have 3 or more consecutive stays, including at least one SNF stay. • Examine the effectiveness of CMS and State enforcement actions taken against noncompliant nursing homes. • Whether controls are in place to preclude duplicate billings under Medicare Part B for services covered under the SNF PPS and assess the effectiveness of Common Working File edits established in 2002 to prevent and detect improper payments. • Examine the type, frequency, and severity of nursing home deficiencies related to Minimum Data Set assessments and care planning . • Extent and nature of any medically unnecessary or excessive billing for imaging and laboratory services provided to nursing home residents . • Assess the implementation of Medicare Part D in nursing homes , including determining how dual eligible nursing home residents are selecting and enrolling in Medicare prescription drug programs and whether these residents are receiving the drugs they need under Part D. 4

Sh i pm a n & Goo dwi n LLP November 2006 • Whether SNFs submit “no-pay” bills as required. • Extent to which psychotherapy services are provided and medically necessary for Medicare beneficiaries residing in nursing facilities. • Whether hospice payments for services for dually eligible patients/ residents residing in nursing facilities are accurate. • Whether assessments were completed and if the plans of care correctly reflect the assessments for beneficiaries receiving hospice care , and whether beneficiaries are receiving services billed for and whether hospices are billing for services at the correct level of care. • Assess the Preadmission Screening and Resident Review (PASRR) program for Medicaid nursing facility residents aged 22 to 64 with serious mental illness or mental retardation. MENTAL HEALTH The following areas have been identified as areas of focus for mental health providers: • Whether Medicaid payments to community mental health centers are made in accordance with applicable Federal and State regulation and guidance. • Whether prepaid inpatient health plans were paid in accordance with Federal laws and regulations. Focus on States’ Medicaid supplemental mental health payments to prepaid inpatient health plans. • Whether there were improper payments and potential cost savings for Medicaid outpatient mental health services . • Whether psychiatric residential treatment facilities for children are in compliance with CMS regulations regarding the use of restraints and seclusion . • Extent to which Medicaid managed care plans are meeting early and periodic screening, diagnostic, and treatment (EPSDT) program requirements for mental health. Focus on how EPSDT programs screen, refer, and provide mental health services to children . 5