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

Shipman & Goodwin LLP

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

• perations, 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.

November 8, 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
• nly” 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
• utlier 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.

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• Extent to which LTCHs admit patients from a sole acute-care hospital.
• Whether hospitals currently reimbursed as LTCHs are in compliance with the

average 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

• f 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.

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• 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

• f 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.

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• 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.

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• Extent to which Medicaid paid for outpatient mental health services for

individual beneficiaries that exceeded State utilization criteria.

LONG TERM AND COMMUNITY CARE

The following areas have been identified as areas of focus for Long Term and Community Care:

• Whether Medicaid made duplicate payments to nursing facilities and

hospitals for the same patients and whether hospitals are receiving payments for Medicaid patients who have been discharged.

• Whether providers were improperly reimbursed for services provided to

residents of assisted living facilities and the associated financial impact

• n the Medicaid program.
• Whether the State claimed costs for Home and Community Based

Services in accordance with Federal and State regulations and whether the State properly monitored compliance with the requirements of the program.

• Extent to which Medicaid paid for Home and Community Based Services

(HCBS) provided after beneficiaries’ dates of death.

• Extent to which Medicaid paid for HCBS during beneficiaries’

institutionalizations in a hospital, nursing home, or intermediate care facility.

QUESTIONS OR ASSISTANCE?

If you have any questions regarding the significance of any of these issues or how to modify your corporate compliance audit and monitoring activities, please do not hesitate to contact Joan Feldman at (860) 251-5104, Alex Lloyd at (860) 251-5102, John Lawrence at (860) 251-5139, Maureen Anderson at (860) 251-5589, or Jeri Barney at (860) 251-5108.

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