Healthcare News & Insights

2016 OIG Work Plan: What hospitals need to look for

Do you know where your hospital needs to focus its compliance efforts in the new year? The Office of Inspector General (OIG) recently released its 2016 Work Plan, and it’s chock full of updates that’ll give facilities an idea of exactly what areas the feds’ll be closely monitoring. 

490654035Many of the heavy-hitters from years past remain part of the new Work Plan.

As you likely expect, the OIG’s placing significant scrutiny on the “two-midnight” rule in the coming year, reviewing how hospitals’ use of inpatient and outpatient stays changes under the rule –as well as any changes in reimbursement hospitals receive.

The agency will also continue to examine the inclusion of salaries in hospital cost reports, making sure all included employee compensation is reasonable and that workers’ roles relate appropriately to facility operations and patient care.

Provider-based facilities owned and operated by hospitals are also on the feds’ radar. In particular, they’re looking to see whether the facilities meet the requirements for payment and whether the Centers for Medicare & Medicaid Services (CMS) is overseeing billing as closely as it should.

Because provider-based facilities are paid for procedures at higher rates than free-standing clinics, the OIG wants to make sure reimbursement is appropriate. It’ll also be comparing provider-based facilities to non-hospital-affiliated clinics to see if the difference in payment is warranted. Be warned: This could lead to reimbursement adjustments down the line.

Payment scrutiny

According to the Work Plan, the OIG will also continue to evaluate the appropriateness of payments for:

  • inpatient claims for mechanical ventilation
  • intensity-modulated radiation therapy
  • duplicate graduate medical education
  • indirect medical education
  • outpatient dental claims
  • cardiac catheterizations
  • endomyocardial biopsies
  • claims with a kwashiorkor diagnosis
  • bone marrow and stem-cell transplants, and
  • other selected inpatient and outpatient billing requirements (to recommend paybacks for what it calls “claims that may be at risk for overpayments”).

The agency is also still looking at hospital wage data that’s used to calculate Medicare payments. It’s checking that hospitals are ensuring the information that’s reported to the feds is correct.

If the OIG finds any big errors, it could result in policy changes that affect how you track and submit this data.

What’s new for 2016

New areas of focus for the OIG abound this year.

One change concerns medical devices. The OIG’s already looking at Medicare costs associated with defective medical devices, but now it’s also reviewing payments for replaced medical devices.

Specifically, the agency will look at surgical procedures where devices were replaced because of complications, defects or recalls to determine whether hospitals were paid properly for these services. Here’s why: Payments should be reduced for these services, but according to the feds, this doesn’t always happen.

Another new focus for 2016: Medicare payments during the MS-DRG payment window. The agency plans to examine payments to acute-care hospitals to see whether claims submitted for reimbursement under Medicare Part B were valid, since some services administered to inpatients are covered under Medicare Part A and shouldn’t be reported separately to Part B.

And for those facilities that feel burdened by quality reporting, it’s not going away. In fact, the OIG’s placing a renewed emphasis on making sure the information is more accurate. During 2016, the agency will be looking at how well CMS is validating the quality-reporting data hospitals are submitting to the feds.

Because it’s used to determine payments under value-based purchasing and the hospital-acquired condition reduction program, this data needs to be correct and thorough, and the OIG is making sure hospitals are dotting their i’s and crossing their t’s before submission.

Make sure your compliance program hones in on the OIG trouble-spots that affect your hospital the most so you can avoid unwarranted scrutiny in the new year.

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