Healthcare News & Insights

2015 OIG workplan: What’s under the microscope next

The Office of the Inspector General (OIG) has released its new workplan outlining what areas of the healthcare industry would be under scrutiny next year. Twenty-two of those areas are related to hospital operations and billing. 

168720747So hospital leaders should get ready for some extra scrutiny this year.

Here’s what you can expect from the OIG in 2015.

Billing scrutiny

A large number of the areas the OIG will be investigating could have serious impact on facilities’ billing and reimbursement.

Some of the reimbursement areas the OIG is looking at include:

  • The affect of updated “new patient” criteria. In particular, the OIG is looking at how the new “two midnight” rule is affecting hospitals’ reimbursement and whether it’s cutting down on the number of inappropriate inpatient payments, as intended.
  • The Centers for Medicare & Medicaid Services’ (CMS) outlier payments for patients that have unexpected high cost for care. The OIG is looking to make sure that all hospitals that qualified for payments were referred for them. However, it may also adjust outlier over- and underpayments based on timing factors.
  • Inpatient claims for mechanical ventilation.
  • Inpatient and outpatient billing requirements for acute-care hospitals. The  OIG will be evaluating facilities for compliance with Medicare requirements and collect any identified overpayments.
  • Outpatient E/M services billed at “new patient” rates.
  • Payments for right heart characterizations and endomyocardial biopsies billed during the same session.

Fluctuating finances

Many providers have already struggled to grasp recent billing changes, such as the “two midnight” rule for establishing inpatient vs. outpatient status. So it’s reasonable to be concerned that billing requirements could become even more complex over the next year.

Additionally, the OIG will review Medicare’s and Medicaid’s meaningful use incentives. Specifically, the OIG wants to  ensure CMS’ auditing process is thorough enough, as well as to find and collect any payments that were inappropriately given since 2011. CMS was going to conduct audits on providers for meaningful use attestation, but the workplan suggests the auditing process might change over the next year — and not necessarily in providers’ favor.

Given how the OIG’s workplan could affect your hospital’s finances, it may be best for facilities to take this time to build up their savings. Having a cushion could help your hospital weather changes without worrying about the new requirements and reimbursement fluctuations. It also may be time to bump up your compliance efforts by conducting and documenting a self-audit of the claims the OIG will be looking at next year.

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