Awareness : Newsletter Articles

2017 Office of Inspector General Work Plan Hospital Initiatives

Each fall, the Department of Health and Human Services Office of Inspector General (OIG) publishes its Work Plan for the upcoming fiscal year to summarize new and ongoing OIG reviews and initiatives. On November 10, 2016, the OIG’s2017 Work Plan was posted to its website.

The OIG’s Work Plan sets forth its initiatives and priorities for the 2017 federal fiscal year (FFY), which the OIG will pursue through audits, investigations, inspections, industry guidance (including advisory opinions) and enforcement actions (including actions to impose civil monetary penalties, assessments and administrative sanctions, such as exclusions). The 2017 OIG Work Plan includes the audits begun in years past that will continue into FFY2017 as well as new audits scheduled to begin in FFY2017.

There are a number of new starts for OIG audits and other reviews included in the 2017 OIG Work Plan. Below are some of the initiatives affecting hospitals.

Incorrect medical assistance days claimed by hospitals

To address the risk of overpayment under the Medicare disproportionate share hospital payments, OIG will determine whether, with respect to Medicaid patient days, Medicare administrative contractors properly settled Medicare cost reports in accordance with federal requirements.

Comparison of provider-based and freestanding clinics

The OIG will review and compare Medicare payments for physician office visits in provider-based clinics and freestanding clinics to determine the difference in payments made to the clinics for similar procedures. The OIG will also assess the potential impact on Medicare and beneficiaries of hospitals’ claiming provider-based status for such facilities. This review was also included in the 2016 OIG Work Plan and has not been revised.

Hyperbaric Oxygen Therapy in Outpatient Setting

OIG previously expressed concerns regarding the appropriateness of and the existence of supporting documentation for hyperbaric oxygen therapy treatment for Medicare beneficiaries. In its 2017 Work Plan, the OIG announced it will review whether Medicare payments related to hyperbaric oxygen therapy outpatient claims were reimbursable. Hospitals should review services and the supporting documentation to ensure Medicare beneficiaries satisfied the covered conditions for reimbursement.

Inpatient rehabilitation hospital patients not suited for intensive therapy

The OIG will assess a sample of rehabilitation hospital admissions to look at whether the Medicare beneficiaries at issue participated in and benefited from intensive therapy.

Inpatient rehabilitation facility payment system requirements

The OIG, based on prior reviews of individual inpatient rehabilitation facilities indicating possible Medicare overpayments, intends to review rehabilitation facilities nationally regarding compliance with Medicare documentation and coverage requirements.  In particular, the OIG will look at whether facilities are specifically documenting in the medical record, at the time of admission, support for a reasonable expectation that the patient needs multiple intensive therapies, is able to actively participate and demonstrate measurable improvement, and requires supervision by a rehabilitation physician to assess and modify the course of treatment to maximize the benefit of the rehabilitation process.

Inpatient psychiatric facility outlier payments

Citing a significant increase in the number of claims with outlier payments, the OIG intends to look at inpatient psychiatric facilities nationally for compliance with Medicare documentation, coverage, and coding requirements relating to outlier payments.