Ann & Natalie’s Compliance Corner
Welcome back to Ann & Natalie’s Compliance Corner! This month, we bring you guidance on updating your compliance plan in response to the recently-released 2008 OIG Work Plan. Missed last month’s article on the Stark Phase III Final Rule? Click here.
Each year, the Department of Health and Human Services Office of the Inspector General (OIG) releases a Work Plan that provides insight into its enforcement priorities for investigations into Medicare and Medicaid spending. On October 1, 2007, the OIG issued its 2008 Work Plan which highlights risk areas affecting a range of healthcare providers.
As in the past, the annual Work Plan offers a preview of the projects planned for the coming fiscal year, and provides your practice with the opportunity to update your compliance plan accordingly.
As expected, the 2008 plan includes initiatives we’ve seen in previous years, ongoing projects, and several newly identified risk areas. In updating your practice’s compliance plan for 2008, you may want to consider reviewing several of the new OIG action areas specific to providers, such as:
- Instances in which providers may be billing beneficiaries in excess of amounts allowed by Medicare requirements in violation of assignment rule, including situations in which providers may be “balance billing” beneficiaries in violation of Medicare rules;
- The extent to which Medicare physicians reassign their benefits to other entities;
- The appropriateness of Medicare Part B payments for physician services, including consultations, surgery, consultations, and home, office and institutional calls;
- The appropriateness of Medicare payments for sleep studies (called polysomnography services), including an examination of the factors contributing to the rise in Medicare payments for sleep studies;
- Improper payments and potential cost savings for Medicaid physical and occupational therapy services, including a review of medical necessity, billing improprieties, and provider qualifications;
- Services furnished by clinical social workers to hospital inpatients and skilled nursing facility residents to determine whether the services were properly billed;
- Whether Medicare Part B long distance physician services are inappropriately billed for beneficiaries of home health and skilled nursing facilities;
- Services and billing patterns in geographic areas with high utilization of ultrasound services for medical necessity; and
- Services and billing patterns in geographic areas with high concentrations of independent diagnostic testing facilities (IDTF); examine the service profiles, provider profiles, and beneficiary profiles in areas of high concentration of IDTFs.
This year’s Work Plan also includes reviews of Medicare Part D to determine whether the program is paying for drugs that are also covered under Medicare Part A or Part B, as well as projects involving the Food and Drug Administration (FDA). In the future, the OIG plans to evaluate the FDA’s oversight of off-label drug promotion, the generic drug approval process, adverse event reporting for medical devices, and oversight of research misconduct by clinical investigators.
Additionally, due to ongoing concerns involving fraud in the durable medical equipment industry, the OIG is also concentrating its efforts in this area, and the 2008 Work Plan includes an examination of Medicare claims paid to providers in South Florida, where recent investigations have revealed claims inconsistent with those in the rest of the nation.
With respect to Medicaid, the OIG is focusing on the areas of hospital outlier payments, billing for Medicaid nursing home patients transferred to hospitals, states’ use of Average Manufacturer Price to establish Medicaid pharmacy reimbursement, and Medicaid asset transfers and estate recovery provisions for nursing home care.
The issues raised here are only a handful of the action areas highlighted by the OIG’s nearly 100-page 2008 Work Plan. To read the document in its entirety, please click here.
Disclaimer: The content of Compliance Corner is for general informational purposes only and should not be interpreted as compliance guidance or advice. Consult your compliance advisor or attorney for compliance or legal advice on specific issues related to your practice or compliance program.
