<P>LEGAL OIG Targets Improper Payments $!oAAaao3+.o,(*o+10(*!/o*!3o!""+.0/o0+o!2(10!o((*#o+),(*!o By Matthew R. Fisher, JDT HE OFFICE of the Inspector Gen- eral (OIG) of the Department of Health and Human Services (HHS) released its annual Work Plan on Jan. 31, 2014. The Work Plan describes ongoing and new projects that the OIG intends to conduct during the coming year. Typically, the OIG issues its annual Work Plan in October of the preceding year, but delayed its release for 2014. While some anticipated that the delay would result in more ambitious new initiatives, overall, the Work Plan does not contain a significant number of new projects. However, certain key initia- tives bear special attention. These projects cover a wide range of issues from reviews of new rules impacting the Medicare and Medicaid programs to reviews of contractors hired by the Centers for Medicare and Medicaid Services (CMS). When setting its project goals, the OIG considers the following factors: mandatory reviews set by statute, regulations or other directives; requests made by HHS, Congress or other government agencies; top challenges facing HHS; work to be performed in collaboration with other organiza- tions; action taken to implement previous OIG recommendations; and timeliness. However, the Work Plan is also a living document and the initia- tives identified by the OIG will change over the course of a year as new issues arise or new fraud or abuse risks are identified. Regardless, each Work Plan provides a good starting point for determining the OIGs priorities and setting areas of focus for compliance plans. This article will highlight several new reviews the OIG planned to initiate in 2014. These reviews seem to track activities the OIG previously identified as concerning, or look at new policies. Indicators of the OIGs priorities can come from legislative pressure, trends in health care activi- ties, follow-up on previous reviews and other sources. A point to keep in mind is that each years new reviews can shed light into current thinking and future enforcement actions, since the reviews can be used to gather information on potential fraud, waste and abuse. Not all of the new reviews are included, nor are ongoing reviews discussed in this article. Medicare Part A and Part B–Hospitals b?New Inpatient Admission Criteria. Changing criteria for hospitals to bill for inpatient services (i.e., the two-midnight rule) creates the oppor- tunity for overpayments and inconsistent billing practices. Under the two-midnight rule, an inpatient admission is presumed to be reason- able and necessary if the individual stays in the hospital for at least two midnights. The OIG will assess the impact of new inpatient admission criteria on hospital billing and Medicare pay- ments and consider how resulting billing varies from hospital to hospital. In particular, the OIG will assess the impact of the two-midnight rule on inpatient admissions. Since publication of the Work Plan, delays have been announced for the two-midnight rule that push off its full effec- tiveness. Additionally, a bill has been introduced in Congress to alter and refine the application of the two-midnight rule. Despite these develop- ments, hospitals should still continue developing compliance plans for the rule and bring their operations into line. b?Analysis of Salaries Included in Hospital Cost Reports. The OIG will examine the extent to which employee compensation is included in operating costs reported to and reimbursed by Medicare. An assessment will then be made as to the potential impact on the Medicare Trust Fund of limiting the amount of employee compensation that could be reported. Currently, such costs can only be included to the extent that they represent reasonable remuneration for managerial, administrative, professional, and other services related to facility operation and furnished in connection with patient care. b?Comparison of Provider-Based and Free- Standing Clinics. Provider-based clinics and free-standing clinics are reimbursed at different rates, and this may result in entities seeking to bill under the higher rate. Provider-based clin- ics receive higher reimbursement for certain services. Hospitals may sometimes try to classify a free-standing clinic as a provider-based one to receive higher reimbursement. The OIG will review such billing to assess whether an appropriate setting was selected. The OIG would be concerned if a hospital attempted to obtain higher reimbursement than to which it is entitled. Determination of setting is expected to become increasingly important and contentious given the fast pace of consolidation and acquisition that has occurred since passage of the Patient Protection and Affordable Care Act in 2010 (PPACA). b?Outpatient Evaluation and Management Services Billed at the New-Patient Rate. The OIG will review hospital billing of outpatient evaluation and management services for new patients to assess whether such claims were submitted for patients who were actually new. If the service is billed incorrectly, then the hospital The OIG will assess the impact of the two-midnight rule on inpatient admissions and on hospital billing and Medicare payments. 10 | Chicago Medicine | August 2014</p> <UL><LI><a href="http://www.mzines.net/publication/698/foalpovap/1/1/">Front-Cover</a></LI> <LI><a href="http://www.mzines.net/publication/698/foalpovap/2/2/">Inside-Front-Cover</a></LI> <LI><a href="http://www.mzines.net/publication/698/foalpovap/3/3/">Page-1</a></LI> <LI><a href="http://www.mzines.net/publication/698/foalpovap/4/4/">Page-2</a></LI> <LI><a href="http://www.mzines.net/publication/698/foalpovap/5/5/">Page-3</a></LI> <LI><a href="http://www.mzines.net/publication/698/foalpovap/6/6/">Page-4</a></LI> <LI><a href="http://www.mzines.net/publication/698/foalpovap/7/7/">Page-5</a></LI> <LI><a href="http://www.mzines.net/publication/698/foalpovap/8/8/">Page-6</a></LI> <LI><a href="http://www.mzines.net/publication/698/foalpovap/9/9/">Page-7</a></LI> <LI><a href="http://www.mzines.net/publication/698/foalpovap/10/10/">Page-8</a></LI> <LI><a href="http://www.mzines.net/publication/698/foalpovap/11/11/">Page-9</a></LI> <LI><a href="http://www.mzines.net/publication/698/foalpovap/12/12/">Page-10</a></LI> <LI><a href="http://www.mzines.net/publication/698/foalpovap/13/13/">Page-11</a></LI> <LI><a href="http://www.mzines.net/publication/698/foalpovap/14/14/">Page-12</a></LI> <LI><a href="http://www.mzines.net/publication/698/foalpovap/15/15/">Page-13</a></LI> <LI><a href="http://www.mzines.net/publication/698/foalpovap/16/16/">Page-14</a></LI> <LI><a href="http://www.mzines.net/publication/698/foalpovap/17/17/">Page-15</a></LI> <LI><a href="http://www.mzines.net/publication/698/foalpovap/18/18/">Page-16</a></LI> <LI><a href="http://www.mzines.net/publication/698/foalpovap/19/19/">Page-17</a></LI> <LI><a href="http://www.mzines.net/publication/698/foalpovap/20/20/">Page-18</a></LI> <LI><a href="http://www.mzines.net/publication/698/foalpovap/21/21/">Page-19</a></LI> <LI><a href="http://www.mzines.net/publication/698/foalpovap/22/22/">Page-20</a></LI> <LI><a href="http://www.mzines.net/publication/698/foalpovap/23/23/">Page-21</a></LI> <LI><a href="http://www.mzines.net/publication/698/foalpovap/24/24/">Page-22</a></LI> <LI><a href="http://www.mzines.net/publication/698/foalpovap/25/25/">Page-23</a></LI> <LI><a href="http://www.mzines.net/publication/698/foalpovap/26/26/">Page-24</a></LI> <LI><a href="http://www.mzines.net/publication/698/foalpovap/27/27/">Page-25</a></LI> <LI><a href="http://www.mzines.net/publication/698/foalpovap/28/28/">Page-26</a></LI> <LI><a href="http://www.mzines.net/publication/698/foalpovap/29/29/">Page-27</a></LI> <LI><a href="http://www.mzines.net/publication/698/foalpovap/30/30/">Page-28</a></LI> <LI><a href="http://www.mzines.net/publication/698/foalpovap/31/31/">Page-29</a></LI> <LI><a href="http://www.mzines.net/publication/698/foalpovap/32/32/">Page-30</a></LI> <LI><a href="http://www.mzines.net/publication/698/foalpovap/33/33/">Page-31</a></LI> <LI><a href="http://www.mzines.net/publication/698/foalpovap/34/34/">Page-32</a></LI> <LI><a href="http://www.mzines.net/publication/698/foalpovap/35/35/">Page-33</a></LI> <LI><a href="http://www.mzines.net/publication/698/foalpovap/36/36/">Back-Cover</a></LI> <LI><a href="http://www.mzines.net/publications/698/x/sitemap.xml" target="_blank">site map</a></LI> </UL>

 

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