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Fraud
& Abuse: Summary
of the OIG Workplan FY
I. Medicare Hospitals
The DHHS Office of Inspector General recently released its Work Plan for fiscal year. The plan identifies hospital-related issues that the OIG will examine in FY, including:
A. Medical Education Payments
The OIG will examine the accuracy of resident counts reported to fiscal intermediaries by hospitals as well as the validity of the resulting medical education payments.
B. Hospital Privileging Activities
The OIG will review whether hospitals are conducting privileging activities in accordance with the Medicare conditions of participation.
C. Consecutive Inpatient Stays
The OIG will analyze acute and postacute care stays at hospitals to identify questionable patterns of billing sequential stays at different inpatient and long term care facilities.
D. Diagnosis-Related Group Coding
The OIG will once again examine diagnosis-related groups that have a history of aberrant coding to determine whether certain acute care hospitals exhibit questionable coding patterns.
E. Medicare Hospital Outlier Payments
The OIG will examine hospital inpatient claims for outliers to determine whether the outlier payments were appropriate and whether the fiscal intermediary's controls over outlier claims are adequate.
F. Outpatient Prospective Payment System
The OIG will evaluate the effectiveness of the internal controls of hospitals intended to ensure that outpatient services are adequately documented, properly coded and medically necessary. Controls over "pass-through" costs will also be reviewed.
G. Outlier Payments Under Outpatient Prospective Payment System
The OIG will identify providers at high risk for incorrectly receiving outlier payments for outpatient services reimbursed under the outpatient prospective payment system.
H. Outpatient Cardiac Rehabilitation Services
The OIG will determine whether cardiac rehabilitation services provided by hospital outpatient departments are being provided in accordance with the direct physician supervision requirements of the "incident to" rule.
II. Physicians & Other Health Professionals
The OIG will examine the following issues with respect to physicians and other health care professionals:
A. Consultations
The OIG will determine the appropriateness of billings for physician consultation services and the financial impact of inaccurate billings on the Medicare program.
B. Coding of Evaluation & Management Services
The OIG will examine claims for evaluation and management services to determine whether the services were accurately coded and billed. The OIG will also examine the adequacy of carrier controls to identify physicians with aberrant coding patterns.
C. Bone Density Screening
The OIG will determine the extent of any inappropriate payments for bone density screening and the impact of those payments on the Medicare program.
D. Chiropractic Care
The OIG will determine the appropriateness of claims for chiropractic services.
E. Services and Supplies Incident to Physicians' Services
The OIG will evaluate the quality and appropriateness of billing for services and supplies billed as "incident to" the services of a physician. The evaluation will include a review of whether physicians are meeting the direct supervision requirements of the "incident to" rule.
F. Medicare Payments to Nonphysician Practitioners
The OIG will examine billings by nonphysician practitioners to assess whether such practitioners are performing and billing for services that are within their scopes of practice.
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