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OIG Work Plan Includes Review of Hospitals

Editor’s Note: This is part of a week long series exploring the impact of the OIG 2013 Work Plan on different types of providers and organizations.

Each year, the Department of Health and Human Services Office of Inspector General (OIG) releases a Work Plan for the upcoming fiscal year. The Work Plan outlines reviews and activities that the OIG plans to conduct in the upcoming fiscal year, and shows the current OIG areas of focus. On October 3, 2012 the OIG released its Work Plan for fiscal year 2013, which included some new issues that did not appear on the FY 2012 Work Plan.

Among the new issues the Work Plan outlines are some that will affect hospitals. The Work Plan states that the OIG will examine:

Diagnosis Related Group Window: The OIG will examine claims data for bundled outpatient services prior to an inpatient hospital admission. Medicare currently bundles outpatient services delivered by the admitting hospital three days prior to inpatient admission into the same diagnosis related group (DRG). This three day span is known as the DRG window. The OIG will review the possibility of expanding the DRG window to outpatient services delivered 14 days prior to inpatient admission, and how much that would reduce Medicare payments.

Compliance with Medicare’s Transfer Policy: The OIG will review Medicare payments made to hospitals that were coded as discharges, but should have been coded as transfers. The review will examine whether the payments were appropriate and the effectiveness of transfer claims processing edits. The DRG amount paid for a discharge could be greater than the DRG payment for a transfer.

Hospitals should also be aware of other issues that appear in the Work Plan. These include:

  • Inpatient Billing for Medicare Beneficiaries
  • Non-Hospital-Owned Physician Practices Using Provider-Based Status
  • Payments for Discharges to Swing Beds in Other Hospitals
  • Payments for Canceled Surgical Procedures
  • Payments for Mechanical Ventilation
  • Quality Improvement Organizations’ Work With Hospitals
  • Acquisitions of Ambulatory Surgical Centers: Impact on Medicare Spending
  • Critical Access Hospitals–Payments for Swing-Bed Services

Hospitals can expect OIG review of these issues to lead to additional focus by CMS and its contractors. It is important that providers implement compliance plans to help prevent recoupment of funds or even legal action.

If you need assistance creating and implementing a compliance plan, or have questions about how the OIG Work Plan could affect you, please contact an experienced Wachler & Associates healthcare attorney at 248-544-0888.