December 2, 2014

The Office of the Inspector General (OIG) for the U.S. Department of Health & Human Services (HHS) releases an annual work plan for each fiscal year, which provides a blueprint to the OIG's upcoming oversight and enforcement efforts. The latest plan covers fiscal year 2015 and has already gone into effect starting in October 2014. The OIG oversees hundreds of federal health care programs to root out fraud, waste and abuse. Its major responsibility is providing oversight for the Medicare and Medicaid programs, which together accounted for approximately two-thirds of the OIG's 2014 budget. Additional responsibilities include oversight of financial assistance payments, operation of health insurance marketplaces, food and drug safety, and ensuring the integrity of contracts and grants. In fiscal year 2015, the OIG plans to focus on the following --

• Health insurance marketplaces;

• Quality and access of care in Medicaid, Medicaid, and public health programs;

• Medicare and Medicaid payment practices;

• The integrity of the food, drug and medical device supply chain;

• Electronic data security; and

• Emergency preparedness.

This is the first of three blog posts describing the highlights of the FY 2015 plan.   Medicare Services OIG says that reducing waste and ensuring quality care in Medicare Parts A and B services in hospitals and other care environments will be its top challenge for fiscal year 2015.   Hospitals OIG plans to target the following aspects of hospital policies, practices, billing and payment:

• Centers for Medicare & Medicaid Services (CMS) reconciliation of outlier Medicare payments;

• The impact of new inpatient admission criteria;

• Claims for defective medical devices;

• Salary reimbursements;

• Provider-based status;

• Differences in payments at provider-based and freestanding clinics;

• Swing-bed service payment policies;

• Claims for ventilators and respirators;

• Billing in previously identified areas at risk of non-compliance;

• Duplicate and indirect payments for interns and residents;

• Outpatient dental claims;

• Improper use of new-patient codes for established patients;

• Cardiac catheterizations and endomyocardial biopsies billed for the same operative sessions;

• Claims for kwashiorkor;

• Bone marrow and stem cell transplant payments; and

• Wage data.

OIG will also focus on these aspects of the quality of care and safety in hospitals:

• Hospitals' participation in quality improvement projects;

• Pharmaceutical compounding;

• Hospital privileges; and

• Adverse events in inpatient rehabilitation facilities and long-term care facilities.

  Nursing Homes, Hospices, and Home Health Services OIG will also focus on Medicare compliance and care quality in settings outside of hospitals, with an emphasis on:

• Medicare A billing by skilled nursing facilities;

• Medicare B billing for services provided to nursing home residents;

• Overseeing State survey agencies;

• Overseeing States' programs for background checks for long-term-care employees;

• Hospitalization of nursing home residents;

• Gathering information on hospices in assisted living facilities;

• Reviewing use of hospice general inpatient care;

• Compliance, including documentation, with the home health prospective payment system; and

• Reviewing whether home health agencies employed individuals with criminal convictions.

Other targets of the OIG's enforcement and oversight efforts for fiscal year 2015 will be covered in subsequent blog posts. These include additional aspects of Medicare, as well as Medicaid, legal and investigative activities, and reviews of public health and of human services. You can contact one of Seigfreid Bingham’s Health Care Attorneys to discuss how the 2015 OIG Plan will affect your medical practice. Image: HHS/OIG *This article is very general in nature and does not constitute legal advice. Readers with legal questions should consult with an attorney prior to making any legal decisions.