February 2006 Newsletter

OIG 2006 Work Plan

By: Corporate Compliance Officer

Each fall, the Department of Health & Human Services (HHS) Office of Inspector General (OIG) issues its Work Plan for the upcoming year. This annual plan gives a sneak preview of the areas federal investigators will focus their attention in the coming year. The 2006 Work Plan includes issues previously dealt with, ongoing issues, and a few new targeted areas. In addition to the projects outlined in the Plan, the OIG will also continue their oversight of HHS programs regarding their provision of relief to victims of Hurricanes Katrina and Rita. Below are selected excerpts from the CMS portion of the Plan:

Medicare Hospitals

Outpatient Department Payments

The OIG will review payments to hospital Outpatient departments under the outpatient prospective payment system (OPPS) to determine the extent to which they were made in accordance with Medicare laws and regulations. It will review the appropriateness of payments made for multiple procedures, repeat procedures, and global surgeries.

Unbundling of Hospital Outpatient Services

The agency will determine the extent to which hospitals and other providers are submitting claims for services that should be bundled into outpatient services.

“Inpatient Only” Services Performed in an Outpatient Setting

The OIG will determine if Medicare payments are appropriately denied for “Inpatient Only” and related services performed in an outpatient setting and assess the extent to which Medicare beneficiaries are held liable for denied inpatient claims for these services. It will also assess whether CMS computers implement the required OPPS edits.

Medicare Physicians and Other Health Professionals

Cardiography and Echocardiography Services

The OIG will review Medicare payments for cardiography and echocardiography services to determine whether physicians billed appropriately for the professional and the technical components of the services.

Potential Duplicate Physical Therapy Claims

The agency will assess whether CMS’s systems are able to identify and prevent payment for potential duplicate claims for physical therapy submitted by providers. In May 2004, CMS issued a fraud alert regarding physical therapy suppliers switching their submission of claims between Part A and Part B. It will review the current Common Working File operations to determine whether edits are adequately identifying potential duplicate claims.

Coordination and Oversight of Medicare Part B and D to Avoid Duplicate Payments

The agency will determine whether there is sufficient coordination and oversight of Medicare B and Part D to prevent duplicate payments for drugs. Drugs for which payment is available under Medicare Part B will continue to be covered by Part B and should not also be reimbursed under Medicare Part D drug coverage.

Other Medicare Services

Medicare Pricing of Laboratory Services

The OIG will compare Medicare payment rates for certain laboratory tests with the rates of other Federal and State health programs and private payers. This study will build upon prior OIG work, which found that Medicare paid significantly higher prices than other payers for certain laboratory tests.

Laboratory Proficiency Testing

The agency will assess laboratory compliance with Clinical Laboratory Improvement Amendments (CLIA) of 1988 requirements to participate in proficiency testing. Proficiency testing is a statutorily mandated condition of participation in which laboratories are graded for their accuracy in analyzing clinical specimens. It is one of the primary mechanisms for ensuring quality testing.

Separately Billable Laboratory Services Under the End Stage Renal Disease Program

The Medicare Modernization Act (MMA) requires a report on a bundled prospective payment system (PPS) for ESRD services. This bundled PPS would include certain clinical laboratory tests that are currently able to be billed separately. The current facility payment (composite rate) includes payments for certain automated multi-channel chemistry (AMCC) tests provided routinely at specified frequencies. Any AMCC tests performed in excess of specified frequencies or that are not included in the composite rate payment are billed separately provided that medical necessity is documented. To ensure that the bundled PPS rate is based on valid data, they will review providers’ current compliance with the current payment policies for AMCC tests.

More information about the complete Work Plan is available at http://oig.hhs.gov/publications/docs/workplan/2006/WorkPlanFY2006.pdf