November 2006 Newsletter

OIG Work Plan

By: Compliance Officer

The Office of Inspector General (OIG) has issued its Work Plan for the upcoming fiscal year. The project areas described in the Plan identify vulnerabilities of the Department of Health & Human Services (HHS) programs and activities. The OIG continually seeks to find ways to promote economy, efficiency, and effectiveness within the HHS programs. Here are some excerpts from the Centers for Medicare & Medicaid Services (CMS) portion of the Plan:

Medicare Hospitals

• Medical Appropriateness and Coding of Diagnosis Related Group Services. The OIG will analyze inpatient hospital claims to identify providers who exhibit high or unusual patterns for selected DRGs and then determine the medical necessity, the appropriate level of coding, and reimbursement for a sample of services. In earlier work, the OIG found the DRG system vulnerable to abuse by providers who wish to increase reimbursement inappropriately through upcoding.
• Inappropriate Payments for Diagnostic X-Rays in Hospital Emergency Departments. The agency will determine the extent of inappropriate payments for diagnostic x-rays performed in hospital emergency departments. The OIG will assess the degree to which Medicare is inappropriately paying for diagnostic x-rays interpreted by emergency room physicians. Interpretations by emergency room physicians of diagnostic x-rays should not be billed separately. They will determine whether the services were medically necessary and if the tests were interpreted contemporaneously with the patient’s treatment.
• Oversight of Specialty Hospitals. The OIG will assess CMS oversight of physician owned specialty hospitals to ensure patient safety and quality of care. As part of this review, they will also examine policies related to staffing requirements at these hospitals.

Medicare Physicians and Other Health Professionals

• Evaluation of “Incident to” Services. The purpose of this study is to evaluate the appropriateness of Medicare services performed “incident to” the professional services of physicians and determine the extent to which the services met Medicare standards for medical necessity, documentation, and quality of care.
• Place of Service Errors. This review will determine whether physicians properly coded the place of service on claims for services provided in ambulatory surgical centers and hospital outpatient departments.
• Violations of Assignment Rules by Medicare Providers. The agency will examine the extent to which providers are billing beneficiaries in excess amounts allowed by Medicare requirements. Providers cannot bill beneficiaries for amounts in excess of Medicare allowed amount. They will also assess beneficiary awareness of their rights and responsibilities regarding potential billing violations and Medicare coverage guidelines.

Other Medicare Services

• Medicare Duplicate Claims. The OIG will examine the current edit process to determine whether the process is effective in identifying potential duplicate claims and preventing overpayments.

More information about the complete Work Plan is available at http://oig.hhs.gov/publications/workplan.html.