November 2010 Newsletter
OIG Work Plan 2011
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
- Medicare Excessive Payments. The OIG will review Medicare claims with high payments to determine whether they were appropriate. Their previous work has shown that claims with unusually high payments may be incorrect for various reasons. They will also review the effectiveness of the claims processing edits used to identify excessive payments.
- Early Implementation of Medicare’s Policy for Hospital-Acquired Conditions. CMS implemented the hospital-acquired conditions (HAC) policy on October 1, 2008, which prevents additional payment under Medicare’s hospital inpatient prospective payment system (IPPS) for certain conditions or complications that are determined to be reasonably preventable. The OIG will review claims data to identify the number of patient stays associated with HACs and analyze their impact on reimbursement. They will also verify the accuracy of present on admission (POA) indicators, which are used for identifying HACs.
- Responses to Adverse Events in Hospitals by Medicare Oversight Entities. An “adverse event” is defined as harm to a patient as a result of medical care. They will review responses of state survey‐and‐certification agencies, Medicare accreditors, and CMS to allegations of adverse events in hospitals. Various Medicare oversight entities have authority to investigate adverse events in hospitals to determine whether those hospitals have taken corrective actions and are in compliance with Medicare standards. The OIG will identify and analyze potential overlaps, conflicts, and gaps in responses and identify opportunities for Medicare oversight entities to improve the quality of oversight and responses to adverse events.
Other Providers and Suppliers
- Excessive Payments for Diagnostic Tests. The agency will review Medicare payments for high‐cost diagnostic tests to determine whether they were medically necessary. They will determine the extent to which the same diagnostic tests are ordered for a beneficiary by primary care physicians and physician specialists for the same treatment.
- Trends in Laboratory Utilization. The OIG will review trends in laboratory utilization under the Medicare program. They will examine the types of laboratory tests and the number of laboratory tests ordered. The agency will also examine how physician specialty, diagnosis, and geographic difference in the practice of medicine affect laboratory test ordering.
- Lab Test Payments: Comparison of Medicare with Other Public Payers. They will review the extent to which Medicare payment rates for laboratory tests vary from other public payers and will compare Medicare laboratory payment rates for the 10 most utilized lab tests with those of other public payers, including the Department of Veterans Affairs (VA) and State Medicaid programs.
Medicare Part A and Part B Contractor Operations
- Medicare Secondary Payer Recovery Contractor: Early Implementation. The OIG will review the effectiveness of the Medicare Secondary Payer (MSP) recovery process. In October 2006, CMS consolidated most recovery functions under a single MSP Recovery Contractor (MSPRC), and the contractor has been responsible for most MSP recovery efforts when Medicare has paid a claim in error, or made a conditional payment for which another payer is ultimately deemed responsible. They will determine whether the MSPRC has increased recoveries, decreased administrative costs, and improved the efficiency of the recovery process.
- Identification and Recoupment of Improper Payments by Recovery Audit Contractors. The agency will review the performance of the Recovery Audit Contractor (RAC) program. The RACs conduct post-payment reviews to identify overpayments and underpayments and attempt to recoup any overpayments they find. Previous OIG work found problems with RACs’ processes for identifying and reporting potential fraud during the RAC demonstration project. The OIG will also review CMS’s oversight of the RAC program.
More information about the complete Work Plan is available at 2011 Work Plan|Office of Inspector General