November 2009 Newsletter
OIG 2010 Work Plan Published
On October 1, 2009, the Department of Health and Human Services (HHS) Office of Inspector General (OIG) issued its annual Work Plan for fiscal year 2010 that addresses the reviews and projects that the agency wants to undertake in the coming year. New this year is a separate section that includes reviews related to the American Recovery and Reinvestment Act of 2009 (ARRA).
Here are some excerpts:
CENTERS FOR MEDICARE & MEDICAID SERVICES
Hospitals
- Hospital Admissions With Conditions Coded Present-on-Admission (POA)-The OIG will review Medicare claims to determine the number of inpatient hospital admissions for which certain diagnoses were coded as being present when patients were admitted to the hospitals and will determine which of the diagnoses were most frequently coded as POA. They will also determine which types of facilities are most frequently transferring patients with a POA diagnosis specified by CMS to hospitals and whether specific providers transferred a high number of patients to hospitals with POA diagnoses.
- Hospital Readmissions-They will review Medicare claims to determine trends in the number of hospital readmission cases. Based on prior OIG work, CMS implemented an edit in 2004 to reject subsequent claims on behalf of beneficiaries who were readmitted to the same hospital on the same day.
- Adverse Events: Various Reviews- The term “adverse event” describes harm to a patient as a result of medical care. The terms “never events,” or “serious reportable events,” refer to a subcategory of adverse events that the National Quality Forum (NQF) deemed “should never occur in a health care setting,” such as surgery on the wrong patient.
- Hospitals: National Incidence Among Medicare Beneficiaries
- Hospitals: Methods To Identify Events
- Hospitals: Early Implementation of Medicare’s Policy for Hospital-Acquired Conditions
- Hospitals: Responses by Medicare Oversight Entities
- Public Disclosure of Adverse Event Information
Other Part A and Part B Providers Payments
- Medicare Incentive Payments for E-Prescribing-The OIG will review Medicare incentive payments made in 2010 to eligible health care professionals for their 2009 electronic prescribing (e-prescribing) activities. The Medicare Improvement for Patients and Providers Act of 2008 (MIPPA) provided for incentive payments to eligible health care professionals for e-prescribing beginning in 2010 and continuing through 2013. They will assess whether, and, if so, the extent to which incentive payments for e-prescribing activities in 2009 were made in error.
- Laboratory Test Unbundling by Clinical Laboratories-The agency will examine the extent to which clinical laboratories have inappropriately unbundled laboratory profile or panel tests to maximize Medicare payments. Medicare contractors must group together individual laboratory tests that clinical laboratories can perform at the same time on the same equipment and then consider the price of related profile tests. Payment for individual tests must not exceed the lower of the profile price or the total price of all the individual tests. The OIG will determine whether clinical laboratories have unbundled profile or panel tests by submitting claims for multiple dates of service or by drawing.
- Payments for Services Ordered or Referred by Excluded Providers-The OIG will review the nature and extent of Medicare payments for services ordered or referred by excluded providers. Excluded or terminated providers have engaged in fraud, program abuse, or other conduct that formed the basis for termination from Medicare, Medicaid, and all other Federal health care programs. Pursuant to the Social Security Act, no payment shall be made for any items or services furnished, ordered, or prescribed by an excluded individual or entity. In April 2009, CMS completed its transition to the use of national provider identifiers (NPI) to identify its Medicare providers. It is possible that during the transition period to NPIs, some referring or ordering providers, referred to as “secondary” providers, did not have NPIs. Secondary providers are not required to enroll in Medicare, and no edits currently exist to determine whether secondary providers have been barred, suspended, or excluded by Medicare or Medicaid.
RECOVERY ACT WORK PLAN
Medicare Part A and Part B
- Breach Notification and Medical Identity Theft in Medicare-They will review CMS’s compliance with new breach notification requirements for personally identifiable information (PII) in the American Recovery and Reinvestment Act of 2009 (Recovery Act) and the Centers for Medicare & Medicaid Services (CMS) oversight measures in cases of medical identity theft within Medicare. Such PII includes health information maintained by Medicare providers and contractors. Breaches of PII can facilitate the theft of health-related PII (medical identity theft). The OIG will examine CMS’s internal procedures and processes related to the Recovery Act’s breach notification requirements.
- Medicare Incentive Payments for Electronic Health Records-The agency will examine the Medicare incentive payments made to eligible health care professionals and hospitals for adopting electronic health records (EHR) and CMS’s safeguards against incentive payments made in error.
More information about the complete Work Plan is available at: http://oig.hhs.gov/publications/docs/workplan/2010/Work_Plan_FY_2010.pdf