Volume 5, #1

February 2008

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OIG 2008 Work Plan

Candace E. Shaeffer, RN, MBA, RHIA
Chief Compliance Officer

The Department of Health and Human Service's Office of Inspector General (OIG) released its 2008 Work Plan on October 1, 2007. The plan outlines the OIG's projects related to the Centers for Medicare and Medicaid Services (CMS), and describes the areas that the agency will investigate and audit in the coming year to determine if services and payments are appropriate. The targeted areas are those the OIG considers at risk for fraud and abuse and in documenting this plan the OIG gives providers valuable information for planning their own compliance efforts for the year.

The OIG has outlined several priorities for investigations, evaluations, and audits related to provision of hospital and physician services for Medicare and Medicaid beneficiaries. There are several areas that will be of interest to LYNX Medical Systems' clients.

Important investigative areas targeted at hospitals

• Appropriateness of diagnostic x-rays in the emergency department (ED). Between 2001 and 2004 there was a 9.6% increase in utilization and the OIG wants to assess if this is justified.
• Compliance with Medicare's transfer policy. The OIG will look for errors in disposition codes and identify "discharged" patients that should have been coded as transfers.
• Evaluation of serious medical errors called "never events." The OIG will review incidence, reporting, and provider response including voluntary reporting. They will also look at Medicare payments for these incidences.
• Oversight of the joint commission to evaluate policies and procedures supporting the accreditation process.
• Evaluation of claims accuracy when Medicare is the secondary payer.
• Inpatient Psychiatric Facility Emergency Departments. The OIG will review payments to inpatient psychiatric facilities to make sure correct adjustments were made for those facilities that operate emergency departments.
• Observation vs. admit for dialysis. With certain exceptions dialysis should be provided on an outpatient basis.
• Emergency health services for undocumented aliens.
• The HIPAA security rule. The OIG will look at CMS oversight of implementation and enforcement of the regulation.
• Enforcement of the Deficit Reduction Act (DRA). The OIG will look at Medicaid and DRA provisions including fraud and abuse controls.

Important investigative areas targeted at physicians

• Payments for x-ray interpretations performed in EDs. The OIG will assess medical necessity and appropriateness.
• Place of Service errors on claims for outpatient and other services. Medicare physician payments are higher when services are performed and coded for a non-facility place of service rather than hospital outpatient.
• Evaluation and management (E/M) services billed during a global surgical period. Most ED services with a global period are billed with a 54 modifier (surgical care only), so this concern doesn't usually apply in the ED.
• Utilization of ultrasounds. There has been a significant increase in utilization of this diagnostic testing and the OIG will audit to determine if the increase is justified.
• Physician reassignment of benefits. The OIG has identified several fraudulent "reassignment of benefit" schemes in Florida and as a result will look into practices elsewhere.
• The practice of "balance billing." The OIG will determine if Medicare beneficiaries are being billed for amounts in excess of Medicare allowables.

To see the complete 2008 Work Plan, visit:

http://oig.hhs.gov/publications/docs/workplan/2008/Work_Plan_FY_2008.pdf