The Department of Health and Human Services’ (HHS) Office of the Inspector
General (OIG) recently released its General Work Plan for FY 2011, which offers
descriptions of activities that OIG intends to begin or continue with respect to
HHS programs and operations in FY 2011. This Work Plan provides the areas where
OIG plans to generally focus its investigative, enforcement and compliance
activities in the coming year.
Areas of the plan that McGuireWoods has identified as of particular interest
to hospitals, long-term care providers, ambulatory surgery centers, dialysis
facilities, durable medical equipment suppliers, and pharmaceutical companies
are set forth below.
First, OIG states that it intends to review cost reports of hospitals that
claim provider-based status for their inpatient and outpatient facilities, to
determine whether such a designation is appropriate and the impact of
inappropriately claiming this status. In addition, OIG plans to review
high-payment Medicare claims to ascertain whether they were appropriate, since
such claims may be incorrect for some reason.
This examination will include outpatient claims where payments surpassed
charges and certain Healthcare Common Procedure Coding System codes with unusual
billing. Also, OIG will review Centers for Medicare and Medicaid Services (CMS)
data to find out whether teaching hospitals made duplicate claims for graduate
medical education payments. Finally, OIG intends to review Medicare payments
made for beneficiaries with another form of insurance, since Medicare should
only be a secondary insurer in such a situation.
Home Health Agencies (HHA) & Nursing Facilities
OIG plans on reviewing Medicare Part B service and medical supply payments
for beneficiaries’ home healthcare to limit inappropriate payments to outside
suppliers. Most such services and supplies are included in the HHA prospective
payment, and when provided under an HHA plan of care, payments for outside
suppliers are included in the prospective payment. Additionally, OIG intends to
review HHA conformity with various pieces of the home health prospective payment
system, and analyze trends in HHA activities because total payments to HHAs have
grown significantly between 2000 and 2008.
Other Providers & Suppliers
First, OIG intends to examine changes made to the revised ambulatory surgery
center (ASC) payment system and the method used to calculate ASC payment rates.
Also, OIG plans to review whether CMS has made inappropriate payments for
evaluation and management (E&M) services. CMS instructs that the code for
service should be based on the content of the service, and proper documentation
should support the code used, but some documentation has been identical across
Additionally, CMS only pays for services that are reasonable and necessary to
diagnose and treat an illness or injury, so OIG intends to review whether
Medicare payments for sleep test procedures conducted at sleep disorder clinics
were appropriate and met Medicare requirements. Further, OIG will review to what
degree Medicare payments are being made for services ordered or referred by
excluded providers. Finally, the Social Security Act limits Medicare coverage
for end stage renal disease (ERSD) beneficiaries who receive coverage due to
special circumstances. OIG intends to review claims for these beneficiaries to
determine to what extent they continue to receive Medicare benefits after their
coverage should have terminated.
Medical Equipment & Supplies
OIG intends to review the correctness of payments by Medicare Part B for
various types of durable medical equipment (DME) by isolating high-volume claim
DME suppliers to establish whether payments were proper.
Medicare Part A & Part B Contractor Operations
The Recovery Audit Contractor (RAC) program, which attempts to discover and
recover Medicare overpayments, will undergo review by the OIG.
If you have any questions about the OIG’s Work Plan or the areas where OIG
plans to generally focus its investigative, enforcement and compliance
activities in the coming year, please contact one of the authors or
a member of McGuireWoods’