Calfee, Halter & Griswold LLPOIG 2017 Work Plan

November 16, 2016

The HHS Office of Inspector General (OIG) has released its work plan for Fiscal Year 2017.  As expected, the Work Plan indicates that the OIG will continue to look at many of the same items and issues identified in prior years’ work plans.  At the same time, the OIG has highlighted several new areas of concern that hospital, physician, and other Medicare providers should review, and address if necessary, as part of their continuing compliance programs.

New items for hospitals:

  • Hyperbaric oxygen therapy services in an outpatient setting: Having previously expressed concerns regarding the appropriateness of and the existence of supporting documentation for hyperbaric oxygen therapy treatment for Medicare beneficiaries, the OIG will review whether Medicare payments related to hyperbaric oxygen therapy outpatient claims were reimbursable.  In other words, this is a good opportunity for hospital providers to review outpatient claims for these services and the supporting documentation to ensure Medicare beneficiaries satisfied the covered conditions for reimbursement.
  • Inpatient rehabilitation hospital patients not suited for intensive therapy:  The OIG will assess a sample of rehabilitation hospital admissions to look at whether the Medicare beneficiaries at issue participated in and benefited from intensive therapy.
  • Inpatient rehabilitation facility payment system requirements:  The OIG, based on prior reviews of individual inpatient rehabilitation facilities indicating possible Medicare overpayments, intends to review rehabilitation facilities nationally regarding compliance with Medicare documentation and coverage requirements.  In particular, the OIG will look at whether facilities are specifically documenting in the medical record, at the time of admission, support for a reasonable expectation that the patient needs multiple intensive therapies, is able to actively participate and demonstrate measurable improvement, and  requires supervision by a rehabilitation physician to assess and modify the course of treatment to maximize the benefit of the rehabilitation process.
  • Inpatient psychiatric facility outlier payments:  Because the number of claims with outlier payments has increased significantly over the last few year (perhaps not surprisingly given these that these hospitals and units provide urgent psychiatric treatment  to individuals with an acute mental health crisis that may involve drug-related problems and the ongoing issues with opioid abuse), the OIG intends to look at inpatient psychiatric facilities nationally for compliance with Medicare documentation, coverage, and coding requirements relating to outlier payments.

New items for physicians and other providers:

  • Mandatory review of monitoring of Medicare payments for clinical diagnostic laboratory tests: Consistent with its statutory obligations, the OIG will analyze the new statutorily required market-based system of setting payment rates for Medicare Part B clinical diagnostic laboratory tests based on rates paid by private payors to labs and will monitor the Center for Medicare & Medicaid Services’ implementation of the new payment system.
  • Payments for transitional care management: The OIG plans to review payments for transitional care management services — those services provided to a patient requiring moderate or high-complexity medical decision-making during transitions in care from an inpatient setting or hospital setting to a community setting under the Medicare Physician Fee Schedule — for compliance with Medicare billing requirements, including the requirement that certain other Medicare-covered services, such as chronic care management, not be billed during the same period as the transitional care management services.
  • Payments for chronic care management: As a counterpart to its review of payments for transitional care management, the OIG is looking at payments for chronic care management services for compliance with Medicare billing requirements, including the requirement that chronic care management services cannot be billed during the same period as transitional care management, home health care, hospice care, and certain other services.
  • Financial interests reported under the Open Payments Programs: The OIG will analyze the number and nature of financial interests reported to the Open Payments website under the Physician Payments Sunshine Act and then look at the Medicare payments for drugs and durable medical equipment, and the volume of drugs and devices, ordered by physicians with financial relationships to drug and equipment manufacturers and group purchasing organizations.  This review highlights the importance of hospital and physician practice conflict of interest policies and ongoing compliance efforts implementing those policies.

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For additional information and discussion on this topic, please get in touch with your regular Calfee contact or the attorney listed below: Michael G. VanBuren 216-622-8343 mvanburen@calfee.com  

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