OIG’s Far-reaching 2017 Work Plan Designed to Root Out Fraud and Abuse

OIG Work PlanThe U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently released its work plan for 2017 and its target list is ambitious.

Each year, the agency releases a plan that summarizes new and existing reviews and areas where it will focus its attention for the coming year. It also shows the areas where work has been completed, revised or removed.

Here’s are some highlights:


Hyperbaric Oxygen Therapy Services: The agency will determine whether Medicare payments related to HBO outpatient claims were reimbursed in accordance with federal requirements. Previous reviews expressed concerns that beneficiaries were receiving treatment for non-covered conditions, that medical documentation did not adequately support such treatment, or that beneficiaries received more treatments than considered medically necessary.

Inpatient Psychiatric Facility Outlier Payments: Noting that the number of claims with outlier payments increased by 28 percent between FY 2014 and FY2015, the agency said it will determine whether inpatient psychiatric facilities complied with Medicare documentation, coverage and coding requirements for stays that resulted in outlier payments. Outliers are additional payments that Medicare provides to hospitals for beneficiaries who incur unusually high costs.

Comparison of Provider-Based and Freestanding Clinics: The agency will review and compare Medicare payments for physician office visits in provider-based clinics and freestanding clinics to determine the difference in payments made to the clinics for similar procedures. It also will assess the potential impact on Medicare and beneficiaries of hospitals’ claiming provider-based status for such facilities.

Selected Inpatient and Outpatient Billing Requirements: This review is part of a series of hospital compliance reviews that focus on hospitals with claims that may be at risk for overpayments. The agency will review Medicare payments to acute care hospitals to determine hospitals’ compliance with selected billing requirements and recommend recovery of overpayments. The review will focus on those hospitals with claims that may be at risk for overpayments.

Nursing Homes and Skilled Nursing Facilities

Unreported Incidents of Potential Abuse and Neglect: The agency will seek to determine to what extent state agencies are investigating the most serious nursing home complaints within the required timeframes. Those complaints categorized as immediate jeopardy and actual harm must be investigated within a 2- and 10-day timeframe, respectively.

Skilled Nursing Facility (SNF) Reimbursement: Previous OIG work found that SNFs were billing for higher levels of therapy than were provided or were reasonable or necessary. The OIG will review the documentation at selected SNFs to determine if it meets the requirements for each particular resource utilization group.

Potentially Avoidable Hospitalizations of Medicare- and Medicaid-Eligible Nursing Facility Residents: Concerned that some hospitalizations might indicate poor quality of care, the OIG will review nursing homes with high rates of patient transfers to hospitals for potentially preventable conditions and determine whether the nursing homes provided services to residents in accordance with their care plans.

Home Health Services

Home Health Compliance with Medicare Requirements: The Centers for Medicare and Medicaid determined that the improper payment error rate for home health claims was 51.4 percent, or about $9.4 billion in 2014.  Other more recent reports found similar high error rates at individual home health agencies. The OIG will review compliance with various aspects of the home health prospective payment system and include medical review of the documentation required in support of the claims paid by Medicare.

Medical Equipment and Supplies

Part B Services During Non-Part A Nursing Home Stays: Durable Medical Equipment The OIG will determine the extent of inappropriate Medicare Part B payments for DMEPOS provided to nursing home residents during non-Part A stays in 2015. It also will determine whether CMS has a system in place to identify inappropriate payments for DMEPOS and recoup payments from suppliers.

Other Durable Medical Equipment Reviews: The agency will look at scooter and power wheelchairs to determine whether savings can be achieved if certain power mobility devices are rented instead of acquired. It will also review Medicare Part B payments for orthotic braces to determine whether they were medically necessary and supported in accordance with Medicare requirements. It will review CMS’ competitive bidding program used to make pricing determinations for certain medical equipment items and services in selected competitive bidding areas. And, it will review Medicare Part B payments for nebulizer machines and related drugs to determine whether the claims from suppliers are medically necessary.

Prescription Drugs

Drug Waste of Single-Use Vial Drug: The OIG will look at how much waste occurs for the 20 single-use-vial drugs with the highest amount paid for waste and whether a different size vial could result waste.

Potential Savings from Inflation-Based Rebates in Medicare Part B The OIG will examine how much the federal government could potentially collect from pharmaceutical manufacturers if inflation-indexed rebates were required under Medicare Part B

Questionable Billing for Compounded Topical Drugs in Part D: The OIG notes that Part D spending for compounded topical drugs grew by more than 3,400 percent between 2006 and 2015. The agency will seek to identify pharmacies with questionable Part D billing for these drugs and any associated prescribers.

These are just a few of the items on the OIGs check list. The entire document is more than 100 pages and can be viewed here.

Many of the items on the OIG’s check list are designed to uncover potential fraud and abuse. Providers should consider the work plan to be a roadmap of matters that they should concern themselves with and use it to help them get ahead of the curve in the days ahead. If you have any questions or concerns, contact the Health Law Offices of Anthony C. Vitale at 305-358-4500.

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It is not intended as professional advice and should not be construed as such.