On Oct. 2, 2012, the U.S. Department of Health and Human
Services' (HHS) Office of Inspector General (OIG) released its
Work Plan for fiscal year 2013. Each year, this is of keen interest
to anyone who deals with the Medicare or Medicaid programs, as it
provides a sneak peek of OIG's enforcement priorities and key
areas of concern. Many investors and lenders in the industry also
look to the Work Plan for guidance in understanding whether certain
widespread practices are being viewed negatively by OIG.
The Work Plan summarizes OIG's upcoming audit and
enforcement priorities with respect to HHS programs. The Work Plan
contains summaries of more than 240 Medicare and Medicaid
initiatives (more than 80 of which are new).
The following points highlight significant aspects of the Work
1. Fraud and Abuse Prevention. The Work Plan
emphasizes OIG's commitment to preventing fraud and abuse. The
OIG makes clear that it plans to continue devoting significant
resources to investigating and prosecuting Medicare and Medicaid
fraud and abuse.
2. Hospital Billing Issues. The Work Plan
features a noticeable focus on hospital billing issues and payments
for certain hospital services. This includes payments made to
hospitals for beneficiary discharges that should have been coded as
transfers, payments for same-day readmissions, payments for
canceled surgical procedures and payments for mechanical
3. Affordable Care Act. The Work Plan includes
a review of the implementation of the Affordable Care Act's
programs and initiatives as they relate to responsibilities of HHS.
The Work Plan also reviews OIG's oversight of the funding that
HHS received under the American Recovery and Reinvestment Act of
2009 relating to Medicare and Medicaid incentive payments for
electronic health records and health information systems and data
4. Post-Acute Care. The Work Plan features
increased scrutiny of post-acute care providers. Specifically, the
Work Plan highlights OIG's interest in examining:
a.The frequency with which home health agencies (HHA) are
complying with face-to-face encounter requirements;
b.The frequency with which both Medicare and Medicaid have paid
for the same Medicare-covered HHA services;
c.Whether HHAs are complying with state requirements to conduct
criminal background checks for HHA applicants and employees;
d.Whether inappropriate payments were made by Medicare for
interrupted stays in long-term care hospitals; and
e.Hospices' marketing practices and financial relationships
with nursing facilities.
5. New Areas of Focus. The Work Plan features
several areas that might be surprising to those who follow the
industry and current trends. The areas in which OIG has expressed
an interest include:
a.Non-hospital-owned physician practices using provider-based
b.Hospital acquisition of ambulatory surgery centers (ASCs) and
converting them into hospital outpatient departments;
c.Compliance of suppliers of power mobility devices with payment
d.Continuiance positive airway pressure supplies and
reasonableness of replacement supplies;
e.Diabetes testing supplies (including both competitive bidding
practices and non-mail-order claims compliance);
f.Payments to providers subject to existing or prior debt
g.Payments for personally performed anesthesia services;
h.Drug shortage issues;
i.Assessment and monitoring of performance by Medicare
j.Part D specialty formulary payments; and
k.Dental services for children under Medicaid, including
inappropriate billing and for-profit dental chains.
Over the next few weeks, McGuireWoods will publish a series of
articles on various focus areas and new initiatives identified in
the Work Plan.
The content of this article is intended to provide a general
guide to the subject matter. Specialist advice should be sought
about your specific circumstances.
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