United States: Highlights From The 2016 OIG Work Plan: Part I

The Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) has released its Work Plan for Fiscal Year 2016. The annual work plan can provide valuable insights into the OIG's planned areas of focus for investigation and enforcement activities in the coming year. You can find our review of last year's work plan here.

Here are the first six of 11 key observations on this year's work plan; the remaining five will be listed in a subsequent email. All 11 are discussed at more length on our website.

1. Ambulatory Surgical Centers – Certification and Quality Oversight. A new addition to the areas typically discussed in an OIG Work Plan is a section on Medicare's oversight system for ambulatory surgery centers (ASCs). Specifically, OIG indicated it would focus on oversight of the state agencies that handle Medicare certification surveys and ASC accreditation organizations. An on-site survey is required for ASCs to be Medicare-certified. ASCs may choose either to have the certification survey completed directly by Medicare, in which case the surveys are performed by the respective state's Department of Health on behalf of Medicare, or a Medicare-approved private accreditation organization. The OIG also noted concern with the infrequency of Medicare certification surveys of ASC facilities. Most private accreditation organizations have policies requiring unannounced surveys every three years. However, the OIG has found that many ASCs are going five or more years without being surveyed. Finally, in the Work Plan the OIG made reference to the lack of public information on the quality of ASCs. The Office of Evaluation and Inspections is expected to conduct a national evaluation to be issued in 2017 on ASC quality oversight.

2. Clinical Laboratory Billing Requirements and Reimbursement Rates. The Work Plan included several sections focused on Medicare billing and payment issues related to independent clinical laboratories. Specifically, the OIG intends to identify laboratories that routinely submit improper claims. The OIG will also identify those diagnostic tests for which Medicare pays more than private insurers. Increased focus on Medicare expenditures related to reimbursement for clinical laboratory testing is likely being driven by the Protecting Access to Medicare Act of 2014 (the "Act"), which will require Medicare to base reimbursement rates for laboratory tests on private insurer rates beginning in 2017. The Act will also impose new reporting requirements on clinical laboratories beginning on January 1, 2016, which will require most laboratories to report to CMS payment rates of private payors for certain tests. CMS will aggregate the reported rates in order to better ensure the Medicare Clinical Laboratory Fee Schedule reflects private market reimbursement rates. The OIG is expected to issue a report in 2016 on its analysis of Medicare expenditures and the new payment system for laboratories.

3. Histocompatibility Laboratories. A new area of focus in the Work Plan is histocompatibility laboratories, as a result of a recent review of cost reports submitted by these types of laboratories. The cost reports indicated histocompatibility laboratories received $131 million in reimbursement between March 31, 2013, and September 30, 2014. These labs commonly perform testing related to organ transplants, including testing the ability of a donor's tissue or organ to be accepted by a recipient. The OIG will review the cost reports more closely to determine whether all tests were reasonable, necessary and proper, as required under Medicare for reimbursement. The OIG is expected to issue a report following its review in 2016.

4. Provider-Based Facilities. The OIG intends to continue its focus on provider-based facilities through its review of such facilities, as we discussed in our summary of the 2014 and 2015 OIG Work Plans, but these reviews will come in light of changes to such facilities included in the Bipartisan Budget Act of 2015. Provider-based facilities are hospital outpatient departments and often are located off-campus. The facilities tend to be paid more than freestanding clinics for similar Medicare services, in recognition of the generally higher levels of overhead and infrastructure necessary to qualify as a hospital-based facility. Unlike at physician practice clinics, a service at a provider-based facility is reimbursed for both a technical fee (for the hospital) and a professional fee (for the physician). These higher payments and differential treatment can increase Medicare beneficiary coinsurance liability and increase costs to the program. These concerns led Congress to exclude such off-campus facilities from receiving enhanced reimbursement starting January 1, 2017 (with limited exceptions). The OIG is revising its focus on provider-based facilities to determine the number of provider-based facilities that hospitals own and the extent to which CMS has methods to oversee provider-based billing. The OIG also plans to review the attestation process for provider-based facilities, and continue to review and compare the actual difference in payments between provider-based clinics and freestanding clinics. Hospitals operating provider-based facilities should continue to ensure that they comply with all Medicare provider-based rules and, in light of the Bipartisan Budget Act, reconsider their development of any additional provider-based facilities.

5. Dental − Medicare Dental Claims in Hospitals. The OIG intends to continue its focus on Medicare hospital outpatient payments for dental services to determine whether such payments were made in accordance with Medicare requirements as we discussed in our summary of the 2015 OIG Work Plan. Dental services generally are excluded from Medicare coverage with certain exceptions, such as extraction of teeth to prepare the jaw for radiation treatment. Current OIG audits have suggested that hospitals are receiving Medicare reimbursement for non-covered dental services, resulting in significant overpayments. Indeed, two reports released in 2015 suggest that 97 percent and 85 percent (respectively) of outpatient claims submitted did not comply with Medicare requirements. See OIG, Kentucky and Ohio Report (July 2015) and Jurisdiction K Report (July 2015). In both samples, the majority of the improper claims involved unallowable tooth extractions and tooth socket repairs. As such, the OIG continues to investigate and review past Medicare dental billing by hospitals. Before billing any such Medicare claim, outpatient departments should verify the claim is appropriate under the Medicare program rules, since most dental services are not covered benefits.

6. Dental − Medicaid Pediatric Dental Services. The OIG plans to continue its focus on Medicaid pediatric dental services through two work plan items that we discussed in our summary of the 2015 OIG Work Plan. First, the OIG will continue to review Medicaid payments by states for dental services to determine whether states properly claimed federal reimbursement. Past OIG reports in New York and Indiana found that a small subset of providers represented the bulk of questionable billing that raise concerns about medical necessity. See, e.g., New York Report (March 2014) and Indiana Report (November 2014). Second, the OIG will continue to review whether children enrolled in Medicaid receive all of their intended dental service benefits. Medicaid covers approximately 37 million low-income children through the program's early and periodic screening, diagnosis and treatment program. Past OIG reports found at least three out of four children had not received all of their required screenings, and the OIG notes that children's dental access has been a longstanding Medicaid problem. For example, in 1993 only one in five children received preventive dental services. See OIG Access and Utilization Report. Dental providers should continue their compliance efforts, including utilization review, to ensure appropriate access to medically necessary dental care and to guard against improper billing practices.

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.

To print this article, all you need is to be registered on Mondaq.com.

Click to Login as an existing user or Register so you can print this article.

Authors
Similar Articles
Relevancy Powered by MondaqAI
McGuireWoods LLP
 
In association with
Related Topics
 
Similar Articles
Relevancy Powered by MondaqAI
McGuireWoods LLP
Related Articles
 
Related Video
Up-coming Events Search
Tools
Print
Font Size:
Translation
Channels
Mondaq on Twitter
 
Register for Access and our Free Biweekly Alert for
This service is completely free. Access 250,000 archived articles from 100+ countries and get a personalised email twice a week covering developments (and yes, our lawyers like to think you’ve read our Disclaimer).
 
Email Address
Company Name
Password
Confirm Password
Position
Mondaq Topics -- Select your Interests
 Accounting
 Anti-trust
 Commercial
 Compliance
 Consumer
 Criminal
 Employment
 Energy
 Environment
 Family
 Finance
 Government
 Healthcare
 Immigration
 Insolvency
 Insurance
 International
 IP
 Law Performance
 Law Practice
 Litigation
 Media & IT
 Privacy
 Real Estate
 Strategy
 Tax
 Technology
 Transport
 Wealth Mgt
Regions
Africa
Asia
Asia Pacific
Australasia
Canada
Caribbean
Europe
European Union
Latin America
Middle East
U.K.
United States
Worldwide Updates
Registration (you must scroll down to set your data preferences)

Mondaq Ltd requires you to register and provide information that personally identifies you, including your content preferences, for three primary purposes (full details of Mondaq’s use of your personal data can be found in our Privacy and Cookies Notice):

  • To allow you to personalize the Mondaq websites you are visiting to show content ("Content") relevant to your interests.
  • To enable features such as password reminder, news alerts, email a colleague, and linking from Mondaq (and its affiliate sites) to your website.
  • To produce demographic feedback for our content providers ("Contributors") who contribute Content for free for your use.

Mondaq hopes that our registered users will support us in maintaining our free to view business model by consenting to our use of your personal data as described below.

Mondaq has a "free to view" business model. Our services are paid for by Contributors in exchange for Mondaq providing them with access to information about who accesses their content. Once personal data is transferred to our Contributors they become a data controller of this personal data. They use it to measure the response that their articles are receiving, as a form of market research. They may also use it to provide Mondaq users with information about their products and services.

Details of each Contributor to which your personal data will be transferred is clearly stated within the Content that you access. For full details of how this Contributor will use your personal data, you should review the Contributor’s own Privacy Notice.

Please indicate your preference below:

Yes, I am happy to support Mondaq in maintaining its free to view business model by agreeing to allow Mondaq to share my personal data with Contributors whose Content I access
No, I do not want Mondaq to share my personal data with Contributors

Also please let us know whether you are happy to receive communications promoting products and services offered by Mondaq:

Yes, I am happy to received promotional communications from Mondaq
No, please do not send me promotional communications from Mondaq
Terms & Conditions

Mondaq.com (the Website) is owned and managed by Mondaq Ltd (Mondaq). Mondaq grants you a non-exclusive, revocable licence to access the Website and associated services, such as the Mondaq News Alerts (Services), subject to and in consideration of your compliance with the following terms and conditions of use (Terms). Your use of the Website and/or Services constitutes your agreement to the Terms. Mondaq may terminate your use of the Website and Services if you are in breach of these Terms or if Mondaq decides to terminate the licence granted hereunder for any reason whatsoever.

Use of www.mondaq.com

To Use Mondaq.com you must be: eighteen (18) years old or over; legally capable of entering into binding contracts; and not in any way prohibited by the applicable law to enter into these Terms in the jurisdiction which you are currently located.

You may use the Website as an unregistered user, however, you are required to register as a user if you wish to read the full text of the Content or to receive the Services.

You may not modify, publish, transmit, transfer or sell, reproduce, create derivative works from, distribute, perform, link, display, or in any way exploit any of the Content, in whole or in part, except as expressly permitted in these Terms or with the prior written consent of Mondaq. You may not use electronic or other means to extract details or information from the Content. Nor shall you extract information about users or Contributors in order to offer them any services or products.

In your use of the Website and/or Services you shall: comply with all applicable laws, regulations, directives and legislations which apply to your Use of the Website and/or Services in whatever country you are physically located including without limitation any and all consumer law, export control laws and regulations; provide to us true, correct and accurate information and promptly inform us in the event that any information that you have provided to us changes or becomes inaccurate; notify Mondaq immediately of any circumstances where you have reason to believe that any Intellectual Property Rights or any other rights of any third party may have been infringed; co-operate with reasonable security or other checks or requests for information made by Mondaq from time to time; and at all times be fully liable for the breach of any of these Terms by a third party using your login details to access the Website and/or Services

however, you shall not: do anything likely to impair, interfere with or damage or cause harm or distress to any persons, or the network; do anything that will infringe any Intellectual Property Rights or other rights of Mondaq or any third party; or use the Website, Services and/or Content otherwise than in accordance with these Terms; use any trade marks or service marks of Mondaq or the Contributors, or do anything which may be seen to take unfair advantage of the reputation and goodwill of Mondaq or the Contributors, or the Website, Services and/or Content.

Mondaq reserves the right, in its sole discretion, to take any action that it deems necessary and appropriate in the event it considers that there is a breach or threatened breach of the Terms.

Mondaq’s Rights and Obligations

Unless otherwise expressly set out to the contrary, nothing in these Terms shall serve to transfer from Mondaq to you, any Intellectual Property Rights owned by and/or licensed to Mondaq and all rights, title and interest in and to such Intellectual Property Rights will remain exclusively with Mondaq and/or its licensors.

Mondaq shall use its reasonable endeavours to make the Website and Services available to you at all times, but we cannot guarantee an uninterrupted and fault free service.

Mondaq reserves the right to make changes to the services and/or the Website or part thereof, from time to time, and we may add, remove, modify and/or vary any elements of features and functionalities of the Website or the services.

Mondaq also reserves the right from time to time to monitor your Use of the Website and/or services.

Disclaimer

The Content is general information only. It is not intended to constitute legal advice or seek to be the complete and comprehensive statement of the law, nor is it intended to address your specific requirements or provide advice on which reliance should be placed. Mondaq and/or its Contributors and other suppliers make no representations about the suitability of the information contained in the Content for any purpose. All Content provided "as is" without warranty of any kind. Mondaq and/or its Contributors and other suppliers hereby exclude and disclaim all representations, warranties or guarantees with regard to the Content, including all implied warranties and conditions of merchantability, fitness for a particular purpose, title and non-infringement. To the maximum extent permitted by law, Mondaq expressly excludes all representations, warranties, obligations, and liabilities arising out of or in connection with all Content. In no event shall Mondaq and/or its respective suppliers be liable for any special, indirect or consequential damages or any damages whatsoever resulting from loss of use, data or profits, whether in an action of contract, negligence or other tortious action, arising out of or in connection with the use of the Content or performance of Mondaq’s Services.

General

Mondaq may alter or amend these Terms by amending them on the Website. By continuing to Use the Services and/or the Website after such amendment, you will be deemed to have accepted any amendment to these Terms.

These Terms shall be governed by and construed in accordance with the laws of England and Wales and you irrevocably submit to the exclusive jurisdiction of the courts of England and Wales to settle any dispute which may arise out of or in connection with these Terms. If you live outside the United Kingdom, English law shall apply only to the extent that English law shall not deprive you of any legal protection accorded in accordance with the law of the place where you are habitually resident ("Local Law"). In the event English law deprives you of any legal protection which is accorded to you under Local Law, then these terms shall be governed by Local Law and any dispute or claim arising out of or in connection with these Terms shall be subject to the non-exclusive jurisdiction of the courts where you are habitually resident.

You may print and keep a copy of these Terms, which form the entire agreement between you and Mondaq and supersede any other communications or advertising in respect of the Service and/or the Website.

No delay in exercising or non-exercise by you and/or Mondaq of any of its rights under or in connection with these Terms shall operate as a waiver or release of each of your or Mondaq’s right. Rather, any such waiver or release must be specifically granted in writing signed by the party granting it.

If any part of these Terms is held unenforceable, that part shall be enforced to the maximum extent permissible so as to give effect to the intent of the parties, and the Terms shall continue in full force and effect.

Mondaq shall not incur any liability to you on account of any loss or damage resulting from any delay or failure to perform all or any part of these Terms if such delay or failure is caused, in whole or in part, by events, occurrences, or causes beyond the control of Mondaq. Such events, occurrences or causes will include, without limitation, acts of God, strikes, lockouts, server and network failure, riots, acts of war, earthquakes, fire and explosions.

By clicking Register you state you have read and agree to our Terms and Conditions