The HHS Office of Inspector General (OIG) Work Plan gets longer and more complicated every year. This means that your hospital is under increasing scrutiny when it comes to coding, billing, reimbursement, and other compliance issues.
Understanding the OIG Work Plan is crucial to complying with federal requirements, avoiding costly penalties—and optimizing healthcare reimbursement in 2019, says hospital compliance expert Duane Abbey in his audio conference, “2019 OIG Work Plan for Coding, Billing & Reimbursement.”
10 Work Plan Items that Matter
The OIG also now provides monthly updates that cover the work planning process and any newly initiated Work Plan items. During 2018, the OIG added numerous active Work Plan items that impact hospitals, including:
- Assessing Inpatient Hospital Billing for Medicare Beneficiaries
- Adverse Events in Hospitals (National Incidence Among Medicare Beneficiaries)
- Hospitals’ Compliance with Medicare’s Transfer Policy with the Resumption of Home Health Services and the Use of Condition Codes
- Physician Billing for Critical Care Evaluation and Management (E/M) Services
- Review of Outpatient 3-Dimensional Conformal Radiation Therapy Planning Services
- Increased Payments for Transfer Claims With Outliers
- Accountable Care Organizations’ Strategies Aimed at Reducing Spending and Improving Quality
- Hospitals’ Reliance on Drug Compounding Facilities
- Medicare Payments for Overlapping Part A Inpatient Claims and Part B Outpatient Claims
- Incidence of Adverse Events in Indian Health Service Hospitals
Compliance Pitfalls to Watch: E/M Services & Transfers
Added in August 2018, the OIG will be scrutinizing physician billing for critical care E/M services, which is an exclusively time-based service, according to VantagePoint, LLC. Physicians must clearly document the time they spend evaluating, providing direct care, and managing the patient. The OIG’s review will look at whether Medicare payments for critical care are appropriate and paid in accordance with Medicare requirements.
Also, the OIG added the transfer policy Work Plan item, which will address situations when hospitals transfer a patient to another facility or home health service, making them subject to a reduction in their diagnosis-related group (DRG) payment.
The OIG wants to determine whether Medicare appropriately paid hospitals’ inpatient claims subject to the post-acute care transfer policy when:
- Patients resumed home health services after discharge; or
- Hospitals applied condition codes to claims to receive a full DRG payment.
Also: Beware of Upcoding
Another new area under the OIG’s scrutiny is inpatient hospital billing. In 2016, hospitals billed Medicare $114 billion for inpatient hospital stays, and the OIG and Centers for Medicare & Medicaid Services (CMS) have found problems with upcoding. The OIG wants to conduct a two-part study to assess inpatient hospital billing.
In the first part, the OIG will analyze Medicare claims data to provide “landscape information” about hospital billing and determine how inpatient hospital billing has changed over time and varied among hospitals.
In the second part, the OIG will target specific hospitals or codes for a medical review to determine just how much and how often the hospitals billed incorrect codes.
OIG Looking for Decline in Adverse Events
Yet another OIG Work Plan item that you should keep your eye on is the 10-year update for adverse events in hospitals. The OIG has crafted 15 reports on adverse events (patient harm) in various healthcare settings since 2008. In 2010, the OIG released a congressionally-mandated study revealing that 27 percent of Medicare beneficiaries experienced adverse events or temporary harm events while hospitalized in 2008.
In the 2019 study, the OIG will use this same methodology for a sample of Medicare beneficiaries admitted to acute-care hospitals during 2018, measuring the incidence of temporary harm and adverse events, as well as whether the events were preventable and the associated Medicare costs. The OIG will then compare the 2018 results with the prior study results to assess hospitals’ progress in reducing harm, as well as to identify differences in harm rates, types, contributing factors, preventability, and costs.
Bottom line: The OIG Work Plan gets more extensive—and therefore harder to comprehend—as well as more intrusive every year. Start off 2019 with the information you need to optimize your coding, billing, and healthcare reimbursement. Join Duane Abbey for his ProfEdOnDemand audio conference on what’s in store for providers in the coming year—and how to take the necessary compliance and patient management steps to protect your hospital.