On July 17, 2017, the Department of Health and Human Services Office of Inspector General (“OIG”) published an updated Work Plan for Fiscal Year (“FY”) 2017 (“Work Plan”) that includes 14 added areas of planned or ongoing legal and investigative initiatives. OIG historically publishes the Work Plan annually, most recently in Fall 2016, and uses the document to describe OIG’s new and continuing audit and enforcement priorities for the upcoming year. In the future, OIG intends to publish updates to its Work Plan every month to enhance transparency surrounding its efforts.
Notably, the updates to the Work Plan come just a few months before the publication of the next annual Work Plan and highlight the significance of the focus areas addressed in this edition. These updates, along with the existing priorities already in the Work Plan, are useful for organizations identifying corporate compliance risk areas, improving policy development and managing audit and other risk management efforts.
A complete copy of the updated Work Plan is available here.
Significant Audit Activities
Of the 14 new and revised areas of focus mentioned in the updated Work Plan, a number of topics are of particular significance to hospitals and other health care providers, including the following.
- Nationwide Medicare Electronic Health Record (“EHR”) Incentive Payments to Hospitals. OIG will review hospital incentive payment calculations to identify potential overpayments that hospitals may have received due to inaccurate calculations. Between January 2011 and December 2016, the Centers for Medicare & Medicaid Services (“CMS”) authorized $14.6 billion in Medicare incentive payments to hospitals that adopted EHR technology, and government agencies including OIG identified improper incentive payments as a risk to the Medicare EHR incentive program. Separately, OIG also found several overpayments by state agencies in the Medicaid EHR incentive program.
- Review of Medicare Payments for Telehealth Services. OIG will assess whether claims for telehealth services met Medicare requirements by reviewing Medicare claims paid for telehealth services provided at distant sites that do not have corresponding claims from originating sites. OIG intends to audit and determine if telehealth services paid for by Medicare meet the coverage conditions of the applicable regulations.
- Review of Medicare Payments for Non-Physician Outpatient Services Provided Under the Inpatient Prospective Payment System. OIG will examine whether nationwide Medicare payments to hospital outpatient providers were correct for non-physician outpatient services provided within three days prior to the date of admission, on the date of admission or during inpatient prospective payment system stays excluding date of discharge. Prior OIG reviews identified significant overpayments for these services furnished shortly before or during inpatient stays, and more recently, OIG still found providers billing inappropriately and contractors making inappropriate payments. Furthermore, OIG concluded that Medicare payment system controls are not preventing or detecting overpayments for such incorrectly billed services.
- High-Risk, Error-Prone Home Health Agencies (“HHA”) Providers Using HHA Data. OIG will identify common characteristics of “at risk” HHA providers that could then be used in targeted pre- or post-payment claim reviews. CMS’s Comprehensive Error Rate Testing program found that the 2016 improper payment error rate for HHA claims was 42 percent or $7.7 billion. Prior and ongoing efforts by OIG during FY 2017 evaluated whether HHAs accurately provided patient information to state agencies for recertification surveys and whether HHA claims were paid in accordance with federal requirements.
- Medicare Payments for Unallowable Overlapping Hospice Claims and Part B Claims. OIG will review Medicare Part A payments to hospices and determine whether claims billed to Medicare Part B for items and services were allowable and in accord with federal regulations. Aside from specific exceptions, hospice beneficiaries waive all rights to Medicare payments for services related to the treatment of the terminal condition for which hospice care was elected. The hospice agency assumes responsibility for medical care related to the beneficiary’s terminal illness and related conditions, and any outside providers furnishing services related to the patient’s terminal illness must look to the hospice for payment. Prior OIG audits, investigations and inspections have identified this as an area for noncompliance with Medicare billing requirements where providers seek separate billing for services.
- Medicaid Claims for Opioid Treatment Program (“OTP”) Services. OIG will determine whether certain state agencies complied with federal and state requirements when claiming Medicaid reimbursement for OTP services. OIG stated that Medicaid covers and funds a large portion of behavioral health treatment services that include the treatment of substance abuse, making reimbursement for these services a significant enforcement priority.
- Medicaid Targeted Case Management. OIG will examine whether Medicaid payments for targeted case management services in certain states were made in accordance with federal requirements. These requirements include satisfaction of the definition of case management services under the Social Security Act and avoidance of duplicate payments made to public agencies under other program authorities for the same service. Previous work by OIG identified 18 percent of case management services claims in a state as unallowable with an additional 20 percent as potentially unallowable.
- Medicare Payments for Unallowable Overlapping Home Health Claims and Part B Claims. OIG will evaluate Medicare Part A payments to HHAs and determine whether claims billed to Medicare Part B for items and services were allowable according to federal regulations. Based on the home health consolidated billing requirements, the HHA that establishes a beneficiary’s home health plan of care has Medicare billing responsibility for services furnished to the beneficiary. Prior OIG audits, investigations and inspections found this area prone to noncompliance with Medicare billing requirements.
Other Audit Activities
Other initiatives mentioned in the updated Work Plan that OIG is investigating or plans to investigate include the following.
- Consumer-Directed Personal Assistance Program
- Health and Safety Standards in Social Services for Adults
- Medicare Part B Payments for Ambulance Services Subject to Part A Skilled Nursing Facility Consolidated Billing Requirements
- Assertive Community Treatment Program
- Children’s Health Insurance Program Reauthorization Act Performance Bonus Payments Received by States
- Recovery of Federal Funds Through Judgments/Settlements
The Work Plan offers providers a preview of OIG’s enforcement priorities, and the monthly updates will give providers additional insight into the current focus of OIG to assist in the identification of significant compliance risk areas. The increased frequency of updates offers new opportunities to tailor compliance efforts and glean insights about subjects of particular import to OIG as they develop. These frequent updates also confirm the continued significance of ongoing enforcement efforts by OIG. Compliance Officers should familiarize themselves with the Work Plan and carefully review the updates to incorporate developments when preparing their organization’s compliance audit priorities to ensure they stay abreast of the pertinent risk areas identified by OIG.
If you have any questions regarding updates to OIG’s Work Plan or would like additional information, please contact:
- Scott Taebel at (414) 721-0445 or firstname.lastname@example.org;
- Katherine Kuchan at (414) 721-0479 or email@example.com;
- Leia Olsen at (414) 721-0466 or firstname.lastname@example.org;
- Patrick Garcia at (443) 951-7043 or email@example.com;
- Kristen Chang at (414) 721-0923 or firstname.lastname@example.org; or
- Your regular Hall Render attorney.