OIG 2016 Work Plan – Impact on Hospitals

The OIG 2016 Work Plan was released earlier last month, and hospitals again lead the pack in terms of OIG auditing projects.  In fact, this year there are 25 OIG auditing projects for hospitals, an increase from 22 last year.  Three of the projects are new, with one revised.  As usual, no projects were taken off the list.  One audit project, Hospitals’ Electronic Health Record System Contingency Plans, is buried back in the Other Public-Health-Related Reviews section.  Two other projects involving Medicare and Medicaid EHR system incentive payments and security of electronic health records are in the section on Recovery Act Reviews.

A few related “shortcuts:”

OIG 2016 Work Plan – New Hospital Projects

Here is a summary of 3 new projects for hospitals, added in the OIG 2016 Work Plan.

(1) Medical device credits for replaced medical devices

Medical devices implanted during inpatient or outpatient procedures may require replacement for a variety of reasons – defects, recalls, mechanical complications, etc.  Medicare payments for replacement of implanted devices is lower than payments for original implantation.  Medicare Administrative Contractors (MACs) have made erroneous payments to hospitals when the device is being replaced.  The OIG will attempt to determine the frequency of these types of mistakes and why they are happening.

(2) Medicare payments during MS-DRG payment window

There are somewhat complicated regulations for acute care hospitals on including certain outpatient services in the claim for inpatient services, when the outpatient services are delivered just before an inpatient stay.  In the OIG 2016 Work Plan for hospitals, the OIG will review payments for inpatient and outpatient services to determine if hospitals are receiving reimbursement under Part B of Medicare for services that should be covered by MS-DRG payments under Part A of Medicare.

(3) CMS validation of hospital-submitted quality reporting data

Data on the quality of services provided in hospitals is one of the keys to the Centers for Medicare and Medicaid (CMS) value-based purchasing program and the hospital-acquired condition payment reduction program.  These programs influence hospital DRG reimbursement.  The OIG will review how CMS is validating the hospital inpatient quality reporting data, and the actions CMS has taken as a result of its validation efforts.

OIG 2016 Work Plan – the relationship of to Your Corporate Compliance Program

Many of the audit projects of the OIG 2016 Work Plan focus on the performance of entities like CMS, Medicare Parts A and B contractors, state Medicaid administration, and public health reviews of organizations like the Centers for Disease Control or the National Institutes of Health.  This can make it seem rather remote from provider organizations such as hospitals, nursing homes and physician practices.  But it is very useful to review the OIG 2016 Work Plan for indications on topics of continuing interest and new projects.  Although these audits sometimes take years to complete, they can and do lead to changes in CMS policies that eventually do affect providers.  We encourage everyone to think about incorporating some of the topics identified in the OIG 2016 Work Plan in their own corporate compliance program.  You may be able to move much quicker when there is a change in policy down the line!

When you need proven expertise and performance

Jim Hook, MPH

Mr. James D. Hook has over 30 years of healthcare executive management and consulting experience in medical groups, hospitals, IPA’s, MSO’s, and other healthcare organizations.