We are entering the second year of the OIG’s new approach to publicizing and managing its FY18-19 Workplan. Just like last year, the OIG Workplan 2019 is not a static document. The OIG publishes a continuously updated list of its Active Workplan Items. The list is searchable by month of listing (or as completed), by agency (e.g., CMS or FDA), by title, and by Report number. You can also easily identify projects that have recently been issued, and recent final reports. Monitoring this list, and incorporating some of the issues can improve a well-managed compliance program and keep you out of trouble!
Selecting Audits for the OIG Workplan 2019
The OIG uses several factors when deciding what audits to include in its OIG Workplan 2019. Some of the most important ones each year include:
- Audits the OIG is mandated to perform based on laws or requests from Congress,
- Actions taken to implement OIG recommendations from previous audits, and
- Reviews which can have an important impact.
Audits by the OIG cover a very wide range of topics. They address questions about compliance with regulations and payments by government programs. But the OIG also assesses the performance of state and local government agencies in carrying out programs mandated by Congress. For instance, the OIG Workplan 2019 addresses recent challenges such as preventing and treating opioid abuse. It also includes mainstays such as ensuring the integrity of the Medicare and Medicaid programs in all their various forms. That’s why the current OIG Workplan 2019 Active list includes 315 entries!
OIG Workplan 2019 by Organizational Categories
The largest single category of audits in the OIG Workplan 2019 as of early January 2019 were related to the programs and performance of the Centers for Medicare and Medicaid (CMS). The active list includes 158 entries in this category. Forty-eight are completed or partially completed, with copies of reports available for download. Two planned audits were removed from the list.
Acute Care Hospitals
The OIG has added five audits during 2018 that affect services rendered to Medicare beneficiaries in acute care hospitals.
- Assessing Inpatient Hospital Billing for Medicare Beneficiaries (Dec 2018). This audit is a two-part study. The first part gathers landscape information about hospital billing, and how it has changed over time. The second part will use the information to target certain hospitals or codes to look for patterns of incorrect coding and billing.
- Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries – 10-Year Update (Nov 2018). A study from 2010 found that 27% of Medicare beneficiaries experience adverse events or temporary harm events while hospitalized in 2008. This audit will assess the progress in reducing harm at the 10-year mark.
- Review of OP 3-Dimensional Conformal Radiation Therapy (3D-CRT) Planning Services (July 2018). This audit will attempt to determine if Medicare can save money by reducing the number of times it will pay for CPT Code 77295 for this therapy. It already denies payment for multiple planning for other types of radiation therapy similar to 3D-CRT.
- Increased Payments for Transfer Claims with Outliers (July 2018). This study will attempt to determine how the additional outlier payments (based on the outlier threshold) by Medicare in transfer cases, compare to the reduction in DRG, Disproportionate Share Hospital and Indirect Medical Education payments, for transfer claims.
- Medicare Part B Outpatient Cardiac and Pulmonary Rehabilitation Services (May 2018). This study will assess whether Medicare payments for outpatient cardiac and pulmonary rehabilitation services were allowable in accordance with Medicare requirements.
- Involuntary Transfer and Discharge in Nursing Homes (November 2018). CMS estimates that as many as one-third of all residents in long-term care facilities are involuntarily discharged. As a part of this study, the OIG will examine the extent to which nursing homes meet CMS requirements for involuntary transfers and discharges.
- CMS Oversight of Nursing Facility Staffing Levels (August 2018). The OIG will examine nursing staffing levels reported by facilities to the Payroll-Based Journal. It will also analyze CMS’s efforts to ensure data accuracy and improve resident quality of care.
- Medicaid Nursing Home Supplemental Payments (April 2018). Prior OIG and Government Accountability Office audits have found that Federal supplemental payments often benefit the State and local governments more than the nursing homes. The OIG will review the nursing home supplemental payment program’s flow of funding and determine how the funds are being used.
- Physicians Billing for Critical Care Evaluation and Management Services (August 2018). This review will determine whether Medicare payments for critical care are appropriate and paid in accordance with Medicare requirements, e.g., documenting time spent evaluating, providing care and managing the patient’s care.
- Review of Post-Operative Services Provided in the Global Surgery Period (July 2018). The OIG will verify the accuracy of the number of post-operative visits reported to CMS by physicians and determine whether global surgery fees reflected the actual number of post-operative services that physicians provided to beneficiaries during the global surgery period.
- Questionable Billing for Off-the-Shelf Orthotic Devices (January 2018). Since 2014, claims for three off-the-shelf orthotic devices [L0648 and L0650 (back braces), and L1833(knee brace)] have grown by 97 percent and allowed charges have grown by 116 percent, reaching $349 million in 2016. The OIG will evaluate the extent to which Medicare beneficiaries are being supplied these orthotic devices without an encounter with the referring physician within 12 months prior to their orthotic claim.
The OIG Workplan 2019 also has pertinent information in some of its completed reports
Overlapping payments, erroneous diagnosis, reporting requirements, Medicare requirements
- The OIG studied Medicare payments for overlapping Part A Inpatient Claims and Part B Outpatient Claims. Medicare overpaid some acute care facilities for outpatient services provided when the patient was an inpatient in another facility. Although the overpayments were the result of nonworking system edits, the OIG recommended CMS recoup over $50 million from acute care hospitals. The hospitals were also supposed to refund over $14 million in beneficiary coinsurance and deductibles (September 2017 – Partially Completed).
- The OIG found that the University of Wisconsin Hospitals and Clinics submitted claims indicating patients had severe malnutrition. Ninety of 100 claims had erroneous diagnosis codes when the medical records were reviewed. If this pattern was consistent for the three years 2014-2016, the hospital was overpaid by $2.4 million (June 2018).
- A study showed that 296 payments (100% of the sample!) for recalled medical devices did not comply with Medicare requirements for reporting manufacturer credits. These errors resulted in total overpayments of $4.4 million (March 2018 – Partially Completed).
- A Medicare Administrative Contractor, Wisconsin Physicians Service, paid providers for Hyperbaric Oxygen Therapy services that did not comply with Medicare requirements. One hundred and two out of 120 claims were deficient. The OIG recommended recouping over $300k in provider payments. (February 2018).
Audits of some individual hospitals released in 2018 identified several specific risk areas for hospital billing that are nearly universal.
- Inpatient claims with same-day discharges and readmissions,
- Inpatient claims with unreported discharges to home health services,
- Outpatient claims billed with modifier -59,
- Inpatient claims paid in excess of charges, and
- Inpatient claims billed with high-severity-level DRG codes.
Audits of other types of providers also showed some dismal results.
- An audit of outpatient physical therapy services showed that 184 claims out of 300 did not comply with Medicare medical necessity, coding or documentation requirements. The OIG extrapolated the overpayments for a six month period in calendar year 2013 to be $367 million (March 2018).
- A chiropractic clinic had 31 out of 100 claims fail Medicare requirements for medical necessity, and two more fail for lack of documentation (September 2018).
How to make use of the OIG 2019 Workplan in your institution or practice
As we mentioned above, the OIG Workplan is a continuously updated document. New projects are added throughout the year, and completed reports are also issued.
Our recommendation is to survey what’s new periodically.
Consider adding audits to your own Compliance Program when you notice the OIG beginning to look at a risk area that is present in your healthcare organization. Many audits start with an evaluation of medical record documentation. These reviews assess whether the indications for a service are present and if the documentation reflects the scope of service covered by Medicare.
Many of the OIG Workplan 2019 audit projects address parts of the healthcare system that don’t directly concern providers such as hospitals, long-term care facilities or physicians. One easy way to look for pertinent update is to visit the What’s New page on the OIG website. You can easily see new completed reports and updates to various lists maintained by the OIG. And the OIG Active Work Plan Items list will keep you abreast of new formal audit projects.
Some routine monitoring of what the OIG is up to can help you avoid an unpleasant surprise – like when the OIG singles out your organization for a specific audit!