While zipping through traffic this morning, doing my usual bang-up job of treating the drivers around me like the inconvenient road cones that they are (the truth hurts), I was deep in thought about how best to present the salient points of the OIG Work Plan for 2011 to the world at large.

The last song that I heard on my satellite radio player this morning was “Will It Go ‘Round In Circles” by Billy Preston. This isn’t bad, I thought to myself, as there are a lot of repeating issues making an encore in the new work plan. Then I started dreaming about what I would look like in Billy Preston’s hair because let’s face it, that man had serious hair. Before I knew it, my car arrived at the door of the office parking garage, I still didn’t have an Afro, and I had completely lost my train of thought.

Having returned to the land of the coherent, I took another, closer look at this year’s plan, and discovered two new patterns of investigation emerging that, while not yet directly impacting the bottom line of the provider community, point to an expansion of focus in a few areas.

The first thing I noticed in an understated, yet increased spotlight on quality of care to Medicare patients. A few examples of this include:

• In the portion of the work plan for hospitals, the OIG will undertake a review of restraint and seclusion-related deaths, looking at the volume of such deaths and what actions were taken based on state investigations of these incidents;
• In the realm of nursing facilities, hospitalizations of nursing home residents will be reviewed, with the OIG believing that these may be an indicator of quality-of-care issues at nursing homes. The CMS oversight of nursing homes with high rates of resident hospitalization will also be assessed;
• As part of the OIG’s review of Part B payments for prescription drugs, the costs and usage patterns of Avastin and Lucentis for treatment of age-related macular degeneration will be assessed.
• The work plan includes a review of services provided to hospice beneficiaries residing in nursing homes, as well as looking at facilities with high percentages of utilization of hospice services. After reading this article in the past week, this couldn’t possibly come at a better time.  

These types of reviews appear to be consistent with the quality of care initiatives put forward by CMS and other carriers, who have at long last decided that as gatekeepers of the health care dollar, they want the majority of the money to go to providers and institutions who demonstrate the best patient outcomes.

The second thread had to do with the increasing reliance on private contractors to monitor payments made by the Medicare and Medicaid programs.  The OIG is undertaking reviews of the Zone Program Integrity Contractors (ZPIC) for general performance and disclosures of potential conflicts of interest, The Recovery Audit Contractors’ (RAC) performance will also be assessed. In addition to looking at the quality of the contractors themselves, the OIG will review the value of the program oversight that CMS currently maintains over these programs, as well as CMS’ response to issues raised by the contractors in the course of their audit activities.

I found this second thread interesting, especially coming on the heels of the recent court decision regarding the definition of “good cause” for RAC audits, an answer that by all rights should have been answered either by CMS or the RAC Validation Contractor. It would appear that these types of reviews of contractor activity are overdue. I do wonder whether these appraisals will carry enough substance to accurately assess the work product of the contractors, given the planned expansion of their activities currently taking place. In other words, which came first, Pandora or the box?

There are some repeat topics of particular interest, especially with regard to Part B claims. Despite the end of reimbursement for consultation codes in 2010, the coding and payment of evaluation and management services will continue as a focus of the OIG work plan. Closely following a recently released report from the OIG regarding the large number of claim payment errors related to incorrect reporting of place-of service, this issue has been retained in the new work plan.

When reading the OIG Work Plan (for those of us who are gluttons for punishment), it is important to keep in mind that while this is an important component of combating fraud and abuse in the Medicare program, this is no longer the sole battle plan that it once was. A calculated wager has been made by the current administration that anti-fraud efforts can pay for the many changes put forth in the Patient Protection and Affordable Care Act (PPACA). The efforts behind this wager are going to dramatically alter the current regulatory environment. While the OIG Work Plan for 2011 carries as much importance as it always has in highlighting areas of fraud and abuse, the work of the private contractors will have a tremendous effect on the plan going forward. And before you ask, yes, it will be greater even than the hypnotizing effect of the thoughts of Billy Preston’s hair during a morning commute.

11:15 am, October 8th, 2010 |