There are subtle indications that this particular October is going to be somewhat different from those past. The NHL is locking out its players, the political season is creating a particularly virulent strain of stupidity and I find that I have suddenly lost my tolerance for Oktoberfest beers.
Yet if it’s early October in the United States, we have something that was released on Tuesday that arrives with the reliability of the Sun and organic death; the 2013 OIG Work Plan.
This year’s plan brings with it 148 pages of new and old areas of focus, which is slightly smaller than last year. Let’s jump right in and discover what to expect over the next year.
The hospital world is already up in arms about one particular aspect of the OIG’s Part A plan. The OIG is going to analyze claims data to determine how much money could be saved by CMS “if it bundled outpatient services delivered up to 14 days prior to an inpatient hospital admission into a DRG payment”. Currently, the DRG payment window is set at 3 days.
In my mind, if this is the first salvo towards a proposed rule on a 14-day payment window, hospitals across the country that were planning to build ambulatory surgical centers (ASC) that they would own and operate more than likely just scrapped their plans. Those hospitals that currently wholly own their ASCs are probably going to redraw the contracts to bring in partial new ownership to make certain that services there never fall under the DRG window. If a patient has a procedure in a hospital-owned ASC, the patient goes home and within two weeks has a complication necessitating an inpatient stay, suddenly the ASC services would be bundled into the DRG payment. Worse yet, if CMS and the OIG define the complication as acquired at the facility, would this lead to CMS paying nothing for eitherencounter under their desired future payment paradigm? It is comparable to being hit by a bus while crossing the street and being sent flying across the double yellow line into the path of a Peterbilt truck.
In 2011, the Work Plan began to look at the proper use of swing beds within a hospital. This year’s plan expands on that, looking at transfers from one hospital into a swing bed at another hospital. Specifically, the OIG wants to know if these cases were handled as discharges by the first hospital, rather than the proper procedure of a transfer. Additionally on this topic, the OIG is going to look at payments for swing-bed services in critical access hospitals and compare them to payments in skilled nursing facilities in an attempt to identify savings.
Also new to the hospital realm within the work plan are:
- An analysis of the changes in inpatient stays from FY 2008 to FY 2012;
- Review of payments for hospital discharges that should have been coded as transfers;
- A closer look at what happens from a payment perspective when a surgical procedure is cancelled during an inpatient stay;
- The appropriateness of Medicare payments for mechanical ventilation;
- Assessing the work product of contracted Quality Improvement Organizations (that’s $1.1 billion in contracts, folks!); AND
- Hospital acquisition of ASCs and possible subsequent conversion to hospital outpatient departments, leading to higher reimbursement.
Continuing in the Part A realm, the OIG is once again revisiting the administration of atypical anti-psychotic drugs, with a closer look at the characteristics of the nursing homes that use them more frequently that others (I think we used to call them “communes” in my infancy).
Let’s delve a little bit into Part B. I’d like to start with some of the new issues on the Program Integrity front. The OIG wants to know how often on-site visits are happening for providers and suppliers during the enrollment / re-enrollment process. The OIG found in a prior review that 33% of DME suppliers in South Florida did not have a physical facility. As an adjunct to this finding, the OIG will also be looking at the improper use of commercial mailboxes opened with the specific intent being to defraud the Medicare program.
A few specialties are new on the radar. Anesthesiologists billing with the “AA” modifier for services (indicating that the services were personally performed, rather than supervised) will have their claims reviewed to verify that this information is correct. Ophthalmologists, who were paid $6.8 billion in FY 2010, will have their claims reviewed for what the OIG calls “questionable billing”. A similar probe will be done for needle EMGs and nerve conduction studies, which puts neurologists and neurosurgeons on notice nationally.
Some issues are continuing from previous years, such as reviews of providers that have proven themselves to be error-prone in CERT testing, the high utilization of sleep testing procedures and ASC payment methodology.
The ongoing drug shortages happening throughout the country are now drawing the attention of the OIG. In addition to studying the experiences of physicians and hospitals dealing with the shortages, the OIG is also looking at manufacturer sales of drugs in short supply. With drugs being vastly overpriced thanks to manufacturer-friendly language in the law that created Medicare Part D, the OIG is looking into instituting a drug rebate program for Part B drugs similar to what is in effect for Medicaid. Along the same lines, the OIG is continuing its investigation into the differences between average sale price and average manufacturer price.
Long overdue is a two-front investigation of Medicare Administrative Contractors which will assess their performance and their use and management of system edits for claims processing. When set alongside the OIG’s intention to review CMS’ contracting landscape and looking into whether contractors are meeting requirements for error-rate reduction, it would appear that a new front has been opened up in investigating why the Medicare payment error rate remains ridiculously high, and in the opinion of this writer, not a moment too soon.
In addition to the work plan, the OIG is planning a free webcast on October 24th as a follow-up to the plan’s release. More information on this can be found here. Enjoy perusing the pages of the work plan, as past plans have provided a foundation for long-standing audit issues. The Work Plan is never the bearer of bad news, but rather the best road map for the future. I know you have plenty of time to read it, as there is no hockey to watch.