Ambulatory surgical centers (ASCs) and clinical laboratories are among the many healthcare operations targeted for close oversight in the 2016 Work Plan from the Office of Inspector General (OIG) of the Department of Health and Human Services.
The focus on ASCs is new to the Work Plan this year, notes Bart Walker, JD, a partner with McGuireWoods in Charlotte, NC. The Work Plan indicates that OIG will focus on oversight of the state agencies that handle Medicare surveys and ASC accreditation organizations, with the agency expressing concern with the infrequency of Medicare certification surveys of ASC facilities. Although most private accreditation organizations traditionally required unannounced surveys every three years, OIG has found that many ASCs have gone for five years, and some for even longer, between surveys. The Work Plan also expresses concern about the lack of public information on the quality of ASCs, Walker notes.
Medicare billing and payment issues related to independent clinical laboratories also are on OIG’s radar. It is planning to identify laboratories that routinely submit improper claims and any diagnostic tests for which Medicare pays more than private insurers. Histocompatibility laboratories will be scrutinized because of a recent review of cost reports indicating that histocompatibility laboratories received $131 million in reimbursement between March 31, 2013, and Sept. 30, 2014, Walker says.
In addition to those concerns, Walker points to other important parts of the 2016 Work Plan:
• Home health prospective payment system (PPS) require-ments.
OIG will conduct a compliance review related to home health Medicare program payments and check that claims included the required documentation. OIG has found that 25% of home health agencies had questionable billing under the home health PPS, so Walker predicts the compliance review will be a top priority.
• Skilled nursing facility (SNF) PPS requirements.
OIG also will conduct compliance reviews of Medicare program payments made under the SNF PPS. Walker says the reviews are most likely to assess whether therapy provided at SNFs is documented as being “reasonable and necessary.” The Work Plan notes that OIG has previously found that Medicare payments for SNF therapy “greatly exceed” the SNF’s actual costs.
• Hospice care.
The Work Plan says OIG intends to review the appropriateness of hospices’ general inpatient care claims, as well as election statements for hospice beneficiaries. One concern is whether the level of service for hospice beneficiaries is being billed when such services are not medically necessary.