What’s up with the feds in 99?

Use this plan to evaluate your program

In October, the Department of Health and Human Services’ (HHS) Office of Inspector General (OIG) in Washington, DC, released its 1999 work plan.

The plan outlines the projects OIG sees as most important in its mission of eliminating fraud, abuse, and waste in federally funded health care programs.

Although the plan gives information about the OIG’s projects, it doesn’t contain a lot of detail, says Mary Grealy, JD, senior Washington counsel at the American Hospital Association’s office in Washington, DC.

OIG may interpret fraud differently

Also, providers should be aware that the OIG could possibly interpret an issue differently than the Health Care Financing Administration (HCFA) in Baltimore or the fiscal intermediaries, she adds. (For more information about fraud and abuse initiatives, see cover story.)

Grealy advises providers to use the work plan to see what areas concern the OIG. Then providers should look at their own operations and see if these areas could be problems for them, too.

Here are some of the areas that the OIG will examine, not all of which are scheduled for completion in this fiscal year:

Hospital projects

- HCFA’s oversight of private accreditation and state certification activities, as well as the role of private accreditation and state licensure;

- the relationship between hospital costs and revenues;

- the extent to which hospitals purchase services under arrangement and which services hospitals purchase most frequently — and the fiscal effects of these arrangements;

- the potential vulnerabilities to Medicare arising from the proliferation of hospital-owned, provider-based physician practices;

- the financial impact of trends in hospital-owned physician practices;

- the recovery of Medicare overpayments to prospective payment system (PPS) hospitals that incorrectly reported PPS transfers;

- cases in which patients are transferred from acquired PPS hospitals to acquiring PPS hospitals without leaving their hospital beds;

- PPS hospitals that routinely report that Medicare patients left the hospital against medical advice (self-discharged);

- Medicare claims for beneficiaries who were discharged and subsequently readmitted on the same day to the same PPS hospital;

- the process by which HCFA updates DRG codes;

- the extent and quality of HCFA’s monitoring of diagnosis-related coding by hospitals;

- whether psychiatric services rendered on an outpatient basis are billed and reimbursed in accordance with Medicare regulations;

- whether hospitals and other providers are inappropriately billing Medicare for items or services provided to beneficiaries as part of research grants and experimental drug trials.

Medicare contractor operations

- methods and approaches contractors use to identify potentially fraudulent providers and assess HCFA oversight in this area;

- the extent of inappropriate or unnecessary services for beneficiaries who receive a large number of medical services in a short time period;

- the costs claimed by various contractors for processing Medicare claims, especially costs claimed by terminated contractors;

- whether information associated with Medicare provider numbers and unique physician identification numbers is accurate and up-to-date;

- potential improvements in the appeals process for Medicare providers, particularly those related to Part B claims and claims under the Part A home health benefit.

Physician projects

o whether physicians are correctly coding evaluation and management services in locations other than teaching hospitals and whether carriers are adequately monitoring physician coding;

o compliance with the Medicare rules governing payment for physician services provided in the teaching setting and to ensure that claims accurately reflect the level of service provided to the patient;

o whether errors found in Medicare billings for physician services are associated with providers’ use of automated encoding software;

o a sample of physicians’ patient billing records to identify and obtain refunds for Medicare and Medicaid overpayments;

o contracts between providers and billing service companies to determine if they comply with Medicare regulations;

o Medicare claims prepared and submitted to billing service companies to determine if they are properly coded in agreement with the physician service provided to patients.

General administration projects

o the adequacy of HCFA’s planning, management, and assessment of the year 2000 system compliance problem and assess the risk that HCFA’s mission-critical, internal information systems may not operate effectively and efficiently on Jan. 1, 2000.

The OIG also said it planned to release compliance program guidance documents during the first half of fiscal year 1999 pertaining to independent third-party billing companies, coordinated care plans in the Medicare+Choice program and durable medical equipment companies.

To view the complete work plan, visit the HHS site on the Web: http://www.dhhs.gov/progorg/oig/.