OIG’s 1999 work plan is blueprint for risk assessment
OIG’s 1999 work plan is blueprint for risk assessment
Want to perform effective risk assessment for compliance to federal regulations in your institution without having to spend a fortune hiring a Big Six accounting firm? Then go to OIG’s Web site and download the agency’s 1999 work plan.
It’s all there. You’ll find the areas that OIG is focusing on — which means the areas you should be focusing on. "I would use it for my risk assessment," advises Roy Snell, a former compliance officer who’s now a consultant for Deloitte and Touche in New York. "I would go down the list and find the areas that apply to my institution."
Your best guides to structuring your compliance program are still input from employees and your own compliance audits, Snell adds. "But to ignore the work plan would be foolish."
Many items, such as the hospital upcoding investigations, won’t be news to anyone. But there are quite a few new issues that OIG says it will be looking at in 1999. One is end-stage renal disease tests. "Our survey disclosed that providers are either separately billing for laboratory tests included in the monthly composite rate or are providing tests that do not conform to professionally recognized standards," says OIG. This could as big and costly an investigation as the lab unbundling probe, says former OIG auditor John Beattie.
OIG makes clear that it will more aggressively use its exclusionary powers, which have been beefed up by the Balanced Budget Act. "We anticipate increasing the number of program exclusions" over the next fiscal year, says the OIG. In addition, "We expect to increase the number of patient anti-dumping cases analyzed, negotiated, and litigated, with the resolution of approximately 50 such cases in FY 1999," OIG predicts.
There are a slew of other targets on OIG’s investigative agenda. Inquiring government minds want to know more about:
Hospitals
- The relationship between hospital costs and revenues to determine whether Medicare payments are reasonable.
- Whether hospitals are pocketing extra money by submitting claims for patients who are being discharged and then readmitted to the same hospital on the same day.
- Whether hospitals are billing Medicare for experimental drugs that are already funded through other programs.
Physicians
- Whether some doctors charge for excessive visits to nursing homes, including those with a high number of visits on a given day or unusually frequent visits to the same beneficiary.
- If physician billing "errors" are linked to the use of new encoding software. "Results of this work may lead to further reviews," the work plan notes.
- If some podiatry claims lack medical necessity.
Home health
- Whether new rules governing hospital discharges to home health have changed home health utilization.
Nursing homes
- Whether SNFs have been billing for unallowable ancillary supplies.
Durable medical equipment
- Whether DME companies are exploiting the nature of billing codes and the difference in contractor claim processing to submit duplicate claims to DME Regional Carriers and Regional Home Health Intermediaries.
Drug reimbursement
- If nursing home cost reports are being inflated by high prices from infusion therapy suppliers.
Managed care
- Whether Medicare is making duplicate fee-for-service payments to providers who should have been paid by HMOs.
- Whether HMOs are providing appropriate services (OIG will examine what kind of fee-for-service treatments beneficiaries need after they leave HMOs. OIG also will begin surveying fraud and abuse in Medicaid managed care.)
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