FY 2013 Work Plan Says OIG Will Focus On Hospital Billing, Medicare Contractors

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By James Swann    

The Department of Health and Human Services Office of Inspector General will focus investigative and audit efforts in fiscal year 2013 on hospital billing and payment issues, as well as on oversight issues surrounding Medicare contractors, according to the agency's Work Plan for Fiscal Year 2013, released Oct. 2.

The work plan highlighted several new areas of concern surrounding hospitals, including payments for mechanical ventilation, payments for canceled surgical procedures, and compliance with Medicare's transfer policy, all of which are under OIG review, with reports expected to be issued in FY 2013.

According to the document, OIG is reviewing mechanical ventilation payments to determine whether providers are completing claims accurately and contractors are processing them correctly. As for canceled surgical procedure payments, OIG is investigating whether Medicare is wasting money by paying claims for the canceled procedures and then paying for rescheduled surgeries.

The review of hospital compliance with Medicare's transfer policy is intended to determine the effectiveness of payments made to hospitals for discharging patients that should have been coded as transfers.

Contractor Reviews.  

In addition to hospital reviews, OIG will review the effectiveness of Medicare contractors, including Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs), and Zone Program Integrity Contractors (ZPICs).

For example, a review underway is focused on the effectiveness of all Medicare Part A and Part B contractors.

"Given the number of contracts and the obligated dollars for which CMS is responsible, oversight and monitoring are vital for ensuring effective programs and safeguarding taxpayer dollars," the 123-page work plan said.

OIG is also reviewing CMS oversight efforts related to MACs and RACs, including determining whether CMS is conducting performance assessments of the MACs.

"We will also describe the extent to which MACs met, did not meet, or exceeded performance standards and determine the extent to which CMS identified and MACs addressed performance deficiencies," the work plan said.

The RAC review is focused on determining whether the contractors are identifying improper payments and referring potential fraud cases to law enforcement, and the ZPIC review is focused on CMS oversight of the program.

Other reviews OIG will perform in FY 2013 include:

• an investigation of the use of atypical antipsychotic drugs in nursing homes;

•  an investigation into whether home health agencies are complying with the requirement that physicians conduct face-to-face visits with patients before certifying them for home health services;

• an investigation into Medicare Part C and Part Program Integrity Contractors; and

• an investigation of state policies related to collecting Medicaid rebates for physician-administered drugs.

 By James Swann   

The work plan is at  https://oig.hhs.gov/reports-and-publications/archives/workplan/2013/Work-Plan-2013.pdf.