The Department of Health and Human Services Office of Inspector General will
focus some of its work in 2013 on determining the effects of nonhospital-owned
physician practices billing Medicare as hospital-based physician practices, a
new topic for the agency and one compliance officials in an Oct. 22 webinar said
they were concerned about.
The agency's Work
Plan for Fiscal Year 2013 highlighted several new areas of concern
surrounding hospitals, including payments for mechanical ventilation, payments
for canceled surgical procedures, and compliance with Medicare's patient
transfer policy, all of which are under OIG review, with reports expected to be
issued in FY 2013 (191 HCDR, 10/3/12).
The webinar, sponsored by the Health Care Compliance Association, focused
solely on the aspects of the work plan related to hospitals. As experts
explained the hospital issues OIG plans to address, compliance officials focused
most of their technical questions about the enforcement of nonhospital providers
billing as if they were part of hospitals.
OIG in its work plan said it will determine the extent to which practices
using the hospital-, or provider-based status met the billing requirements of
the Centers for Medicare & Medicaid Services. According to OIG,
provider-based status allows a subordinate facility to bill as part of the main
provider. Provider-based status can result in additional Medicare payments for
services furnished at provider-based facilities and may also increase
beneficiaries' coinsurance liabilities.
Lewis Morris, an attorney at Adelman, Sheff & Smith in Annapolis, Md.,
did not dismiss the concerns of the webinar listeners. He noted, however, that
just because OIG is addressing a project for the first time in a work plan does
not mean it has not been discussed previously within the agency or elsewhere.
For example, the Medicare Payment Advisory Commission (MedPAC) in 2011 expressed
concerns about the financial incentives presented by provider-based status and
stated that Medicare should seek to pay similar amounts for similar
MedPAC noted that higher payments for provider-based departments are
appropriate because of the increased costs hospitals incur. According to the
commission, hospitals have been increasing employment of physicians, and
services are likely to shift from freestanding physician practices to hospital
outpatient departments (HOPDs). The problem, commissioners agreed, is that
payments under the hospital outpatient prospective payment system are typically
much higher than the physician fee schedule rates (51 HCDR, 3/16/12).
Morris said the overall theme of the OIG work plan that should trigger the
attention of compliance officials is the increasing use by the agency of
predictive analytical data. The work plan projects are examples of “how OIG is
using data in a creative way. It allows them to cast a broader net and look at”
multiple issues at the same time, he said. He also said it can allow them to
better identify outliers across the health care spectrum, not just those related
to technical payments.
The emerging use of technology, Morris said, “is not a passing fad.” In a
follow-up interview, he told BNA that hospital compliance officers should be
looking at the same data as the OIG, “not to anticipate a particular audit,
because you can't. But if the government is looking at your data, you should,
He said following the work plan itself is not enough to form a comprehensive
compliance program, and data should be used to “understand your unique risks”
and the “new and emerging issues” unique to a particular hospital.
By Nathaniel Weixel
The work plan is at https://oig.hhs.gov/reports-and-publications/archives/workplan/2013/Work-Plan-2013.pdf.