Not a Lexis+ subscriber? Try it out for free.
LexisNexis® CLE On-Demand features premium content from partners like American Law Institute Continuing Legal Education and Pozner & Dodd. Choose from a broad listing of topics suited for law firms, corporate legal departments, and government entities. Individual courses and subscriptions available.
By Nathaniel M. Lacktman, Lawrence C.Conn, Maria E. Gonzalez Knavel, M. Leeann Habte, Wiline Justilien, Richard K. Rifenbark, Anil Shankar, Heidi A. Sorensen, Lawrence W. Vernaglia, Judith A. Waltz, Adria Warren and Torrey K. YoungAt the beginning of each new fiscal year, the Office of Inspector General (OIG) at the Department of Health & Human Services (HHS) issues its Work Plan. The Work Plan in large part reflects only two aspects of the work of OIG: projects originating within the Office of Audit Services (OAS), which conducts financial, billing, and performance audits of HHS programs; and projects originating within the Office of Evaluations and Inspections (OEI), which provides management reviews and evaluations of HHS program operations. What it does not reflect, except by providing general statistics, is the work of the Office of Investigations or the Office of Counsel to the Inspector General in investigating and litigating matters involving individual providers and suppliers.
Like many to-do lists, OIG's plan is aspirational and, as a result, many projects are carried over from year-to-year as priorities shift and projects planned in the beginning of the fiscal year are set aside. The fact that a project has not been carried over does not suggest that OIG is no longer interested in that area. If a project is carried over, rather than cancelled, it typically means OIG continues to remain interested in it, notwithstanding its changing priorities.
Overall, the 2012 Work Plan reflects a greater focus on the new issues raised by the changes introduced by the Patient Protection and Affordable Care Act (PPACA). There are a significant number of new projects related to state Medicaid programs, as well as an emphasis on fraud and abuse reviews. Medicare Parts C and D also received an increased share of OIG's attention regarding new projects. As might be expected, these new projects and the overall direction of the 2012 Work Plan reflect a focus on evolving areas of fraud and abuse and resource allocation under federal health care programs.
Below is an overview of some of the major projects from the 2012 Work Plan, with particular emphasis on new projects. We also indicate which OIG office has primary responsibility for the project. Providers and suppliers relying on the Work Plan to design their own compliance agendas for the upcoming year should review the Work Plan in full, and also are reminded that, as discussed above, the Work Plan is not an all-inclusive listing of OIG's areas of interest.
Medicare Parts A and B
Hospitals
The 2012 Work Plan identifies 23 projects targeting hospitals. Of these 23, six are new projects. OIG will continue reviews related to hospital reporting of adverse events and present on admission conditions, as well as outlier payments and reporting of quality data. New OIG projects include the following:
Physicians and Non-Physician Providers
The 2012 Work Plan identifies 36 projects targeting physicians and other Medicare Part B Provider/Suppliers. Of these 36, 13 are new projects. OIG will continue reviews related to physicians, ambulatory surgical centers, evaluation and management services, clinical social workers, independent therapists, sleep testing, diagnostic radiology, laboratories, partial hospitalization programs, and end-stage renal disease facilities. OIG also will continue medical claims reviews of error-prone providers, and will continue to review the extent to which Medicare payments are billed for services ordered or referred by excluded providers. New OIG projects include the following:
Nursing Homes
The 2012 Work Plan identifies eight projects targeting nursing homes. Of those eight, three projects are new projects. OIG continues its review of services provided to beneficiaries in skilled nursing facilities, focusing mainly on quality issues such as oversight of poorly performing nursing homes (OEI) and the facilities' adherence to quality of care requirements (Medicare requirements for quality of care in skilled nursing facilities (OEI)), as well as an analysis of skilled nursing facilities with high rates of hospitalizations. OIG will continue its examination of the accuracy of Part A payments and facilities' Resource Utilization Groups (RUG) coding. OIG will continue its review of nursing homes' emergency plans and emergency preparedness and evacuation deficiencies.
The following three nursing home projects are new this year.
Medical Equipment and Supplies
The 2012 Work Plan reflects a continued increase in OIG's focus on suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). Of the 14 projects outlined in the 2012 Work Plan, four are new this year.
Diagnostic Testing and Imaging
Potential overutilization of sleep testing is a long-standing government concern, and OIG reiterated that that it will review the appropriateness of payments for sleep test procedures, including examining the factors contributing to the rise in Medicare payments for sleep studies. OIG also will assess provider compliance with federal program requirements for sleep studies, including whether appropriate modifier codes are being reported. Additionally, OIG will review payments for high-cost diagnostic radiology tests to determine whether they were medically necessary and the extent to which the same diagnostic tests are ordered for a beneficiary by primary care physicians and physician specialists for the same treatment.
Laboratory
No new reviews were proposed in the Work Plan for clinical laboratories, but ongoing projects were noted, all of which are expected to be completed during FY 2012. These include a review of trends in laboratory utilization, including the types of tests and the numbers of tests ordered. This analysis also will include OIG scrutiny as to what factors may influence physician ordering of laboratory tests. Another ongoing review will examine how the methods of establishing Medicare laboratory test payment rates vary from those of state Medicaid and Federal Employee Health Benefits programs. The methodology for this review will compare Medicare payment rates for 20 lab tests (those identified as most frequently ordered and most costly in terms of total dollars paid) against the payment rates of those other programs. Finally, OIG will continue to work on its review of Part B payments for glycated hemoglobin A1C tests, with a focus on the Medicare contractors' procedures for screening for appropriate frequency of testing.
Home Health Services
Of the nine projects outlined in the 2012 Work Plan, five are new this year. OIG will continue to review CMS' oversight of Outcome and Assessment Information Set (OASIS) data submitted by Medicare-certified Home Health Agencies (HHAs), which has been used by CMS for its HHA prospective payment system (PPS) since 2000. OIG also will continue to review compliance with various aspects of the home health PPS, including the documentation required in support of the claims paid by Medicare. In addition, OIG will review Medicare claims submitted by HHAs to determine the extent to which the claims meet Medicare coverage requirements. This will include an assessment of the accuracy of resource group codes submitted for Medicare home health claims in 2008. Finally, OIG will review cost report data to analyze HHA revenue and expense trends under the home health PPS to determine whether the payment methodology should be adjusted. OIG will examine various Medicare and overall revenue and expense trends for freestanding and hospital-based HHAs. New OIG projects include the following:
Hospices
The 2012 Work Plan identifies two projects targeting hospices, one of which is a new project. OIG will continue to review the use of hospice general inpatient care from 2005 to 2010, and will assess the appropriateness of hospices' general inpatient care claims and hospice beneficiaries' drug claims billed under Part D. The new OIG project is the following:
Part BPayments for Prescription Drugs
Reimbursement for prescription drugs under the Medicare Part B program continues to be a topic of interest for OIG. Of the 11 projects, five of them are new. In addition to the new projects described below, OIG has ongoing evaluations/inspections related to a number of pricing benchmarks, including ASP, AMP, and WAMP. OIG also has ongoing projects related to billing for immunosuppressive drugs, payments for off-label anticancer pharmaceuticals and biologicals, and both an audit and an evaluation related to the use of the drugs Lucentis and Avastin to treat wet age-related macular degeneration. New OIG projects include the following:
Medicare Part C
In the 2012 Work Plan, OIG continues many of the Medicare Part C - Medicare Advantage (MA) projects listed in its prior Work Plan (including enhanced payment to plans for certain beneficiaries; enrollment for Special-Needs Plans; MA risk adjustments data submission/validation; duplicate payments for drugs for institutionalized beneficiaries; and MA reporting requirements). There are three new OIG projects, described below.
Medicare Part D
Drug pricing and reimbursement for drugs under the Medicare Part D program continues to be a hot topic for OIG, as evidenced by the 21 Part D projects highlighted in the 2012 Work Plan. Of these 21 projects, 10 are new. OIG continues its review of potentially duplicated Medicare Part D claims in Parts A and B, characteristics associated with billing in 2009, sponsors' drug cost under retail discount generic programs, and drug claims for hospice beneficiaries that are duplicated under Parts A and D. OIG also has ongoing projects related to unusual claims for Schedule II and other drugs, pharmaceutical manufacturer rebates, and off-formulary drugs. Finally, OIG continues to review Part D formulary coverage determinations and beneficiary appeals process, risk sharing and corridors, true out-of-pocket costs tracking, and implementation of supporting systems at small- and medium-size plans and plans new to Medicare. New OIG projects include the following:
Medicaid
The 2012 Work Plan identifies 82 projects regarding state Medicaid programs. Of these, 21 are new projects. The Work Plan continues OIG's emphasis on the review of manufacturers' reporting of costs, states' pursuit of drug rebates, and documentation to support both costs and claims amounts. The Work Plan continues prior projects related to potentially excessive hospital payments, and its review of payments for specific services, such as hospice, medical equipment, family planning, physical therapy, occupational therapy, and speech therapy. New OIG projects include the following:
Medicaid Prescription Drug Pricing, Reimbursement, and Rebates
Legal/Investigative Activities
Legal Activities
OIG's legal activities consist of the resolution of civil and administrative health care fraud cases, including litigating the exclusion of individuals and entities from federal health care programs, pursuing Civil Monetary Penalty cases, working with prosecutors from the Department of Justice to develop Federal False Claims Act cases against individuals and entities that defraud the government, and the negotiation of corporate integrity agreements with health care providers as part of the settlement of federal health care program investigations. The 2012 Work Plan identifies one new project:
Investigative Activities
OIG's investigative activities include the review and investigation of allegations of fraud and misconduct. These investigations lead to criminal prosecutions and exclusions of individuals and entities from federal health care programs and the recovery of damages and penalties through civil and administrative proceedings. In the 2012 Work Plan, specific areas of interest for OIG's investigative functions include individuals, facilities, or entities that bill Medicare and/or Medicaid for claims not rendered, the submission of false claims, and claims that manipulate payment codes to inflate reimbursement amounts; business arrangements that violate the federal Anti-Kickback Statute and/or physician self referral law; quality of care issues in nursing facilities, institutions, community-based settings, and other care settings, including the billing of unnecessary services; and illegal schemes involving Medicare and Medicaid drug benefits.
Public Health Reviews
OIG conducts reviews of the public health agencies within the HHS. Of the 45 projects identified in the 2012 Work Plan, 19 are new. New OIG projects include the following:
Department-wide Issues
OIG engages in a number of department-wide reviews, including reviews related to financial statements, financial accounting, and information systems management. The 2012 Work Plan identifies 19 reviews of department-wide matters, including one new project.
Conclusion
OIG has announced a long set of priorities in its plan for audits and evaluations in this second post-health care reform year. DMEPOS suppliers continue to be targeted for review, but entities involved in Parts C and D also will note the increased attention. In addition, OIG has directed its efforts on examining state Medicaid programs, with 21 new projects identified this year. With the size and scope of these various projects, we can anticipate OIG will be required to balance priorities and assess which projects will be of most important interest. Ultimately, health care providers, suppliers, facilities, and payors are advised to keep in mind the OIG projects related to their line of business, as it can help shed light on those areas of compliance that the OIG believes important.
You can access a copy of the complete OIG 2012 Work Plan online at http://tinyurl.com/3uhvl2f.
_______________________________
Legal News Alert is part of our ongoing commitment to providing up-to-the-minute information about pressing concerns or industry issues affecting our health care clients and colleagues. If you have any questions about this alert or would like to discuss this topic further, please contact your Foley attorney or any of the following individuals:
Nathaniel M. Lacktman Tampa, Florida 813.225.4127 nlacktman@foley.com
Lawrence C.Conn Los Angeles, California 213.972.4781 lconn@foley.com
Maria E. Gonzalez Knavel Milwaukee, Wisconsin 414.297.5649 mgonzalezknavel@foley.com
M. Leeann Habte Los Angeles, California 213.972.4679 lhabte@foley.com
Wiline Justilien Washington, D.C. 202.672.5432 wjustilien@foley.com
Richard K. Rifenbark Los Angeles, California 213.972.4813 rrifenbark@foley.com
Anil Shankar Los Angeles, California 213.972.4584 ashankar@foley.com
Heidi A. Sorensen Washington, D.C. 202.672.5596 hsorensen@foley.com
Lawrence W. Vernaglia Boston, Massachusetts 617.342.4079 lvernaglia@foley.com
Judith A. Waltz San Francisco, California 415.438.6412 jwaltz@foley.com
Adria Warren Boston, Massachusetts 617.342.4092 awarren@foley.com
Torrey K. Young Boston, Massachusetts 617.502.3294 tyoung@foley.com
© 2011 Foley & Lardner LLP
Legal & Privacy Policy
. . . .
Explore the LEXIS.com Estates, Gifts & Trusts and Elder Law resources
Discover the features and benefits of LexisNexis® Tax Center
For more information about LexisNexis products and solutions connect with us through our corporate site.
Great post , Thank you for writing so well on such a difficult but important subject. It was really helpful to solve my confusion
Thanks for the post. The subject is very unique, It was really helpful to solve my confusion.
Great post, Keep on writing such stuffs. I will be keeping track of your next one.