Payment Matters

October 27, 2011

OIG's 2012 Work Plan - What's in it for Hospital and Physician Providers?

By: Aaron J. Rabinowitz *

The Department of Health and Human Services, Office of the Inspector General (OIG) released its Fiscal Year (FY) 2012 Work Plan [PDF] on October 5, 2011. The OIG Work Plan provides an overview of what the OIG will focus on in the coming year. It gives providers insight into the areas that the OIG believes are susceptible to fraud, waste and abuse. This is the first of two articles summarizing OIG Work Plan provisions that providers should consider addressing in their compliance plans.

This article focuses on the Work Plan provisions that affect hospital and physician providers. It has been divided into “new” and “continuing” initiatives based on whether the issue was previously addressed in the FY 2011 Work Plan or whether it is a new focus.

Federal Pre-Existing Condition Insurance Plan Broadens Access to Uninsured Individuals

By: Christopher P. Dean

A recent Government Accountability Office (GAO) report [PDF] on the federal Pre-existing Condition Insurance Plan (the PCIP) noted that the fledgling program had enrolled only a fraction of its anticipated individuals during its first year. Initially the PCIP permitted individuals to obtain subsidized health insurance only if they obtained documentation that they were denied health insurance coverage because of pre-existing medical conditions. In the last six months the PCIP has relaxed this criteria to include individuals: (i) who have a documented pre-existing medical condition that may result in a denial of coverage; or (ii) who have a documented increased premium rate because of a pre-existing medical condition. Health care providers who routinely provide care to uninsured individuals should be mindful of these eligibility changes and consider assisting these eligible individuals to enroll in the PCIP and obtain health care insurance.

The PCIP was created by the Patient Protection and Affordable Care Act (PPACA) in March 2010 to provide a subsidized high-risk insurance pool to individuals who were denied creditable coverage because of a pre-existing medical condition. PPACA allocated $5 billion to the PCIP to pay for health care claims made by enrollees and the PCIP’s administrative expenses. The $5 billion was provided to fund the program until its termination on January 1, 2014, at which time the individuals enrolled in the PCIP are expected to obtain health insurance via the soon-to-be-implemented health insurance exchanges.