The Office of Inspector General (OIG) issued its annual Work Plan on October 1, 2007. The Work Plan provides a broad description of the focus areas for the OIG in the coming fiscal year. It serves as an important tool, providing a roadmap to potential risk areas. Providers should evaluate their compliance programs to determine if the current program should be modified to incorporate any of the OIG focus areas for 2008. Some of the areas listed in the 2008 Work Plan are summarized below:

Hospitals

Hospital Capital Payments: Although a similar initiative appeared in the 2007 Work Plan, the OIG claims its new 2008 initiative will assess whether capital payments to hospitals are being made at an appropriate level for expenditures associated with acquiring new equipment and facilities.
Inpatient Hospital Payments for New Technologies: The OIG will review payments made to hospitals for new devices and technologies to determine whether claims were submitted in accordance with applicable criteria.
Long-Term Care Hospital (LTCH) Payments for Interrupted Stays: The OIG plans to evaluate the appropriateness of payments made to LTCHs for interrupted stays, i.e., where a beneficiary returns to an LTCH within a specified time frame after being discharged from the LTCH to another facility.
LTCH Short Stay Outliers: The OIG will examine the distribution and amount of payment made to LTCHs for short-stay outliers, including reviewing cases that barely exceed the short-stay outlier threshold.
Compliance With Medicare’s Transfer Policy: The OIG will analyze whether hospital’s are improperly coding transfers of patients as discharges to receive the full DRG rate for a discharge, rather than the graduated per diem for transfers.
Payments for Diagnostic X-Rays in Hospital Emergency Departments: Noting increased concerns with the rise of imaging expenditures, the OIG plans to review a sample of paid Medicare Part B claims and associated medical records for diagnostic imaging services provided in hospital emergency departments.
Oversight of the Joint Commission Hospital Accreditation Process: Following the 2004 revamp of the Joint Commission’s accreditation process that required hospitals to conduct an additional self-evaluation process, the OIG plans to evaluate the sufficiency of CMS’ policies and procedures regarding Joint Commission accreditation.
Medicare Payments for Observation Services Versus Inpatient Admission for Dialysis Services: The OIG will evaluate whether Medicare payments to hospitals for renal dialysis services are appropriately billed as inpatient services or whether the services should have been provided as outpatient observation services paid at a reduced rate.
Laboratory Services Rendered During an Inpatient Stay: The OIG will review Medicare Part B payments for laboratory services furnished to hospital inpatients, which are typically included as part of the hospital’s Medicare Part A payments.
Emergency Health Services to Undocumented Aliens: The OIG will review claims submitted by various types of providers for emergency services provided to undocumented aliens and other specified aliens to evaluate whether payments were made in accordance with applicable criteria.
Provider Eligibility for Medicaid Reimbursement: Acknowledging that the OIG has previously identified unallowable Medicaid payments made to hospitals that did not meet the Medicare eligibility requirements, the OIG states that it intends to review whether states are appropriately evaluating providers eligibility for Medicaid reimbursement.
Disproportionate Share Hospital (DSH) Payments: The OIG will be focusing on both the Medicare and Medicaid portions of DSH payments.
- The OIG will review the components of the formula used to determine the Medicare DSH payments and examine the total amounts of uncompensated care costs hospitals incur.
- The OIG will review whether States are properly evaluating hospitals’ eligibility for Medicaid DSH payments.
- The OIG will review several state Medicaid programs to determine the extent of DSH funding that is being applied to services for individuals aged 21 to 64 who reside in institutions for mental diseases.
- The OIG will assess the appropriateness of the Medicaid inpatient utilization rate used to determine eligibility for Medicaid DSH payments and identify if any changes need to be made to the threshold requirement.
In addition to the foregoing initiatives, the OIG will continue to look into the following issues relating to hospitals:
- Audit adjustments for direct and indirect graduate medical education
- Appropriateness of payments for nursing and allied health education programs
- Accuracy of hospital wage data that is submitted and used to calculate wage indices
- Payments made to organ procurement organizations
- Provider bad debts

Long-Term Care

Oversight of Medicare Skilled Nursing Facility (SNF) Cost Reports: The OIG intends to evaluate a sample of SNF cost reports to determine the extent to which CMS is monitoring SNF compliance with the guidelines and requirements for reporting of cost data.
Accuracy of Coding for Medicare SNF Resource Utilization Groups' (RUGs) Claims: Noting that a 2006 OIG report found that 22 percent of Medicare claims submitted by SNFs were upcoded, the OIG plans to evaluate a national sample of Medicare claims submitted by SNFs to determine whether the RUGs included on the claims were accurate and supported by the beneficiaries' medical charts.
Part B Services in Nursing Homes: The OIG plans to extensively review Part B services provided in SNFs for residents whose stays are no longer covered under Part A. The OIG will evaluate the extent of Part B services provided to SNF residents in 2006 and look for patterns of billing by SNFs and other providers. In addition, the OIG plans to conduct a closer review of several types of Part B services, such as DME and enteral nutrition therapy.
Mental Health and Psychotherapy Services in Nursing Homes: The OIG will review the medical necessity, appropriateness of coding, and documentation of Medicare Part B payments for psychotherapy services provided to nursing home residents during noncovered Part A stays.
Minimum Data Set and Resident Assessment Protocols in Nursing Homes: The OIG will assess nursing home compliance with the use of the federal Minimum Data Set and Resident Assessment Protocols in development of nursing home resident's plans of care.
Payments for Part D Drugs: The OIG will review payments made under Part D for drugs for beneficiaries who are already covered under either a Medicare Part A SNF stay or a hospice per diem rate.
Implementation of Part D in Nursing Facilities: The OIG will review whether dual-eligibles are receiving medically necessary drugs and the factors contributing to the drugs they receive. Part D includes provisions requiring plan coordination with respect to beneficiaries eligible for prescription drug coverage under both Medicaid and Medicare Part D.
State and Federal Oversight of Medicaid Funded Assisted Living Facilities (ALFs): The OIG will evaluate the extent to which states are providing adequate oversight of ALFs receiving funds under a Medicaid Waiver. States are required to set their own requirements to ensure the safety of recipients, and Medicaid beneficiaries in ALFs must meet the same eligibility requirements as beneficiaries residing in nursing homes.

Home Health

Accuracy of Data on the Home Health Compare Website: The OIG intends to evaluate the CMS Home Health Compare Website to review, among other things, the procedures used by CMS to identify and update inaccurate or incomplete information.
Accuracy of Coding and Claims for Medicare Home Health Resource Groups: The OIG will review the accuracy of the home health resource groups (HHRG) as a case-mix adjustment to payment for home health agencies (HHAs). The OIG will evaluate the accuracy of HHRG assignments and look for any potential patterns of upcoding by HHAs.
Part B Therapy Payments for Home Health Beneficiaries: The OIG will evaluate Part B payments for therapy services, which are supposed to be included as part of the HHA prospective payments. The OIG will review claims made to outside suppliers on behalf of beneficiaries in home health episodes.
Medicaid Home Health Agency Claims: The OIG will evaluate Medicaid claims of HHAs to determine whether providers met the standards and conditions for participation set forth in 42 C.F.R. §§ 440.70 and 484 and whether the beneficiaries have met the eligibility criteria, including a doctor's determination that the beneficiary needs medical care in the home.

Various Providers

Bad Debts: The OIG will scrutinize the appropriateness of bad debt payments made to acute care hospitals, LTCHs, SNFs, and other providers, paying particular attention to whether recoveries from prior year write-offs were appropriately used to reduce the cost of beneficiary services for the period in which the recoveries were made.
Medicare Secondary Payor: The OIG will review Medicare payments to beneficiaries who have other insurance coverage and evaluate the capability of current procedures to prevent inappropriate payments to beneficiaries with other coverage, including procedures for identifying credit balance situations.
Pressure-Reducing Support Surfaces: Due to the $164 million in payment for pressure-reducing support surfaces in 2006, the OIG will conduct a claims review to determine if payments were appropriate.

Physicians and Other Professionals

Place of Service Errors: The OIG will continue to review the coding of claims for services rendered in ambulatory surgical centers and hospital outpatient departments to determine if physicians are improperly coding place of service to receive increased payment.
Long Distance Physician Claims Associated with HHA and SNFs: The OIG will evaluate the appropriateness of Medicare Part B payments made to physicians that provide services to Medicare beneficiaries, who reside in SNFs or receive HHA benefits, and live a significant distance from the physician billing for services.

Click here to view a full text version of the OIG's Fiscal Year 2008 Work Plan: oig.hhs.gov/publications/docs/workplan/2008/Work_Plan_FY_2008.pdf.