OIG 2000 work plan moves beyond billing focus
October 18, 1999 4 minutes read
OIG 2000 work plan moves beyond billing focus
No end yet for PATH, transfer payments, and DRG payment window initiatives
The Department of Health and Human Services' Office of Inspector General (OIG) released a hefty 40-page Work Plan for FY 2000 that sets the stage for a range of new investigations for the year ahead. Compliance experts that comb the OIG's blueprint year after year say the new Work Plan, released Oct. 5, is a combination of ongoing investigations and new initiatives that shows the OIG is continuing its reach into all corners of hospital and provider operations.
"The overriding impression I had was that there is an increasing focus on quality of care, as opposed to just billing issues," says Chris Idecker, a partner with Ernst & Young in Atlanta. He adds that increased focus carries a risk for providers. "It is very difficult to measure because it is a lot more subjective than billing. It is also extremely difficult to monitor."
According to Lisa Murtha, KPMG's managing director in New York City, it is also clear that the OIG has yet to complete several ongoing investigations, notably the Physicians at Teaching Hospitals, Prospective Payment System Transfers and DRG Payment Window initiatives. "Some of these are things we have seen time and time again," she says. "The government has been able to recoup a fair amount of money in these areas, so there is really no incentive for them to stop now."
On a positive note, Idecker and Murtha both applaud the OIG for its treatments of DRG investigations. "It is a more detailed work plan that I think shows an increasing acumen on the part of the OIG," says Idecker. He specifically points to the OIG's investigation into PPS discharge transfers, which has now been broken up into four separate parts.
"I like the fact that the OIG has included some of the specific DRGs they will be looking at, such as DRG 14 for cerebrovascular disorders," adds Murtha. "They have obviously identified some misuse and are going to be looking at that, but at least folks have a heads-up."
In addition to those familiar items, Murtha says hospitals and other providers should take heed at several items that have either been added to the OIG's Work Plan or moved up on its list of priorities. Here is a rundown of several of those areas:
- Cost reports. According to Murtha, the OIG's focus on cost reports may be a byproduct of the ongoing Columbia HCA investigation or other perceived issues related to cost reports. But she notes the OIG's Work Plan covers that area in considerable detail.
"It will be interesting to see how many organizations do cost report reviews in the coming year," she says, "because most of them tend to focus more on coding, billing, and charge master reviews."
- Uncollected beneficiary deductibles and coinsurance. According to Murtha, the issue of uncollected copayments and deductibles is a growing concern for many providers because it opens the door to the issue of 'professional courtesy.’ She says the root question is whether providers should offer discounts and waive copayments and deductibles to employees within a hospital or provider group.
"This is an important development and something that people should pay a lot of attention to," Murtha warns. At a minimum, she says providers should get policies and procedures in place to identify what is acceptable in terms of professional courtesy.
- Graduate Medical Education. "Any organization that is involved in research of any kind should be paying a lot of attention to GME," cautions Murtha. She says the OIG is casting a potentially wide net over the entire issue of research compliance.
According to Murtha, one specific area that has captured the attention of many regulators is Medicare reimbursement as it relates to research grants. High on the list of potential targets are areas that are medically necessary but not related to the research grant, she says. In some cases, there may have been cases of double billing if reimbursement came through a research grant, as well as the Medicare program.
- Medicare and Medicaid managed care. Murtha says she expected to see Medicare and Medicaid managed care surface in the Work Plan, but was surprised at the level of detail included in the OIG's Work Plan. She notes that a growing number of managed care organizations are now seeking to develop and implement compliance programs around their Medicare and Medicaid business. Some are also looking to initiate specific investigations into some of the areas that the government has identified, such as physician incentive plans, the usefulness of the Medicare+Choice performance measures, and how individual companies stack up against those measures.
Murtha says the issue of outpatient prescription drugs and drug rebates also appears to be coming under more scrutiny. "Some of these so-called rebates have been interpreted to be kickbacks." She warns that any party involved in one of those relationships should pay close attention to this initiative. "At a minimum, they should think about a risk assessment to identify any potential vulnerabilities."
The OIG's Work Plan also includes a significant emphasis on nursing homes, says Paul DeMuro of Latham & Watkins, in Los Angeles. "I am sure the greater emphasis on skilled nursing facilities will continue to be an issue," he predicts.
According to DeMuro, the Work Plan has few surprises for physicians. He notes the plan does include examination of advanced beneficiary notices. "That has been a hot issue for the last couple years but if you look at the things set forth in the plan there really is not that much that's new," he says.
DeMuro notes that reassignment of physician benefits is probably the most noteworthy item given the OIG's crackdown on certain clinics and the use of provider numbers. "But the OIG has also been working on that with HCFA for some time."
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