Review areas outlined for Part A payments
Hospitals, home health under OIG microscope
The 2001 work plan for the Office of Inspector General includes several hospital-, home health- and hospice-related areas that will be examined. An review of these areas by the Foley & Lardner law firm of Washington, DC says the hospital targets will include:
• DRG-related payment window.
The OIG will review hospital compliance with settlement agreement provisions that prohibited duplicate billing for nonphysician outpatient services under the prospective payment system (PPS). The OIG will also initiate a companion review to determine whether Part B service providers, such as laboratory services, submitted duplicative claims for services provided to inpatients.
• Patient transfers.
The OIG will check for improperly reported transfers between PPS hospitals, and seek to recover overpayments related to those transfers. One of the new transfer-related projects involves an assessment of utilization patterns for 10 DRGs. For these DRGs, federal law requires that postacute services be treated as transfers and not discharges for payment purposes. According to Foley & Lardner, the OIG will review provider utilization patterns, such as whether the provider issues notices of noncoverage to beneficiaries or codes inpatient stays to fall into other DRGs, to determine whether providers are attempting to circumvent the new rule.
• Outpatient services.
The OIG will review implementation of hospital outpatient PPS, specifically the effectiveness of internal controls used to ensure services are adequately documented, coded, and medically necessary. One OIG project will evaluate whether outpatient pharmacy and medical supply services were appropriately billed in periods before implementation of outpatient PPS. Specifically, the review will focus on charges for self-administered drugs, which are generally not covered under Medicare Part B, and charges for undocumented, unnecessary, and noncovered medical supplies and services.
In the home health field, areas that Foley & Lardner expect to be examined include:
— compliance programs;
— impact of the new home health prospective payment system;
— physician certification of medical necessity for home health patients.
For skilled nursing facilities, areas being examined include:
— quality-of-care reviews at these facilities, especially the role of medical directors;
— PPS billing requirements;
— ineligible stays;
— physical therapy services;
— quality standards.
For hospice care, review areas include:
— plans of care;
— payments to nursing homes;
— continuous home care.
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