2016 OIG Work Plan Available
By Brenda Edwards, CPC, CPB, CPMA, CPC-I, CEMC
The OIG 2016 Work Plan recently was announced; it includes ongoing work performed in the 2015 Work Plan and the announcement of some new areas of focus.
The Work Plan is divided by provider type and includes hospitals, nursing homes, hospices, home health services, medical equipment and supplies, prescription drugs, provider services as well as Medicare Part C and D programs and Medicaid programs.
New areas of focus include:
- Medical device credits for replaced medical devices
Review if improper payments to hospitals for inpatient and outpatient claims were made.
- Medicare payments during MS-DRG payment window
Review if services provided during inpatient stays were paid when they should not be separately reported.
- CMS validation of hospital-submitted quality reporting data
CMS uses quality data for hospital value-based purchasing programs and hospital acquired condition reduction programs to validate the quality reporting program.
- Skilled nursing facility prospective payment system requirements
Review documentation requirements for claims paid by Medicare
Medical Equipment and Supplies
- Orthotic braces-reasonableness of Medicare payments compared to amounts paid by others
Compare Medicare payments to those paid by non-Medicare payers for orthotic braces to identify wasteful spending.
- Osteogenesis stimulators-lump-sum purchase versus rental
Determine cost effectiveness of renting versus purchasing bone-growth stimulators.
- Orthotic braces-supplier compliance with payment requirements
Determine if DMEPOS suppliers’ claims were reasonable and necessary and met Medicare requirements.
- Increased billing for ventilators
Review if suppliers are inappropriately billing for ventilators on patients with non-life threatening conditions which would not meet medical necessity
Providers and Suppliers
- Ambulatory surgical centers-quality oversight
Previous reviews found poor oversight and time spans greater than five years between certification surveys for some ASCs. CMS requires ASCs become Medicare-certified by a state survey and certification agency to show conditions have been met.
- Physicians-referring/ordering Medicare services and supplies
Review of DME referred/ordered by providers to determine if payments were made in accordance with Medicare requirements. Providers must be enrolled in Medicare to refer/order services.
- Anesthesia Services-non-covered services
Determine if the beneficiary had services that were reasonable and necessary.
- Physician home visits-reasonableness of services
Verify documentation for medical necessity of a home visit instead of an office/outpatient visit.
- Prolonged services-reasonableness of services
Prolonged services are considered to be rare and unusual; review of necessity of and appropriate use with a companion E/M service.
- Histocompatibility laboratories-supplier compliance with payment requirements
Review services for accuracy and reasonable costs and necessary services.
Other Part A and B Program Management Issues
- Accountable Care Organizations (ACO): Strategies and Promising Practices
Review of ACOs including performance on quality measures and cost savings.
- Medicare payments for unlawfully present beneficiaries in the United States-mandated review
Review procedures to prevent and recoup Medicare payments to unlawfully present beneficiaries in the United States.
- Medicare payments for incarcerated beneficiaries-mandated review
Determine if payments were made for items and services on incarcerated beneficiaries since Medicare does not have a legal obligation to pay these services.
- CMS management of ICD-10 implementation
Review CMS and MACs to determine how the transition has affected claims processing, including resubmissions, appeals and medical review.
This is a summary of the new areas of focus. Find the full details and the complete for the 2016 OIG Work Plan .
Coding & Compliance Specialist
Kansas Medical Mutual Insurance Company (KaMMCO)
Brenda has over 25 years experience; her current responsibilities at KaMMCO include chart auditing, coding and compliance education, and contributing articles to the company website and publications as well as writing articles for coding publications. Brenda is a Certified Professional Coding Instructor (CPC-I), AAPC ICD10-CM/PCS Training Expert, and an AAPC workshop presenter. She is a frequent speaker for local chapters and AAPC conferences. She served