2016 OIG Work Plan Available

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:

Hospital

  • 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.

Nursing Homes

  • 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.

Anesthesia and Pain Management CANPC

This is a summary of the new areas of focus. Find the full details and the complete for the  2016 OIG Work Plan .

Brenda Edwards

Brenda Edwards

Senior Managing Consultant of Risk Adjustment at Medical Revenue Solutions
Brenda Edwards, CPC, CDEO, CPB, CPMA, CPC-I, CEMC, CRC, CMRS, CMCS, is executive consultant of risk adjustment at SCBI. She has for over 30 years with experience in chart audit, coding and billing, education, consulting, practice management, and compliance. Edwards shares her expertise writing for Healthcare Business Monthly, as well as other national publications, such as American Academy of Family Physicians (AAFP) and BC Advantage. Edwards helps students obtain their coding credentials through the AAPC Professional Medical Coding Curriculum, and she is an AAPC ICD10-CM/PCS Training Expert. Edwards served on the AAPC Chapter Association Board of Directors from 2010-2014 and held office as chair. She has been involved in the Hardship Fund for AAPC since its inception. Edwards is a mentor and co-founder of the Northeast Kansas (NEKAAPC) AAPC chapter and has served many officer roles.
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Brenda Edwards, CPC, CDEO, CPB, CPMA, CPC-I, CEMC, CRC, CMRS, CMCS, is executive consultant of risk adjustment at SCBI. She has for over 30 years with experience in chart audit, coding and billing, education, consulting, practice management, and compliance. Edwards shares her expertise writing for Healthcare Business Monthly, as well as other national publications, such as American Academy of Family Physicians (AAFP) and BC Advantage. Edwards helps students obtain their coding credentials through the AAPC Professional Medical Coding Curriculum, and she is an AAPC ICD10-CM/PCS Training Expert. Edwards served on the AAPC Chapter Association Board of Directors from 2010-2014 and held office as chair. She has been involved in the Hardship Fund for AAPC since its inception. Edwards is a mentor and co-founder of the Northeast Kansas (NEKAAPC) AAPC chapter and has served many officer roles.

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