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The OIG & You: Health Care Compliance Programs (and ACOs) in 2011 and Beyond. May 10, 2011. Douglas A. Grimm, FACHE Pillsbury Winthrop Shaw Pittman firstname.lastname@example.org. Pillsbury’s Health Care Capabilities.
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May 10, 2011
Douglas A. Grimm, FACHE
Pillsbury Winthrop Shaw Pittman
Average spending on healthper capita ($US PPP)
Total expenditures on healthas percent of GDP
Note: $US PPP = purchasing power parity.
Source: Organization for Economic Cooperation and Development, OECD Health Data, 2009 (Paris: OECD, Nov. 2009).
Cost in Billions
Source: Thomson Reuters, 2011
“U.S. Department of Health and Human Services Secretary Kathleen Sebelius and U.S. Associate Attorney General Thomas J. Perrelli today announced a new report showing that the government’s health care fraud prevention and enforcement effortsrecovered more than $4 billion in taxpayer dollars in Fiscal Year 2010. This is the highest annual amount ever recovered from people who attempted to defraud seniors and taxpayers.”*
In 2009, recovered $2.5 billion**
*Sources: HHS press release Jan. 24, 2011
Protect program integrity and the well being of program beneficiaries by detecting and preventing waste, fraud, and abuse.
Identify opportunities to improve program economy, efficiency, and effectiveness.
Hold accountable those who do not meet program requirements or who violate Federal laws.
Conduct audits, evaluations, and investigations.
Provide guidance to industry.
When appropriate, impose civil monetary penalties, assessments, and administrative sanctions.
Describes the activities and audits on which the OIG will focus for the protection of federal health program integrity.
Furthers OIG’s goals to detect and mitigate fraud, waste, and abuse.
Hold accountable those who do not meet program requirements.
2011 Work Plan was released October 1, 2010.
Several new priorities.
Largely builds on objectives in 2010 Work Plan.
2011 Work Plan omits EMTALA and coding and documentation under the MS-DRG system.
General areas of focus – less specific than in past years.
New topics address quality, billing concerns.
Any time OIG adds new issues to the work plan, providers who provide these services and other Medicare stakeholders should be knowledgeable of these changes.
(1) Replacement Devices
Hospital receives full or partial credit from a device manufacturer – hospital must use modifiers on the inpatient and outpatient claims.
Medicare not responsible for the full cost of a replaced medical device when hospital receives a credit from manufacturer of 50 percent or more for a replacement device.
(2) Radiation Therapy Quality and Safety Review
OIG to review safety and quality of intensity-modulated radiation therapy and image-guided radiation therapy.
(3) Brachytherapy Reimbursement
(4) Payments for Non-Physician Outpatient Services Under the Inpatient Prospective Payment System (“IPPS”)
OIG to review appropriateness of the payments for non-physician outpatient services shortly before or during hospital stays.
Priorities continued from the 2010 Work Plan include:
OIG reviewing cost reports of hospitals claiming provider based status to determine the appropriateness of the designation and the potential impact on Medicare.
Hospitals should review the provider-based requirements (42 C.F.R. § 413.65(d)).
Physicians’ Evaluation and Management (“E&M”) coding and documentation.
OIG reviewing the extent of potentially inappropriate payments for E&M services and consistency of E&M medical review determinations.
Payments to Critical Access Hospitals (“CAHs”)
OIG determining whether CAHs meet the conditions of participation and whether CAHs have met the designation criteria in the Social Security Act.
Medicare Excessive Payments
OIG continuing to review Medicare claims with unusually high payments to determine their appropriateness.
Medicare Disproportionate Share Payments (“DSH”)
OIG continuing to determine whether these payments have been made in accordance with Medicare requirements.
Medicare Outlier Payments
OIG reviewing outlier payments and identifying national trends and characteristics of hospitals with high or increasing rates of outlier payments.
Duplicate Graduate Medical Education (“GME”) Payments
OIG continuing to review provider data from CMS’s Intern and Resident Information System to determine whether duplicate GME payments have been claimed.
Hospital Capital Payments
OIG reviewing Medicare inpatient capital payments to determine whether capital payments to hospitals are appropriate.
Hospital Acquired Conditions (“HAC”)
OIG reviewing early implementation of the CMS HAC policy; also reviewing Medicare claims data to identify the number of beneficiary stays associated with HACs and determine impact on reimbursement.
OIG continuing to review claims to determine readmission trends.
Place of Service Errors
OIG reviewing place of service coding on Medicare Part B for hospital outpatient departments.
ASC Payment Rates
OIG reviewing the appropriateness of the methodology for setting ASC payment rates under the revised ASC payment system.
Excluded Providers and Deceased Beneficiaries
OIG assessing the extent to which Medicare paid for services ordered or referred by excluded providers; OIG continuing to review claims with dates of service that occur after the beneficiary’s death.
Independent Physical Therapists
OIG focusing on independent physical therapists with high utilization rates for outpatient therapy services to assess compliance with Medicare regulations.
Skilled Nursing Facilities (“SNFs”)
OIG reviewing Medicare Part A payments to SNFs and conducting reviews to determine the medical necessity of claims and whether the claims were sufficiently documented and correctly coded during CY 2009.
Continuing oversight of poorly performing nursing homes and reviewing the extent to which nursing home residents are hospitalized.
Reviewing Part B payments for services and medical supplies provided to beneficiaries in home health episodes and examining the adequacy of controls established to prevent inappropriate Part B payments for services and medical supplies.
Part III: Deviations from the Normal (How to Handle a Problem – Qui Tams, Internal Investigations, Self-Disclosure)
“The OIG’s use of voluntary self-disclosure programs . . . is premised on a belief that health care providers must be willing to police themselves, correct underlying problems and work with Government to resolve these matters.”
Federal Register, Vol. 63, No. 21, October 30, 1998.
Part IV: Accountable Care Organizations - Legal Structure and Governance Issues
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