What’s New in the 2013 OIG Work Plan

As you know, the OIG released its work plan for 2013. The document focuses on projects the OIG intends to address during the fiscal year by various Offices including Audit, Investigations, and Counsel. It covers Medicare and Medicaid, HHS, public health agencies, the administrations for Children & Families and Aging, as well as state and local government use of federal funds. There have been additions this year – I am going to focus on Medicare Part A & Part B hospitals only. The new foci include inpatient billing for Medicare, DRG window expansion, non-hospital owned physician practices and provider-based-status, ‘discharges’ to swing beds in other hospitals, reimbursement for inpatient surgery that was cancelled, payments for mechanical ventilation, and QIOs’ work with hospitals. These new projects apply to acute care hospitals that are not children’s acute care. There are new initiatives for other types of facilities as well. You can read more on the new initiatives here.

My Take

The OIG is doing a bang-up job.  The more data they have to sift through, the more issues they find. Two new projects (inpatient billing and DRG window) focus on DRG assignment variance and the idea that if outpatient services 14 days prior to admission are bundled, the Trust Fund will save a lot of money:

  • OIG noticed that provider-based status can result in higher payments for services furnished at provider-based facilities. Hence the non-hospital-owned physician status project.
  •  Apparently coders are having a problem accurately coding claims for discharges that should have been transfers and discharges coded as ‘discharges’ to swing beds in another hospital.  Both practices resulted in new project status for 2013.

My personal favorite new initiative is the inpatient claim for care when surgery is cancelled. OIG learned the services provided should have been billed as outpatient short stays. Interestingly, hospitals rebilled the inpatient surgery claim when the surgery was actually completed, but in many cases, no surgery was ever performed because they never got a claim. Hmmm. What else? Here are a few more brief highlights of what’s to come.

  • Be sure to comply with the mechanical vent 96-hour rule – apparently it’s a problem because it’s been added to the Work Plan.
  •  Expect to get cozier with your QIO next year. OIG is looking at the $1.1 billion dollars QIO bill. They want to be sure you are working together.

This is a heads-up overview – I will be looking more closely at compliance issues as 2013 unfolds.

Barbara Aubry is a Regulatory Analyst with 3M Health Information Systems.

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