OIG WORKPLAN 2004 vs. 2003

Patricia Nervina, MHA, CHE

The OIG Work Plan for this year features a few new areas of focus for hospital and physician providers, in addition to the areas from the previous year.  The first one is the appropriateness of payments to nursing and allied health education programs. These payments are made on a reasonable cost basis, and will be validated with fiscal intermediaries and providers.

Another area is the update factors of the inpatient prospective payment system rates. The elements that make this up will be looked at, along with the impact of using estimated data as opposed to actual data in calculating the update figures. This is expected to expand to other prospective payment rates and update figures.  Wage indices will be analyzed.

Organ acquisition costs on cost reports will be assessed for accuracy, including costs that should have been allocated to post transplant activities. Reimbursement is retrospectively on a reasonable cost basis, and overpayments can occur if hospitals engage in cost-shifting to pre-transplant activities and from other cost centers.

The impact of providers’ charges on Medicare reimbursement will be analyzed, and, if necessary, determine whether reimbursement policies need to be revised. Specifically, long-term care, rehabilitation, and psychiatric hospitals will be looked at, as well as the appropriateness of the entity’s classification.

Coronary artery stents, inserted both on an inpatient and outpatient basis, will be reviewed for appropriateness of payment.  Medical necessity and supporting documentation will be examined.  Also, those claims for stent implants during multiple surgical procedures will be reviewed to determine if these should have been performed simultaneously.

One area, although not listed in the Work Plan, but addressed at a recent HFMA teleconference, is the offering of options to patients for post-acute services.  Some hospitals tend to channel patients into their own nursing homes or home health programs, without presenting them with choices.

For physician providers, some new areas include the appropriateness of using modifier –25. The only time a separate procedure should be billed on the same day as an evaluation and management service is if the procedure is unrelated, as designated by modifier-25. Similarly, the appropriateness of using modifiers to get services through the NCCI edits will be looked at, when coding paired services

ESRD capitated payments will be reviewed for the proper number of physician services provided. The monthly capitation payment covers all work components of physician services to ESRD beneficiaries. This includes E&M services for exams, treatments, and like services. 

Place of service coding errors will be looked at; different payment levels are made based on where the service is performed and higher payments are made for physician office services.

Care plan oversight claims will be evaluated for efficiency. This physician supervision is required for beneficiaries receiving Medicare home health and hospice benefits. These beneficiaries are in need of complex or multidisciplinary care requiring ongoing physician involvement.

Billing for diagnostic tests and medical necessity will be a focus, particularly for nerve conduction studies. Payment for these increased 37% in 2001 from the previous year.

Radiation Therapy will be reviewed to determine correct reimbursement for the professional component.  Payment is made as one billable unit of service for every five sessions of treatment.

Physicians excluded from Medicare that continue to order services will be quantified, as they should not be providing services to Medicare beneficiaries.

These areas, as well as those from last year, are perceived by the OIG as critical to its mission, although the focus and timing may shift in response to new information or issues and prioritization.

View the Office of Inspector General Work Plan in its entirety