On October 5, 2011, the Office of the Inspector General (“OIG”) revealed plans for 2012 in its 2012 Work Plan that call for even closer scrutiny of the healthcare industry. In the Work Plan, the OIG states that it plans “to use data-mining techniques to review” those “hospitals deemed ‘high risk’ to submit improper bills to Medicare.” The OIG will examine “submissions of certain billing codes, and then target hospitals with high use of those codes for focused reviews.” Another initiative “will focus on proper documentation of patients’ conditions at the time of admission.”
There are three new items specifically pertaining to hospitals. The first is “Medicare Inpatient and Outpatient Payments to Acute Care Hospitals.” The OIG indicates that it will review Medicare payments to hospitals to determine compliance with selected billing requirements. The OIG will use the results of these reviews to recommend recovery of overpayments and identify providers that routinely submit improper claims. Based on computer matching and data mining techniques, the OIG will select hospitals for focused reviews of claims that may be at risk for overpayments. Using the same data analysis techniques, the OIG will identify hospitals that broadly rank as least risky across compliance areas and those that broadly rank as most risky. The OIG will then review the hospitals’ policies and procedures to compare the compliance practices of these two groups of hospitals. Further, the OIG will survey or interview hospitals’ leadership and compliance officers to provide contextual information related to hospital compliance programs.
The second new item on the Work Plan is “Acute-Care Hospital Inpatient Transfers to Inpatient Hospice Care.” In this item, the OIG will review Medicare claims for inpatient stays for which the beneficiary was transferred to hospice care and examine the relationship, either financial or common ownership, between the acute-care hospital and the hospice provider and how Medicare treats reimbursement for similar transfers from the acute-care setting to other settings. The plan states that a general inpatient care day is one on which an individual who has elected hospice care receives general inpatient care in an inpatient facility for pain control or acute or chronic symptom management that cannot be managed in other settings.
The third new item is “Accuracy of Present-on-Admission Indicators Submitted on Medicare Claims.” The OIG will be reviewing the accuracy of Present-on-Admission (“POA”) indicators submitted on inpatient claims made by hospitals nationally in October 2008. Beginning in FY 2008, CMS required hospitals to submit POA indicators with each diagnosis code on Medicare hospital inpatient claims. These indicators identify which diagnoses were present at the time of admission and those conditions that developed during the hospital stay. The OIG will use certified coders to review medical records and Medicare claims for these indicators. The Affordable Care Act provides that hospitals with high rates of hospital-acquired conditions (“HAC”) will receive reduced payments. The OIG states that accurate POA indicators are needed for CMS to implement the requirements in the Deficit Reduction Act and the Affordable Care Act.