The Health and Human Services (“HHS”) Office of Inspector General (“OIG) released the 2017 Work Plan (“Work Plan”) outlining its priorities for new and ongoing audits and evaluations for the current and coming year. The OIG Work Plan also provides an update on items that have been completed, postponed or canceled, and identifies new items that have begun or have been planned since April 2016. Healthcare providers, particularly compliance officers, should thoroughly review and integrate, as applicable, the Work Plan as it serves as a useful resource for planning and prioritizing compliance activities.
Below are examples of reviews and activities outlined in the OIG Work Plan:
- Four (4) new areas of review for hospitals:
- hyperbaric oxygen therapy services outpatient claims,
- the proper settlement for Medicare disproportionate share hospital payments in cost reports,
- outlier payments for inpatient psychiatric facilities and
- a study of patients that participated in and benefited from the intensive therapy in inpatient rehabilitation hospitals
- Continued efforts on seventeen (17) items for hospitals including:
- outpatient outlier payments for short-stays,
- hospitals’ use of outpatient and inpatient stays under Medicare’s two-midnight rule, and
- Medicare payments for overlapping Part A inpatient claims and Part B outpatient claims.
- Three (3) new areas of review for skilled nursing facilities and hospice
- New reviews based on statutory mandates:
- review of Medicare payments for the top 25 clinical diagnostic laboratory tests required by Protecting Access to Medicare Act of 2014
- reporting by manufacturers to the Centers for Medicare & Medicaid Services (“CMS”) of payments made to physicians and teaching hospitals required by the Physician Payments Sunshine Act
- Medicare Access and CHIP Reauthorization Act of 2015 (“MACRA”) requires CMS to establish policies and implement claim edits to prevent Medicare payments for deceased individuals.
- review of CMS’ planning and early implementation of the Quality Payment Program to describe timeline/key milestones, and identify key challenges and potential vulnerabilities CMS is facing during implementation.
- Several health IT and EHR concerns as specified in prior plans with the stated expectation “to broaden its portfolio regarding information privacy and security, including issues that arise from the continuing expansion of the Internet of Things.”
- Several reviews related to the Part D Prescription Drug Program, including reviewing “questionable billing” for compounded topical drugs, and increased scrutiny on drug prices.
The healthcare industry continues to evolve in its care delivery, payment models and how fraud is combatted. The OIG Work Plan is a valuable tool for healthcare providers to help guide them in determining where to focus its internal compliance efforts for the coming year. Therefore, healthcare organizations should review their risk assessment, and audit and monitoring plans to ensure applicable review areas from the Work Plan are incorporated.