Kusserow on Compliance: OIG 2017 Work Plan projects relating to hospitals

The OIG released the 2017 Work Plan that summarizes new and ongoing reviews and activities they plans to pursue.  They removed items that were completed, postponed, or canceled, as well as those “Revised” items.  The major focus of the OIG is on the programs of CMS, which include Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP).  These programs account for more than 80 percent of HHS’s budget with total Federal program spending of $986 billion for FY 2016.  Medicare alone accounted for approximately $595 billion, which includes inpatient hospital, skilled nursing, home health, hospice, and physician services payments, as well as incentive payments for adopting health information technology, such as electronic health records (EHRs). CMS uses Medicare Administrative Contractors to administer Medicare Part A and Medicare Part B and to process claims for both parts for more than 37 million people and approximately $371 billion in payments. In addition, Medicare expended over $85 billion in Part D benefit payments in CY 2015, serving over 41 million beneficiaries. The following projects are those related to hospital.

  1. Hyperbaric oxygen (HBO) therapy. Determine whether Medicare payments related to HBO outpatient claims were reimbursed in accordance with Federal requirements.
  2. Incorrect Medical Assistance Days Claimed by Hospitals. Determine whether Medicare administrative contractors properly settled Medicare cost reports for Medicare disproportionate share hospital payments in accordance with Federal requirements.
  3. Inpatient Psychiatric Facilities. Determine whether such facilities complied with Medicare documentation, coverage, and coding requirements for stays that resulted in outlier payments.
  4. Inpatient rehabilitation (rehab) hospitals. Assess a sample of rehabilitation hospital admissions to determine whether the patients participated in and benefited from intensive therapy; and identify reasons patients were not able to participate and benefit from therapy.
  5. Intensity-modulated radiation therapy (IMRT). Determine whether the payments were made in accordance with Federal requirements.
  6. Outpatient Outlier Payments for Short-Stay Claims. Determine the extent of potential Medicare savings if hospital outpatient stays were ineligible for an outlier payment.
  7. Comparison of Provider-Based and Freestanding Clinics. Determine the difference in payments made to the clinics for similar procedures; and assess the potential impact on Medicare and beneficiaries of hospitals’ claiming provider-based status for such facilities.
  8. Reconciliations of Outlier Payments. Determine whether CMS performed necessary reconciliations in a timely manner to enable Medicare contractors to perform final settlement of the hospitals’ associated cost reports, as well as whether the Medicare contractors referred all hospitals that meet the criteria for outlier reconciliations to CMS.
  9. Hospitals’ Use of Outpatient and Inpatient Stays Under Medicare’s Two-Midnight Rule. Determine how hospitals’ use of outpatient and inpatient stays changed under Medicare’s two-midnight rule by comparing claims for hospital stays in the year prior to and the year following the effective date of that rule; and the extent to which the use of outpatient and inpatient stays varied among hospitals.
  10. Medicare Costs Associated with Defective Medical Devices. Identify the costs to Medicare resulting from additional use of medical services associated with defective or recalled medical devices.
  11. Payment Credits for Replaced Medical Devices That Were Implanted. Determine whether Medicare payments for replaced medical devices were made in accordance with Medicare requirements.
  12. Medicare Payments for Overlapping Part A Inpatient Claims and Part B Outpatient Claims. Determine whether outpatient claims billed to Medicare Part B for services provided during inpatient stays were made in accordance with Federal requirements.
  13. Selected Inpatient and Outpatient Billing Requirements. Determine hospitals’ compliance with selected billing requirements and recommend recovery of overpayments. Focus will be on those hospitals with claims that may be at risk for overpayments.
  14. Duplicate Graduate Medical Education Payments. Assess the effectiveness of preventing duplicate payments for DGME costs; and any appropriate payments.
  15. Indirect Medical Education Payments. Determine whether the IME payments were calculated properly.
  16. Outpatient Dental Claims. Roll up the results of our audits of Medicare hospital outpatient payments for dental services to provide CMS with cumulative results and make recommendations for any appropriate changes to the program.
  17. Nationwide Review of Cardiac Catheterizations and Endomyocardial Biopsies. Review Medicare payments to hospitals nationwide for outpatient RHCs and endomyocardial biopsies performed during the same patient encounter.
  18. Payments for Patients Diagnosed with Kwashiorkor. Roll up the results of our audits of Medicare hospital payments for kwashiorkor to provide CMS with cumulative results and make recommendations for any appropriate changes to the program.
  19. Review of Hospital Wage Data Used to Calculate Medicare Payments. Review hospital controls over the reporting of wage data used to calculate wage indexes for Medicare payments.
  20. CMS Validation of Hospital-Submitted Quality Reporting Data. Determine the extent to which CMS-validated hospital inpatient quality reporting data are accurate and complete.
  21. Long-Term-Care Hospitals Adverse Events in Postacute Care for Medicare Beneficiaries. Identify factors contributing to these events and determine the extent to which the events were preventable.
  22. Hospital Preparedness and Response to Emerging Infectious Diseases. Describe hospitals’ efforts to prepare for the possibility of public health emergencies resulting from emerging infectious disease threats; review use of HHS resources; and identify lessons and challenges faced by hospitals as they prepare to respond to emerging infectious disease threats.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2016 Strategic Management Services, LLC. Published with permission.

Scarce GME funding has states, organizations on a scavenger hunt

Training opportunities for medical residents are becoming fewer and farther between, but the need for trained physicians isn’t changing, causing state medical organizations and governments to search for ways to find the funds to pay for graduate medical education (GME). Those concerned are leaving no stone unturned to find funding or cut costs in existing programs.

Most of the money to support GME programs comes from the federal government through the Medicare and Medicaid programs. The problem is that, like other health-care programs, Congress capped spending over the years to reduce the drain on the federal budget.

Children’s hospital GME funding

To address this lack of funding, organizations such as the American Hospital Association, the American Academy of Pediatrics, and Children’s Hospital Association are starting at the top when it comes to requesting money. Together, they urged President Obama to fully fund the Children’s Hospitals Graduate Medical Education program at the authorized level of $300 million allocated in the Department of Health and Human Services budget for fiscal year 2017.

“The 56 freestanding children’s hospitals that receive CHGME funding train approximately half of all future pediatricians and the majority of all residents in pediatric subspecialties,” the organizations wrote. “CHGME funding has decreased 17% since FY 2010, from $317.5 million to $265 million in FY 2015. The effects of continued diminished support for pediatric training are felt by children and their families. Serious pediatric workforce shortages persist, most acutely among pediatric subspecialties. Localized shortages of pediatric primary care also continue, particularly in certain rural areas. There are also several pediatric specialties at risk of sustaining tremendous losses as the current workforce retires and not enough new specialists are trained. Additionally, cuts have slowed the ability to grow in areas of need, which will result in fewer pediatric subspecialists across the country.”

Unified funding

Physician advocates for GME funding have also found another place to save money by developing a single accreditation system which should be fully implemented by July 2020. The system will allow graduates of osteopathic and allopathic medical schools to complete their residency and fellowship education in Accreditation Council for Graduate Medical Education (ACGME) accredited programs. Under the new system, all physicians in training will be able to demonstrate their achievements by meeting a common set of milestones and competencies.

“Over the years, we’ve had a number of GME programs that are dually accredited—they were accredited by the ACGME and AOA—and those programs had to answer to two different accrediting bodies and pay two different sets of accrediting fees,” Dr. Buser, American Osteopathic Association (AOA) Trustee and President-Elect Boyd R. Buser, DO said. “This is an unnecessary duplication and cost.”