2016 OIG Work Plan (Part 1): Revisions

The OIG published its Work Plan for 2016 on November 2, 2015. The annually published plan details the OIG’s audit enforcement priorities for 2016. The Plan is useful for healthcare providers as it allows you to identify potential compliance risks and fine-tune your current compliance and auditing efforts. Individuals responsible for the compliance of your organization should review the Work Plan before preparing annual compliance priorities to ensure that high risk areas identified by the OIG are included.

When you review the 2016 OIG Work Plan, it’s clear that hospitals are the focus for audits once again. Under the OIG audit umbrella there are a total of 25 projects for audit: Three new projects, one that has been revised, plus all of the ongoing projects that still remain. Part 1 of this blog post will deal with the revised item, Medicare Oversight of Provider-Based Status, from the 2016 OIG Work Plan.

A Summary of the OIG 2015 Accomplishments

For the fiscal year (FY) 2015 the OIG documented the following monetary realizations:

• $1.3 billion in audit receivables
• $2.22 billion in investigative receivables
• -$286.6 million in non-HHS investigative receivables.
• $20.6 billion in savings estimated on OIG actions.

The OIG also details the following exclusions, criminal actions, and civil actions:

• Reported exclusions of 4,112 individuals and entities
• Undertook 925 criminal actions
• Undertook 682 civil actions

Revised: Medicare Oversight of Provider-Based Status

The revision states that the OIG will determine the number of provider-based facilities that hospitals own and the extent to which CMS has methods to oversee provider-based billing.

The OIG will also determine the extent to which provider-based facilities meet requirements described in 42 CFR Sec. 413.65 and CMS Transmittal A-03-030, and whether there were any challenges associated with the provider-based attestation review process.

Hospitals: Billings and Payments

Provider-based status allows facilities owned and operated by hospitals to bill as hospital outpatient departments. This status can result in higher Medicare payments for services furnished at provider-based facilities and may increase beneficiaries’ coinsurance liabilities.

The risks associated with this revised item are numerous, however, shared space is one that stands out tremendously. There are a host of requirements for coding and billing purposes and non-compliance puts the hospital at risk of losing the provider-based status.

Provider-based status is available for hospital-owned entities located outside of the hospital’s four walls. CMS does not authorize provider-based status in advance however, hospitals may submit attestations of their compliance to CMS. Hospitals can be audited at any time regardless of whether or not they self-attest and recoupment is a possibility if provider-based entities are determined to be out of compliance in any way. The benefit of declaring provider-based status, of course, is financial: Hospital code, bill, and collect for both a facility and professional fee for services. This also means that patients will receive two bills.

Provider-based entities are required to operate under the same license as the hospital and must be financially and clinically integrated with the hospital, share medical records, and follow many other regulations. As an example, provider-based entities are required to indicate their hospital affiliation on signs and bills, and warn patients they face two copays: 1) for the facility fee and, 2) for the physician fee.

For more information on this revised item and what your organization can do to meet compliance, watch our on-demand webinar on the "2016 OIG Work Plan for Hospitals" by clicking the button below:

• Continue Reading . . . Part 2 of the OIG Work Plan Update Series >>