Deeper Than the Headlines: New OIG Work Plan Items for Aug 2018

The OIG has added more items to their work plan in August (2018). Let’s take a quick look at some of the areas they will be scrutinizing. If your organization provides these types of services, it might be wise to check your compliance as well.

CMS Oversight of Nursing Facility Staffing Levels

Staffing levels in nursing facilities can impact residents' quality of care. Nursing facilities that receive Medicaid and Medicare payments must provide sufficient licensed nursing services 24 hours a day, including a registered nurse for at least 8 consecutive hours every day. CMS uses auditable daily staffing data, called the Payroll-Based Journal, to analyze staffing patterns and populate the staffing component of the Nursing Home Compare website - a site that enables the public to compare the results of health and safety inspections, the quality of care provided at nursing facilities, and staffing at nursing facilities. OIG plans to examine nursing staffing levels reported by facilities to the Payroll-Based Journal and CMS's efforts to ensure data accuracy and improve resident quality of care by both enforcing minimum requirements and incentivizing high quality staffing above minimum requirements.

Hospitals' Compliance with Medicare's Transfer Policy with the Resumption of Home Health Services and the Use of Condition Codes

Medicare payments to acute care hospitals for inpatient stays under Medicare Part A are made based on prospectively set rates. Normally, Medicare pays a hospital discharging a beneficiary the full amount for the corresponding diagnosis-related group (DRG). In contrast, a hospital that transfers a beneficiary to another facility or to home health services is paid a graduated per diem rate, not to exceed the full DRG payment. When transferring a patient to home health services, the hospital can apply specific condition codes to the claim and receive the full DRG payment. The hospital is responsible for coding the bill based on its discharge plan for the patient or adjusting the claim if it finds out that the patient received post-acute care after the discharge. OIG will determine whether Medicare appropriately paid hospitals' inpatient claims subject to the post-acute care transfer policy when (1) patients resumed home health services after discharge or (2) hospitals applied condition codes to claims to receive a full DRG payment.

Physicians Billing for Critical Care Evaluation and Management Services

Critical care is defined as the direct delivery of medical care by a physician(s) for a critically ill or critically injured patient. Critical care is usually given in a critical care area such as a coronary, respiratory, or intensive care unit, or the emergency department. Payment may be made for critical care services provided in any location if the care provided meets the definition of critical care. Critical care is exclusively a time-based code. Medicare pays physicians based on the number of minutes they spend with critical care patients. The physician must spend this time evaluating, providing care and managing the patient's care and must be immediately available to the patient. This review will determine whether Medicare payments for critical care are appropriate and paid in accordance with Medicare requirements.

Review of States' Oversight of Opioids

Opioid abuse and overdose deaths are at crisis levels in the United States, with more than 42,000 Americans dying from opioid use in 2016. We will analyze data from 2013 to 2016 on opioid overdose trends from the Centers for Disease Control and Prevention to select multiple States for review. OIG will review the oversight of opioid prescribing and monitoring of opioid use in the selected States. Specifically, OIG will review policies and procedures, data analytics, programs, outreach, and other efforts. To support HHS' ongoing efforts to identify and disseminate effective practices to address the opioid epidemic in the United States, OIG will highlight these statewide efforts.

Review of Federal Programs Administered by American Indian and Alaska Native Tribes

HHS provides Federal funds to American Indian and Alaska Native (AI/AN) tribes for various programs, including Head Start, Child Care and Development Block Grant, and Indian Self-Determination programs. There are approximately 6.6 million AI/ANs who are members of the 567 federally recognized tribes located in 36 States. OIG has identified as one of HHS' top management challenges ensuring the effective delivery of crucial services to AI/ANs and protecting funds from fraud, waste, and abuse. Prior OIG audits found that grantees did not always operate Federal programs, including Head Start, in accordance with Federal regulations and did not always manage and account for Federal funds in accordance with Federal requirements. OIG will audit tribal programs serving AI/AN communities to determine whether the tribes operated these programs and managed HHS funds in accordance with Federal requirements.

These are just some of the new items the OIG has added to their Work Plan in August 2018.  Make sure you review all the items in their work plan on a regular basis to keep on top of areas of potential risk that your own compliance program should be proactively reviewing.