News: 2017 OIG Work Plan released

Every year the Office of the Inspector General (OIG) publishes a list of its audit targets for the following calendar year. Although this hefty tome tops 100 pages, it’s worth a review to ensure the OIG’s targets aren’t diagnoses and documentation trouble spots at your facility.

This year’s Work Plan includes a number of items related to care setting (i.e., should this patient be treated as inpatient or outpatient) including:

• Selected inpatient and outpatient billing requirements: The OIG plans to review Medicare payments to acute care hospitals to determine compliance and recover any overpayments.
• Overlapping Part A and Part B claims: Certain items, services, supplies, etc., provided under Part A shouldn’t be billed separately under part B. Previous investigations illuminated this as a risk area, so the OIG will look to make sure hospitals file claims “in accordance with Federal requirements.”
• Two-midnight rule: With all the hullaballoo regarding the 2013 changes to this rule—which established that if a physician expects the patient to require care to last at least over two midnights then inpatient admission is generally warranted—the OIG plans to dig into claims for hospitals stays during the year prior to and immediately following the rule’s implementation date and analyze the extent of changes in inpatient and outpatient stays.
• Outliers for short-stay claims: CMS pays for patients with unexpectedly high costs. According to the Work Plan, “Prior OIG reports concluded that a hospital’s high charges, unrelated to cost, lead to excessive inpatient outlier payments.” So the agency expects to report more fully on the matter in 2017.

It also includes a number of items related procedures and diagnoses that the OIG suspects warrant additional interrogations, including a nationwide review of cardiac catheterizations and endomyocardial biopsies. Although hospitals may bill for both procedures to cover expenses related to right heart catheterizations as long as they are truly separate and distinct, previous reviews indicate that wasn’t always the case.

Kwashiorkor made it onto the OIG’s Work Plan again this year. The form of severe protein malnutrition, which typically only affects children in periods of famine and is rarely seen in the United States, continues to appear on hospital claims. In the coming year, the OIG says it will roll up its collective audit results and make recommendations to the OIG for solutions to the problem.