Every year the Office of Inspector General (“OIG”) of the U.S. Department of Health and Human Services (“HHS”) publishes a Work Plan detailing the various areas of focus for the upcoming fiscal year.  OIG’s 2017 Work Plan describes many new and ongoing priorities that will affect the compliance activities and risk concerns facing healthcare professionals and providers of all sizes throughout the industry.  The new year is now upon us, and here are some of the focus areas we can expect from the OIG this year:

Hyperbaric Oxygen (“HBO”) Therapy Services – OIG plans to scrutinize Medicare payments for HBO outpatient services to determine whether such claims complied with federal regulations.  This focus is based on CMS’s concern with reimbursing providers in situations where patients with non-covered conditions receive HBO services, medical documentation does not support the need for the service, or patients receive more HBO treatments than is medically necessary.

Incorrect Medical Assistance Days Claimed by Hospitals – Calculations of Medicare disproportionate share hospital (“DSH”) payments are dependent on serval complex variables, including the number of furnished Medicaid patient days listed on cost reports submitted to and settled by Medicare administrative contractors (“MACs”). With respect to the number of Medicaid patient days, OIG plans to review whether Hospitals received overpayments based on properly settled cost reports with MACs.

Payments for Medicare Services and Durable Medical Equipment/Prosthetics/Orthotics/Supplies (“DMEPOS”) Referred or Ordered by Physicians – OIG plans to review Medicare reimbursements for certain services, supplies, and DMEPOS to determine whether such items and services were ordered by eligible physicians and non-physician practitioners as required by CMS.

Financial Interests Under the Open Payments Program – OIG plans to analyze data obtained through the Open Payments website to scrutinize the number and nature of financial interests of physicians relating to medical device and drug manufacturers. OIG plans to use such analysis to determine how much CMS pays for drugs and DMEPOS ordered by physicians who have financial relationships with manufacturers.

Medicare Payments for Chronic Care Management (“CCM”) – OIG plans to determine whether payments for non-face-to-face CCM services to Medicare beneficiaries complied with CMS’s requirement that CCM services not be billed during the same period as transitional care management, home health care supervision, hospice care, or certain end-stage renal disease services. 

Payments for Service Dates After Individuals’ Dates of Death – OIG and CMS will continue efforts to detect and end Medicare reimbursements made for services ostensibly rendered to deceased patients. Such scrutiny will also focus on prospective payments made under Part D for service dates after individuals’ dates of death.

Hospices & Home Health – OIG plans to continue focusing on Medicare’s hospice program, and plans to provide further recommendations to improve the program based on evaluations, audits, and investigations of Medicare hospices.  As part of this focus, OIG plans to review medical records and billing documentation to determine whether hospice services comply with CMS requirements.  OIG also plans to review the frequency of RN home visits to ensure hospice patients are receiving at least one RN on-site visit every 14 days as required by CMS.  OIG also plans to increase efforts to help identify unqualified or fraudulent Home Health providers.

Skilled Nursing Facility (“SNF”) Reimbursement – As part of an ongoing trend in enforcements and settlements, OIG plans to review documentation from selected SNFs to determine whether they are billing for appropriate levels of services actually rendered for reasonably necessary purposes. Also in regard to SNFs, OIG plans to review unreported incidents of potential abuse and neglect, and adverse event screening.

Questionable Billing for Compounded Topical Drugs in Part D – Based on both the 3,400% increase in Part D spending for compounded topical drugs and the increase in investigations involving compounded drugs, OIG intends to identify pharmacies and associated prescribers with questionable billing practices related to compounded drugs.  

And many others – You can read the 2017 Work Plan in its entirety here: https://oig.hhs.gov/reports-and-publications/archives/workplan/2017/HHS%20OIG%20Work%20Plan%202017.pdf

The attorneys at Chilivis Grubman represent healthcare providers of all types and sizes in connection with regulatory and compliance matters, as well as government investigations and audits.  For any questions, or if we can assist you in connection with a healthcare regulatory or compliance issue or audit/investigation, please contact us at (404) 262-6505 or sgrubman@cglawfirm.com.