August 25, 2004
Earlier this year, the Office of Inspector General (OIG) published its 2004 work plan, which sets forth projects that the agency will address during the fiscal year. Because it outlines OIG's concerns and priorities, the work plan is an important document for providers and should be reviewed periodically. In the winter issue of its Quarterly Insights newsletter, HFMA's Healthcare Compliance Forum asked three experts what they thought were the most significant areas of the OIG work plan for hospitals. The following are excerpts from that article:
EMTALA Compliance
Although EMTALA is not a new work plan issue, there may be renewed focus in this area given the revised regulations that went into effect in November 2003, notes Bill Sarraille, partner and member of the healthcare practice group of the Washington, D.C., office of Sidley Austin Brown & Wood, LLP. The Centers for Medicare and Medicaid Services (CMS) and the OIG work together in this area, with increased training of CMS survey staff. Hospitals should not interpret this to mean, however, that until the state survey agencies are trained in the new regulations, neither CMS nor OIG will aggressively enforce EMTALA rules. The added attention on EMTALA compliance will actually fuel more investigations, so hospitals should take this opportunity to revise their EMTALA policies and conduct extensive training to enhance compliance.
Diagnostic Tests in the ED
The work plan includes a study of the appropriateness of Medicare billing for diagnostic tests performed in hospital emergency departments (EDs), with a focus on medical necessity and whether the tests were interpreted at the same time as treatment, said Joanne Judge, Esq., FHFMA, CPA, shareholder and co-chair of the healthcare department at Stevens & Lee, Reading, PA.
EMTALA has heightened the emphasis on appropriate screening of ED patients, and now the OIG will scrutinize diagnostic tests to satisfy the EMTALA requirements. If diagnostic studies are being done but not interpreted in a timely manner, the medical necessity for the studies is in jeopardy and payment is at risk.
Medicaid Outlier Payments
The work plan includes the continued review of Medicare inpatient outlier payments, and this year the plan was expanded to review payments by state Medicaid programs, said Judge. The national attention being given to this issue makes it a critical area of analysis. Every hospital should understand, at a minimum, how much it receives in outlier payments from the Medicare and Medicaid programs, and what that amount represents as a percentage of total payments from those programs. If the percentages are high, an internal analysis should be done to determine if there is a reasonable explanation for the outlier amounts.
"Excessive" Claims
One of the most important issues for hospitals and health systems in 2004 is the OIG's planned review of "excessive" claims for inpatient and outpatient services, commented Sarraille. The OIG will be looking at claims submitted, as well as reviewing the process for updating reimbursement rates for hospital inpatient and outpatient services. This review follows the enforcement and regulatory crackdown on outlier payments and is a reflection of those kinds of concerns.
Sequential Care Claims
The OIG plans to analyze sequential acute and post-acute care claims for stays at different hospitals to identify attempts to circumvent PPS payment rules. This component is particularly important for hospitals and health systems that have PPS-exempt units or are hosting a long-term acute care hospital, notes Judge. Hospitals and health systems may want to analyze short-stay admissions that result in a transfer to a post-acute care unit or hospital, as well as readmissions to the acute care hospital to identify any potential problem areas that could translate to future repayments.
Hospitals Within Hospitals
Medicare charges involving "hospitals within hospitals" will also be examined, said Sarraille. To be PPS-exempt, "hospitals within hospitals" must have average stays of more than 25 days. In a situation in which a patient is readmitted to the "hospital within a hospital" after being returned to the short-term hospital, the stay is often to be considered as one stay, rather than two. The OIG plans to evaluate the extent to which long-term care hospitals have followed these rules correctly.
Organ Acquisition Costs
The OIG will review organ acquisition costs claimed on certified transplant centers' cost reports to determine whether the costs have been accurately reported, commented Holley Thames Lutz, partner in the health law department of the Washington, D.C., office of Gardner Carton & Douglas LLP. Medicare pays on a cost basis for pretransplant costs related to organ acquisition (for example, procurement coordinator salaries, preadmission outpatient services for the donor and patient, and tissue typing). Because this reimbursement is outside the PPS, the OIG will investigate whether providers improperly load unallowable costs into these cost centers.
Coronary Artery Stents
The OIG will review inpatient and outpatient claims involving implanted arterial stents to determine whether claims for these services were medically necessary and supported by adequate documentation, said Lutz. A companion compliance issue is whether beneficiaries who had stent implantations during multiple surgical procedures should have received the stent simultaneously with other procedures. This is primarily a quality-of-care issue in that the OIG is concerned that providers are offering separate surgical procedures to maximize reimbursements. The OIG and the Department of Justice both have been active in pursuit of quality-of-care-based claims, and this is the latest in that line of cases.
SOURCE:
HFMA Healthcare Compliance Forum Quarterly Insights Winter Issue 2004. (Access to full text available to Healthcare Compliance Forum members only.)
Additional Resources
Ready-to-Use PowerPoint Presentations (online access available to HFMA members only)
- 2004 OIG Work Plan for Hospitals
- 2004 OIG Work Plan for Home Health Agencies
- 2004 OIG Work Plan for Nursing Homes
- 2004 OIG Work Plan for Physicians/Health Professionals
HFMA Highlights: OIG Issues Proposed Rule Regarding Submission of Claims Containing Excessive Charges (online access available to HFMA members only)
Compliance: Comprehensive Listing of HFMA Products and Services
If you have questions or comments about HFMA Wants You to Know, contact editor Laura Noble.
HFMA Wants You to Know ISSN: 1540-0697. Volume III, Issue 18. Copyright 2004, Healthcare Financial Management Association. All rights reserved.