oig 2011 work plan

8/8/2019 OIG 2011 Work Plan

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OfficeofInspectorGeneral i WorkPlan

FiscalYear2011 IntroductoryMessage

AMessageFromthe

OfficeofInspectorGeneral

Weare

pleased

to

present

the

OfficeofInspectorGeneralWorkPlanforFiscalYear2011. This

publicationprovidesbriefdescriptionsofactivitiesthattheOfficeofInspectorGeneral(OIG)

planstoinitiateorcontinuewithrespecttotheprogramsandoperationsoftheDepartmentof

Health&HumanServices(HHS)infiscalyear(FY)2011. ToplacetheWorkPlanincontext,wedescribebelowourmissionandactivities,organization,programintegrityresources,

workplanningprocess,andrelatedmatters.

MissionandActivities

OIGsoperationalmissionistoprotectprogramintegrityandthewellbeingofprogram

beneficiariesbydetectingandpreventingwaste,fraud,andabuse;identifyingopportunitiesto

improveprogram

economy,

efficiency,

and

effectiveness;

and

holding

accountable

those

who

donotmeetprogramrequirementsorwhoviolateFederallaws. Wecarryoutourmissionby

conductingaudits,evaluations,andinvestigations;providingguidancetoindustry;and,when

appropriate,imposingcivilmonetarypenalties,assessments,andadministrativesanctions. We

workcloselywithHHSanditsOperatingandStaffDivisions;theDepartmentofJustice(DOJ)

andotheragenciesintheexecutivebranch;Congress;andStatestobringaboutsystemic

changes,successfulprosecutions,negotiatedsettlements,andrecoveryoffunds.

CoreValues

Integrity:Acting

with

independence

and

objectivity.

Credibility: Buildingonatraditionofexcellenceandaccountability.

Impact: Yieldingresultsthataretangibleandrelevant.

OrganizationFollowingaredescriptionsoftheOIGcomponentsthatcarryoutouraudit,evaluation,

investigation,enforcement,andcomplianceactivities.

TheOfficeofAuditServices(OAS)providesauditingservicesforHHS,eitherbyconductingauditswithitsownauditresourcesorbyoverseeingauditworkdoneby

others. AuditsexaminetheperformanceofHHSprogramsand/oritsgranteesand

contractorsincarryingouttheirrespectiveresponsibilitiesandareintendedtoprovide

independentassessmentsofHHSsprogramsandoperations. Theseassessmentshelp


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OfficeofInspectorGeneral ii WorkPlan


reducewaste,abuse,andmismanagementandpromoteeconomyandefficiency

throughoutHHS.

TheOfficeofEvaluationandInspections(OEI)conductsnationalevaluationstoprovideHHS,Congress,andthepublicwithtimely,useful,andreliableinformationonsignificant

issues.These

evaluations

focus

on

preventing

fraud,

waste,

and

abuse

and

promoting

economy,efficiency,andeffectivenessinHHSprograms. OEIreportsalsopresent

practicalrecommendationsforimprovingprogramoperations.

TheOfficeofInvestigations(OI)conductscriminal,civil,andadministrativeinvestigationsoffraudandmisconductrelatedtoHHSprograms,operations,and

beneficiaries. WithinvestigatorsworkinginalmosteveryStateandtheDistrictof

Columbia,OIactivelycoordinateswithDOJandotherFederal,State,andlocallaw

enforcementauthorities. TheinvestigativeeffortsofOIoftenleadtocriminalconvictions,

administrativesanctions,orcivilmonetarypenalties.

TheOfficeofCounseltotheInspectorGeneral(OCIG)providesgenerallegalservicestoOIG,renderingadviceandopinionsonHHSprogramsandoperationsandprovidingall

legalsupportforOIGsinternaloperations. OCIGrepresentsOIGinallciviland

administrativefraudandabusecasesinvolvingHHSprograms,includingFalseClaims

Act,programexclusion,andcivilmonetarypenaltycases. Inconnectionwiththesecases,

OCIGalsonegotiatesandmonitorscorporateintegrityagreements. OCIGrenders

advisoryopinions,issuescomplianceprogramguidance,publishesfraudalerts,and

providesotherguidancetothehealthcareindustryconcerningtheantikickbackstatute

andotherOIGenforcementauthorities.

Theorganizational

entities

described

above

are

supported

by

the

Immediate

Office

of

the

InspectorGeneralandtheOfficeofManagementandPolicy.

ProgramIntegrityResources

OIGsprogramintegrityresourcesderivefrommultiplesources,includingasingle

discretionaryappropriation1andmultiplestatutoryfundingstreamsprovidedthroughother

legislation. Forthepastseveralyears,OIGsdiscretionaryappropriationhasrepresentedon

averageabout20percentofourtotalannualfunding,whileseparatestatutoryfundingstreams

thataremandatedforouroversightofMedicareandMedicaidhaveprovidedabout80percent.

OurannualbudgetisdevotedlargelytooversightofMedicareandMedicaid,consistentwith

ourstatutory

mandates.

1OIGreferstoitsannualappropriation,madeaspartoftheoverallappropriationforHHS,asits

discretionaryappropriation. ThisisdistinguishedfromthepermanentappropriationfortheHealth

CareFraudandAbuseControlProgram(HCFAC)containedintheSocialSecurityAct,1817(k),and

otherfundsappropriatedbyCongressinotherlegislationforspecifiedpurposes.


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OfficeofInspectorGeneral iii WorkPlan


WorkPlanningProcessAtthebeginningofeachFY,weissueourannualWorkPlan,whichdescribesthespecificauditsandevaluationsthatwehaveunderwayorplantoinitiateintheyearaheadconsideringour

discretionaryandstatutorilymandatedresources. TheWorkPlanalsoprovidesgeneralfocusareasforourinvestigative,enforcement,andcomplianceactivities.

Todevelopproposalsforspecificprojectsandactivities,weundertakeacomprehensive

workplanningprocess. Weengageourstakeholderstoidentifytheissuesofgreatestpriority

andwiththegreatestpotentialimpactonHHSprogramsorbeneficiaries. Inaddition,we

coordinatewithandkeepcurrentwiththeworkofotheroversightentities. Wealsostay

attunedtothelatestdevelopmentsandeventsaffectingtheNationshealthcare,publichealth,

andhumanservicesprogramsandbeneficiaries.

Workplanningisanongoinganddynamicprocess,andadjustmentsaremadethroughoutthe

yeartomeetprioritiesandtoanticipateandrespondtoemergingissueswiththeresources

available.We

assess

relative

risks

in

the

programs

for

which

we

have

oversight

authority

to

identifytheareasmostinneedofattentionand,accordingly,tosetprioritiesforthesequence

andproportionofresourcestobeallocated. Inevaluatingworkplanproposals,weconsidera

numberoffactors,including:

requirementsforOIGreviews,assetforthinlaws,regulations,orotherdirectives; requestsmadeorconcernsraisedbyCongress,HHSsmanagement,ortheOfficeof

ManagementandBudget(OMB);

significantmanagementandperformancechallengesfacingHHS; workperformedbypartnerorganizations; managementsactionstoimplementourrecommendationsfrompreviousreviews;and timeliness.

ANoteAboutThisEdition

ThiseditionoftheWorkPlan,effectiveasofOctober2010,describesforeachreviewthesubject,primaryobjective,andcriteriarelatedtothetopic. TheWorkPlanalsoprovidesforeachreviewits

internal

identification

code,

the

year

in

which

we

expect

one

or

more

reports

to

be

issued

as

a

resultofthereview,andindicateswhethertheworkwasinprogressatthestartofthefiscal

yearorwillbeanewstartduringtheyear. Typically,areviewdesignatedasworkin

progresswillresultinreportsissuedinFY2011,butareviewslatedtobegininFY2011

(newstart)couldresultinFY2011orFY2012reports,dependinguponwhentheassignments

areinitiatedduringtheyearandthecomplexityandscopeoftheexaminations.


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OfficeofInspectorGeneral iv WorkPlan


ThebodyoftheWorkPlanispresentedinsevenmajorpartsfollowedbyAppendixA,whichdescribestheOfficeofInspectorGeneralsoversightofthefundingthatHHSreceivesunderthe

AmericanRecoveryandReinvestmentActof2009(RecoveryAct).

DetailedtablesofcontentsareprovidedatthebeginningofeachmajorpartandAppendixA.

AppendixB

spells

out

most

acronyms

and

abbreviations

of

terms,

organizations,

and

laws

that

areusedintheWorkPlan. Ifyouhavequestionsaboutthepublication,pleasecontactourOfficeofExternalAffairsat(202)6191343.

Anoutlineofthemajorpartsandappendixesfollows.


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OfficeofInspectorGeneral v WorkPlan

FiscalYear2011 Outline

OutlineofMajorPartsandAppendixes

PartI:

Medicare

Part

A

and

Part

B

PartII: MedicarePartCandPartD

PartIII: MedicaidReviews

PartIV: LegalandInvestigativeActivities

PartV: PublicHealthReviews

PartVI:

Human

Services

Reviews

PartVII: DepartmentwideIssues

AppendixA: RecoveryActReviews

AppendixB: AcronymsandAbbreviations


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OfficeofInspectorGeneral WorkPlanPartI

FiscalYear2011 MedicarePartAandPartB

WorkPlanPartI:

MedicarePartAandPartB


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OfficeofInspectorGeneral i WorkPlanPartI


TableofContents

Hospitals ................................................................................................................................................ 1PartAHospitalCapitalPayments.................................................................................................................................... 1ProviderBasedStatusforInpatientandOutpatientFacilities.....................................................................................1HospitalPaymentsforNonphysicianOutpatientServicesUndertheInpatientProspectivePaymentSystem.... 2NoninpatientProspectivePaymentSystemHospitalPaymentsforNonphysicianOutpatientServices............... 2CriticalAccessHospitals ...................................................................................................................................................2MedicareExcessivePayments........................................................................................................................................... 3MedicareDisproportionate SharePayments ..................................................................................................................3MedicareOutlierPayments...............................................................................................................................................3DuplicateGraduateMedicalEducationPayments ........................................................................................................ 3HospitalOccupationalMixDataUsedToCalculateInpatientHospitalWageIndexes........................................... 4MedicareSecondaryPayer/OtherInsuranceCoverage.................................................................................................4ReliabilityofHospitalReportedQualityMeasureData ............................................................................................... 4HospitalReadmissions.......................................................................................................................................................5HospitalAdmissionsWithConditionsCodedPresentonAdmission ....................................................................... 5EarlyImplementation ofMedicaresPolicyforHospitalAcquiredConditions ........................................................5ResponsestoAdverseEventsinHospitalsbyMedicareOversightEntities .............................................................. 6HospitalReportingforAdverseEvents........................................................................................................................... 6HospitalReportingforRestraint andSeclusionRelatedDeaths ................................................................................ 6MedicareBrachytherapyReimbursement....................................................................................................................... 6PaymentsforDiagnosticRadiologyServicesinHospitalEmergencyDepartments................................................. 7HospitalsComplianceWithMedicareConditionsofParticipationforIntensityModulatedand

ImageGuidedRadiationTherapyServices ................................................................................................................7MedicareInpatientandOutpatientHospitalClaimsfortheReplacementofMedicalDevices ..............................7ObservationServicesDuringOutpatientVisits.............................................................................................................. 8HospitalInpatientOutlierPayments ............................................................................................................................... 8Inpatient

Rehabilitation

Facility

Transmission

of

Patient

Assessment

Instruments.................................................. 8

HomeHealthAgencies........................................................................................................................8 PartBPaymentsforHomeHealthBeneficiaries............................................................................................................ 8HomeHealthAgenciesClaimsforMedicareHomeHealthResourceGroups.........................................................9OversightofHomeHealthAgencyOutcomeandAssessmentInformationSetData .............................................. 9HomeHealthProspectivePaymentSystemControls....................................................................................................9HomeHealthAgencyProfitability................................................................................................................................. 10MedicareHomeHealthAgencyEnrollment................................................................................................................. 10

NursingFacilities ...............................................................................................................................10MedicarePartAPaymentstoSkilledNursingFacilities............................................................................................. 10Medicare

Requirements

for

Quality

of

Care

in

Skilled

Nursing

Facilities................................................................ 11

AssessmentandMonitoringofNursingHomeResidentsReceivingAtypicalAntipsychoticDrugs .................. 11OversightofPoorlyPerformingNursingHomes ........................................................................................................ 11Hospitalizations ofNursingHomeResidents .............................................................................................................. 11NursingHomeEmergencyPreparednessandEvacuationsDuringSelectedNaturalDisasters........................... 12CriminalBackgroundChecksforNursingFacilityEmployees.................................................................................. 12ProgramforNationalandStateBackgroundChecksforLongTermCareEmployees.......................................... 12MedicarePartBServicesDuringNonPartANursingHomeStays: 2008Overview............................................ 13


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OfficeofInspectorGeneral ii WorkPlanPartI


OtherProvidersandSuppliers ........................................................................................................ 13HospiceUtilizationinNursingFacilities....................................................................................................................... 13ServicesProvidedtoHospiceBeneficiariesResidinginNursingFacilities..............................................................13PlaceofServiceErrors..................................................................................................................................................... 14AmbulatorySurgicalCenterPaymentSystem .............................................................................................................14CodingofEvaluationandManagementServices ........................................................................................................ 14PaymentsforEvaluationandManagementServices................................................................................................... 14EvaluationandManagementServicesDuringGlobalSurgeryPeriods.................................................................... 15MedicarePaymentsforPartBImagingServices.......................................................................................................... 15BillingofPortableXRaySuppliers................................................................................................................................ 15ServicesPerformedbyClinicalSocialWorkers............................................................................................................ 15PartialHospitalizationProgramServices...................................................................................................................... 16OutpatientPhysicalTherapyServicesProvidedbyIndependentTherapists.......................................................... 16QuestionableBillingforMedicareOutpatientTherapyServices............................................................................... 16AppropriatenessofMedicarePaymentsforPolysomnography ................................................................................ 17MedicarePaymentsforSleepTesting............................................................................................................................ 17ExcessivePaymentsforDiagnosticTests ...................................................................................................................... 17LaboratoryTestUnbundlingbyClinicalLaboratories................................................................................................ 17MedicarePartBPaymentsforGlycatedHemoglobinA1CTests .............................................................................. 18TrendsinLaboratoryUtilization.................................................................................................................................... 18LabTestPayments: ComparisonofMedicarewithOtherPublicPayers................................................................. 18GeographicAreasWithaHighDensityofIndependentDiagnostic TestingFacilities .........................................18IndependentDiagnosticTestingFacilitiesComplianceWithMedicareStandards................................................ 19ComprehensiveOutpatientRehabilitationFacilities................................................................................................... 19MedicareProvidersComplianceWithAssignmentRules......................................................................................... 19MedicarePaymentsforClaimsDeemedNotReasonableandNecessary ................................................................ 20MedicareBillingsWithModifierGY.............................................................................................................................. 20PaymentsforServicesOrderedorReferredbyExcludedProviders......................................................................... 20PaymentsforESRDBeneficiariesEntitledtoMedicareUnderSpecialProvisions.................................................. 21ErrorProneProviders: MedicarePartAandPartB ................................................................................................... 21ComprehensiveErrorRateTestingProgram: FY2010ErrorRateOversight..........................................................21MedicareServicesBilledWithDatesofServiceAfterBeneficiariesDatesofDeath ..............................................22

MedicalEquipmentandSupplies...................................................................................................22 MedicarePaymentsforVariousCategoriesofDurableMedicalEquipment........................................................... 22FrequencyofReplacementSuppliesforDurableMedicalEquipment...................................................................... 22MedicarePaymentstoDurableMedicalEquipmentSuppliersforPowerWheelchairs......................................... 23MedicarePaymentsforDurableMedicalEquipmentClaimsWithModifiers......................................................... 23CompetitiveBiddingProcessforMedicalEquipmentandSupplies......................................................................... 24CompetitiveBiddingProgram: SupplierInfluenceonPhysicianPrescribing ........................................................ 24MedicarePricingforParenteralNutrition ....................................................................................................................24MedicarePartBPaymentsforHomeBloodGlucoseTestingSupplies.................................................................... 24MedicareMarketSharesofMailOrderDiabeticTestingStrips................................................................................. 25Medicare

Enrollment

and

Monitoring

for

Suppliers

of

Durable

Medical

Equipment,

Prosthetics,

Orthotics,andSupplies................................................................................................................................................ 25MedicareQualificationsofOrthotistsandProsthetists............................................................................................... 25MedicarePartBPaymentsforLowerLimbProsthesesin2009................................................................................. 26

PartBPaymentsforPrescriptionDrugs ........................................................................................26ComparingAverageSalesPricestoAverageManufacturerPrices ........................................................................... 26ComparisonofAverageSalesPricestoWidelyAvailableMarketPricesforSelectedDrugs................................ 26


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OfficeofInspectorGeneral iii WorkPlanPartI


FluctuationofAverageSalesPriceforMedicarePartBDrugs ..................................................................................26MedicarePaymentsforPartBDrugs.............................................................................................................................27BillingforImmunosuppressiveDrugs .......................................................................................................................... 27PaymentsforOffLabelAnticancerPharmaceuticalsandBiologicals....................................................................... 27AcquisitionCostsandPaymentsforLucentisandAvastinUsedinTreatingWetAgeRelatedMacular

Degeneration................................................................................................................................................................. 28Usage

Patterns

and

Payments

for

Avastin

and

Lucentis

in

Treating

Wet

Age

Related

Macular

Degeneration . 28

MedicarePartAandPartBContractorOperations.....................................................................29 PreawardReviewsofContractProposals ..................................................................................................................... 29ContractorsAdministrative Costs................................................................................................................................. 29MedicareSummaryNotice.............................................................................................................................................. 29HandlingofHotlineReferrals......................................................................................................................................... 29QualityImprovementOrganizationHospitalQualityImprovementProjects......................................................... 29FirstLeveloftheMedicareAppealsProcess................................................................................................................. 30MedicareAdministrative LawJudgeDecisions........................................................................................................... 30AccuracyoftheNationalProviderEnumerationandMedicareProviderEnrollmentData.................................. 30MedicareSecondaryPayerRecoveryContractor:EarlyImplementation.................................................................30MedicareAdministrative Contractors: QualityAssuranceSurveillancePlanPerformanceEvaluation ............. 31ZoneProgramIntegrityContractorsIdentificationofPotentialFraudandAbuse................................................ 31ConflictsofInterestintheZoneProgramIntegrityContractingProcess .................................................................31VulnerabilitiesIdentifiedbyMedicareBenefitIntegrityContractors ....................................................................... 32IdentificationandRecoupmentofImproperPaymentsbyRecoveryAuditContractors....................................... 32ProvidersandSupplierswithCurrentlyNotCollectibleDebt................................................................................... 32VariationinCoverageofServicesandMedicareExpendituresDuetoLocalCoverageDeterminations ............ 33PerformanceoftheNationalSupplierClearinghouse ................................................................................................. 33ProviderEducationandTraining: MedicareAffiliatedContractorsProgressiveCorrectionAction ................. 33PensionSegmentation...................................................................................................................................................... 34PensionCostsClaimed .................................................................................................................................................... 34UnfundedPensionCosts ................................................................................................................................................. 34PensionSegmentClosing ................................................................................................................................................ 34PostretirementBenefitsandSupplemental EmployeeRetirementPlanCosts......................................................... 34

Note: selectedacronymsandabbreviationsofterms,titles,organizations,andlawsusedinthe

WorkPlanarespelledoutinAppendixB.


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OfficeofInspectorGeneral I1 WorkPlanPartI


MedicarePartAandPartB

MedicarePartAhelpscoverinpatientcareinhospitals,includingcriticalaccesshospitals,

skillednursing

facilities

(excepting

custodial

or

long

term

care),

hospice

care,

and

some

home

healthcare. MedicarePartBhelpscoverphysiciansservicesandoutpatientcare. Italsocovers

designatedothermedicalservicesthatPartAdoesnotcover,suchassomephysicaland

occupationaltherapyservicesandhomehealthcare.

Historically,Medicarecontractorsthatareknownasfiscalintermediaries(FI)andcarriers

havehandledMedicaresclaimsadministrationactivities,withtheFIsprocessingclaimsfor

MedicarePartsAandBforcertainfacilities(includinghospitalsandskillednursingfacilities

(SNF)andthecarriersprocessingclaimsforMedicarePartB(includingforphysicians,

laboratories,andotherservices). TheCentersforMedicare&MedicaidServices(CMS)also

engagescontractorsthatperformspecificfeeforservice(FFS)businessfunctions. Pursuantto

theMedicarePrescriptionDrug,Improvement,andModernizationActof2003(MMA),911,

CMSisimplementingaMedicarecontractingreforminitiativethatwillreplaceFIsandcarriers

withMedicareAdministrativeContractors(MAC)thatwillprocessbothPartAandPartB

claims. ThereformplanincludesspecialtyMACsthatwillservicesuppliersofdurablemedical

equipment(DME).

DescriptionsofourworkinprogressandplannedreviewsofMedicarePartAandPartB

paymentsandservicesforfiscalyear(FY)2011follow.

Hospitals

PartAHospitalCapitalPaymentsWewillreviewMedicareinpatientcapitalpayments. Capitalpaymentsreimbursea

hospitalsexpendituresforassetssuchasequipmentandfacilities. Thebasicmethodologyfor

determiningcapitalprospectiveratesisfoundintheCodeofFederalRegulations(CFR)at

42CFR412.308. Wewilldeterminewhethercapitalpaymentstohospitalsareappropriate.

(OAS;W000935300;W001035300;variousreviews;expectedissuedate: FY2011;workin

progress)

ProviderBasedStatusforInpatientandOutpatientFacilitiesWewillreviewcostreportsofhospitalsclaimingproviderbasedstatusforinpatientand

outpatientfacilities. Pursuantto42CFR413.65(d),Medicaremaypermithospitalsthatown

andoperatemultipleproviderbasedfacilitiesordepartmentsindifferentsitestooperateasa

singleentity,solongasspecificrequirementsaremet. Hospitalsthatreceivethisprovider

basedstatusmayreceivehigherreimbursementwhentheyincludethecostsofaprovider

basedentityontheircostreports. Freestandingfacilitiesmayalsobenefitfromenhanced


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disproportionatesharehospital(DSH)payments,upperpaymentlimit(UPL)payments,or

graduatemedicaleducationpaymentsforwhichtheywouldnotnormallybeeligible.

ProviderbasedstatusforoutpatientclinicsmayincreasecoinsuranceliabilityforMedicare

beneficiaries. Wewilldeterminetheappropriatenessoftheproviderbaseddesignationandthe

potentialimpactontheMedicareprogramanditsbeneficiariesofhospitalsimproperlyclaiming

providerbasedstatusforinpatientandoutpatientfacilities.(OAS;W001035424;W001135424;variousreviews;expectedissuedate: FY2011;workin

progress)

HospitalPaymentsforNonphysicianOutpatientServicesUndertheInpatient

ProspectivePaymentSystemWewillreviewtheappropriatenessofpaymentsfornonphysicianoutpatientservicesthat

wereprovidedtobeneficiariesshortlybeforeorduringMedicarePartAcoveredstaysatacute

carehospitals. PursuanttotheSocialSecurityAct,1886(a)(4),and42CFR412.2,inpatient

prospectivepaymentsystem(IPPS)paymentstohospitalsforinpatientstaysarepaymentin

fullforhospitalsoperatingcostsandhospitalsgenerallyreceivenoadditionalpaymentsfornonphysicianservices. Fornonphysicianservicesprovidedtoinpatientsbyentitiesunder

arrangementswiththehospitals, theSocialSecurityAct,1862(a)(14)and1861(w)(1),as

interpretedbyCMSinitsFY1983IPPSfinalrule,prohibitssubmissionsofanyadditional

claimstoPartB. Section1886(a)(4)prohibitsseparatepaymentsforoutpatientdiagnostic

servicesandadmissionrelatednondiagnosticservicesrenderedupto3daysbeforethedates

ofadmission. PriorOfficeofInspectorGeneral(OIG)workinthisareafoundsignificant

numbersofimproperclaims.

(OAS;W001035436;variousreports;expectedissuedate: FY2011;workinprogress)

NoninpatientProspective

Payment

System

Hospital

Payments

for

Nonphysician

OutpatientServicesWewillreviewtheappropriatenessofpaymentsfornonphysicianoutpatientservicesthatwere

providedtobeneficiariesshortlybeforeorduringMedicarePartAcoveredstaysatnonIPPS

hospitals. PursuanttotheSocialSecurityAct,1886(a)(4),paymentstononIPPShospitalsfor

inpatientclaimsshouldincludediagnosticservicesandotherservicesrelatedtoadmission

providedduring1dayimmediatelyprecedingthedateofthepatientsadmission. For

nonphysicianservicesprovidedtoinpatients,CMSsMedicareClaimsProcessingManual,

Pub.No.10004,ch.3,40.3Band40.3C,prohibitssubmissionsofadditionalclaimstoPartB

foroutpatientdiagnosticservicesandadmissionrelatednondiagnosticservicesrenderedupto

1daybeforeandonthedateofadmission.

(OAS;W001135450;variousreviews;expectedissuedate: FY2011;newstart)

CriticalAccessHospitalsWewillreviewpaymentstocriticalaccesshospitals(CAH). PursuanttotheSocialSecurityAct,

1814(l)(1)and1834(g),CAHsaregenerallypaid101percentofthereasonablecostsof

providingcoveredCAHservices. WewilldeterminewhetherCAHshavemettheCAH


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designationcriteriaintheSocialSecurityAct,1820(c)(2)(B),andconditionsofparticipation

(CoP)at42CFRpt.485,subpartF,andwhetherpaymentstoCAHswereinaccordancewith

Medicarerequirements.


progress)

MedicareExcessivePaymentsWewillreviewMedicareclaimswithhighpaymentstodeterminewhethertheywere

appropriate. Ourpriorworkhasshownthatclaimswithunusuallyhighpaymentsmay

beincorrectforvariousreasons. PursuanttoCMSsMedicareClaimsProcessingManual,

Pub.No.10004,ch.4,20.4,hospitalsarerequiredtoreportunitsofserviceasthenumber

oftimesthataserviceorprocedurewasperformed. Ourworkwillincludecertainoutpatient

claimsinwhichpaymentsexceededchargesandselectedHealthcareCommonProcedure

CodingSystem(HCPCS)codesforwhichbillingsappeartobeaberrant. Wewillalsoreview

theeffectivenessoftheclaimsprocessingeditsusedtoidentifyexcessivepayments.

(OAS;W

00

10

35518;

W

00

11

35518;

various

reviews;

expected

issue

date:

FY

2011;

work

in

progress)

MedicareDisproportionateSharePaymentsWewillreviewMedicareDSHpaymentstohospitals. PursuanttotheSocialSecurityAct,

1886(d)(5)(F)(i)(I),Medicaremakesadditionalpaymentstoacutecarehospitalsthatservea

significantlydisproportionatenumberoflowincomepatients. MedicareDSHpaymentshave

beensteadilyincreasing. OIGwilldeterminewhetherthesepaymentswereinaccordancewith

MedicaremethodologyintheSocialSecurityAct,1886(d)(5)(F)(vvii). Wewillalsoexamine

thetotalamountsofuncompensatedcarecoststhathospitalsincur.

(OAS;

W

00

10

35402;

W

00

11

35402;

various

reviews;

expected

issue

date:

FY

2011;

work

in

progress)

MedicareOutlierPaymentsWewillreviewMedicareoutlierpaymentstodeterminewhetherCMSappropriatelyreconciled

thepayments. Outliersareadditionalpaymentsmadeforbeneficiarieswhoincurunusually

highcosts. PursuanttoFederalregulationsat42CFR412.84(i)(4),outlierpayment

reconciliationsmustbebasedonthemostrecentcosttochargeratiofromthecostreportto

properlydetermineoutlierpayments. Outlierpaymentsalsomaybeadjustedtoreflectthetime

valueofmoneyforoverpaymentsandunderpayments.


DuplicateGraduateMedicalEducationPaymentsWewillreviewproviderdatafromCMSsInternandResidentInformationSystem(IRIS)to

determinewhetherduplicategraduatemedicaleducationpaymentshavebeenclaimed.

Medicarepaysteachinghospitalsfordirectgraduatemedicaleducation(DGME)andindirect

medicaleducation(IME)costs. Federalregulationsat42CFR 413.78(b)and412.105(f)(1)(iii)


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specifythatinthecalculationofpaymentsforDGMEandIMEcosts,nointernorresidentmay

becountedbytheMedicareprogramasmorethanonefulltimeequivalent(FTE)employee.

IRISsprimarypurposeistoensurethatnointernorresidentiscountedasmorethanoneFTE.

Ifduplicatepaymentswereclaimed,wewilldeterminewhichpaymentwasappropriate. We

willalsoassesstheeffectivenessofIRISinpreventingprovidersfromreceivingpaymentsfor

duplicategraduatemedicaleducationcosts.(OAS;W000935432;W001035432;W001135432;variousreviews;expectedissuedate:

FY2011;workinprogress)

HospitalOccupationalMixDataUsedToCalculateInpatientHospitalWageIndexesWewilldeterminewhetherhospitalsreportedoccupationalmixdatausedtocalculateinpatient

wageindexesincompliancewithMedicareregulations. Hospitalsmustaccuratelyreportdata

every3yearsontheoccupationalmixoftheiremployeesinaccordancewiththeSocialSecurity

Act,1886(d)(3)(E). CMSusesdatafromtheoccupationalmixsurveytoconstructan

occupationalmixadjustmenttoitshospitalwageindexes. Accuratewageindexesareessential

elementsof

the

Medicare

prospective

payment

system

(PPS)

for

hospitals.

We

will

determine

theeffectontheMedicareprogramofinaccuratereportingofoccupationalmixdata.


MedicareSecondaryPayer/OtherInsuranceCoverageWewillreviewMedicarepaymentsforbeneficiarieswhohaveotherinsurance. Pursuantto

theSocialSecurityAct,1862(b),Medicarepaymentsforsuchbeneficiariesarerequiredtobe

secondarytocertaintypesofinsurancecoverage. Wewillassesstheeffectivenessofprocedures

inpreventinginappropriateMedicarepaymentsforbeneficiarieswithotherinsurancecoverage.

Forexample,wewillevaluateproceduresforidentifyingandresolvingcreditbalance

situations,

which

occur

when

payments

from

Medicare

and

other

insurers

exceed

the

providers

chargesortheallowedamounts.


ReliabilityofHospitalReportedQualityMeasureDataWewillreviewhospitalscontrolsforensuringtheaccuracyofdatarelatedtoqualityof

carethattheysubmittoCMSforMedicarereimbursement. TheSocialSecurityAct,

1886(b)(3)(B)(vii),requiresthathospitalsreportqualitymeasuresforasetof10indicators

establishedbytheSecretaryasofNovember1,2003. Section501(b)oftheMMAestablisheda

reductioninpaymentsof0.4percenttohospitalsthatdidnotreportqualitymeasurestoCMS.

TheSocialSecurityAct,1886(b)(3)(viii),asaddedbytheDeficitReductionActof2005(DRA),

5001(a),expandedthepaymentreductionto2percenteffectiveatthebeginningofFY2007.

Wewilldeterminewhetherhospitalshaveimplementedsufficientcontrolstoensurethattheir

qualitymeasurementdataarevalid.



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HospitalReadmissionsWewillreviewMedicareclaimstodeterminetrendsinthenumberofhospitalreadmission

cases. BasedonpriorOIGwork,CMSimplementedaneditin2004torejectsubsequentclaims

onbehalfofbeneficiarieswhowerereadmittedtothesamehospitalonthesameday. Pursuant

toCMSsMedicareClaimsProcessingManual,Pub.No.10004,ch.3,40.2.5,ifasameday

readmissionoccursforsymptomsrelatedtoorforevaluationormanagementofthepriorstaysmedicalcondition,thehospitalisentitledtoonlyonediagnosisrelatedgroup(DRG)payment

andshouldcombinetheoriginalandsubsequentstaysintoasingleclaim. Providersare

permittedtooverridetheeditincertainsituations. Wewilltesttheeffectivenessoftheedit.

Wewillalsodeterminetheextentofoversightofreadmissioncases. PursuanttotheSocial

SecurityAct,1154(a)(13),qualityimprovementorganizations(QIO)arerequiredtoreview

hospitalreadmissioncasestodeterminewhetherthehospitalservicesmetprofessional

standardsofcare. Areadmissionisdefinedasacaseinwhichthebeneficiaryisreadmittedto

ahospitallessthan31daysafterbeingdischargedfromahospital.


progress)

HospitalAdmissionsWithConditionsCodedPresentonAdmissionWewillreviewMedicareclaimstodeterminewhichtypesoffacilitiesaremostfrequently

transferringpatientswithcertaindiagnosesthatwerecodedasbeingpresentwhenpatients

wereadmitted,referredtoaspresentonadmission(POA). PursuanttotheSocialSecurity

Act,1886(d)(4)(D),andCMSsChangeRequest5679(Pub.10020,OneTimeNotification,

Transmittal289),acutecarehospitalsarerequiredtoreportontheirMedicareclaimswhich

diagnoseswerepresentwhenpatientswereadmitted. ForcertaindiagnosesspecifiedbyCMS,

hospitalsreceivealowerpaymentifthespecifieddiagnoseswereacquiredinthehospital. We

willalso

determine

whether

specific

providers

transferred

ahigh

number

of

patients

to

hospitalswithPOAdiagnoses.


progress)

EarlyImplementationofMedicaresPolicyforHospitalAcquiredConditionsWewillreviewtheearlyimplementationofCMSshospitalacquiredconditions(HAC)policy.

Pursuanttosection5001(c)oftheDRA,CMSimplementedtheHACpolicyonOctober1,2008.

TheHACpolicypreventsadditionalpaymentunderMedicareshospitalIPPSforcertain

conditionsorcomplicationsthataredeterminedtobereasonablypreventable. Wewillreview

MedicareclaimsdatatoidentifythenumberofbeneficiarystaysassociatedwithHACsand

determinetheirimpactonreimbursement. WewillalsoverifytheaccuracyofPOAindicators,

whichareusedforidentifyingHACs.

(OEI;060900310;expectedissuedate: FY2011;workinprogress)


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ResponsestoAdverseEventsinHospitalsbyMedicareOversightEntitiesWewillreviewresponsesofStatesurveyandcertificationagencies,Medicareaccreditors,

andCMStoallegationsofadverseeventsinhospitals. Anadverseeventisdefinedasharm

toapatientasaresultofmedicalcare. VariousMedicareoversightentitieshaveauthorityto

investigateadverseeventsinhospitalstodeterminewhetherthosehospitalshavetaken

correctiveactionsandareincompliancewithMedicarestandards. Wewillidentifyandanalyzepotentialoverlaps,conflicts,andgapsinresponsesandidentifyopportunitiesforMedicare

oversightentitiestoimprovethequalityofoversightandresponsestoadverseevents.


HospitalReportingforAdverseEventsWewillreviewthetypeofinformationhospitalsinternalincidentreportingsystemscapture

aboutadverseevents. Mosthospitalshaveincidentreportingsystemsthatenablemedicaland

hospitalstaffmemberstoreportinformationaboutpatientsafetyincidentswhentheyoccurand

tousereportedinformationtopreventrecurrence,holdstaffmembersaccountable,andnotify

families. Usingdatacollectedfora2010OIGstudyexaminingthenationalincidenceofadverseeventsamonghospitalizedMedicarebeneficiaries,wewilldeterminetheextenttowhich

hospitalsystemscapturedadverseeventsandreportedtheinformationtoexternalpatient

safetyoversightentities.


HospitalReportingforRestraint andSeclusionRelatedDeathsWewillreviewhospitalreportedrestraintandseclusionrelateddeathstodeterminethe

volumeofreportsandtheiroutcome. ThePatientsRightsHospitalConditionofParticipation

ruleat42CFR482.13(g)requiresthathospitalsreporttoCMSeachdeaththatoccurswhilea

patientis

in

restraint

or

seclusion,

as

well

as

each

death

that

occurs

within

24

hours

after

a

patienthasbeenremovedfromrestraintorseclusion. CMSregionalstaffmembersdetermine

whetheradeathrequiresaninvestigationbyaStateagency. A2006OIGreportfoundproblems

withtherestraint andseclusionreportingprocessandstatedthatthereportingrequirements

andreportingprocessmayhindertheeffectivenessofCMSsandStateagencieseffortsto

identifyandrespondtorestraint andseclusionrelateddeaths. Wewillalsodeterminethe

outcomeofStateinvestigationsofrestraintandseclusiondeathsandtheactiontheState

agenciestookagainsthospitals.

(OEI;000000000;expectedissuedate: FY2012;newstart)

MedicareBrachytherapyReimbursementWewillreviewpaymentsforbrachytherapy,aformofradiotherapywherearadiationsourceis

placedinsideornexttothearearequiringtreatment,todeterminewhetherthepaymentsarein

compliancewithMedicarerequirements. PursuanttotheSocialSecurityAct,1833(t)(16)(C),

asamendedbytheMedicareImprovementsforPatientsandProvidersActof2008(MIPPA),

142,Medicarepaysforradioactivesourcedevicesusedintreatmentofcertainformsofcancer.


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progress)

PaymentsforDiagnosticRadiologyServicesinHospitalEmergencyDepartmentsWewillreviewMedicarePartBpaidclaimsandmedicalrecordsforinterpretationsand

reportsofdiagnosticradiologyservices(xrays,CTs,andMRIs)performedinhospitalemergencydepartmentstodeterminetheappropriatenessofpayments. Interpretationsand

reportsfurnishedbyphysiciansarereimbursedaccordingtotheMedicarePhysicianFee

Schedule(MPFS)providedthattheconditionsforpaymentforradiologyservicesat42CFR

415.102(a)and415.120aremet. InitsMarch2005testimonybeforeCongress,theMedicare

PaymentAdvisoryCommission(MedPAC),reportedconcernsabouttheincreasingcostof

imagingservicesforMedicarebeneficiariesandpotentialoveruseofdiagnosticradiology

services. In2008,Medicarereimbursedphysiciansabout$227millionforimaging

interpretationsperformedinemergencydepartments. Wewilldeterminewhetherdiagnostic

radiologyinterpretationsandreportscontributedtothediagnosesandtreatmentof

beneficiariesreceiving

care

in

emergency

departments.


HospitalsComplianceWithMedicareConditionsofParticipationforIntensity

ModulatedandImageGuidedRadiationTherapyServicesWewillreviewhospitalscompliancewithMedicarerequirementsconcerningthesafetyand

qualityofintensitymodulatedradiationtherapy(IMRT)andimageguidedradiationtherapy

(IGRT)services. Pursuantto42CFR482.26,therapeuticradiologicalservices,suchasIMRT

andIGRT,mustmeetprofessionallyapprovedstandardsforsafetyandpersonnelqualification.

Hospitalsmustmaintainappropriateradiologicservicestoensuresafetyforpatientsand

personnelin

compliance

with

Medicare

CoP.

We

will

also

assess

CMSs

oversight

of

IMRT

and

IGRTservicesprovidedinhospitals.


MedicareInpatientandOutpatientHospitalClaimsfortheReplacementofMedical

DevicesWewilldeterminewhetherhospitalssubmittedinpatientandoutpatientclaimsthatincluded

proceduresfortheinsertionofreplacementmedicaldevicesincompliancewithMedicare

regulations. TheSocialSecurityAct,1862(a)(2),excludesfromMedicarecoverageanitemora

serviceforwhichneitherthebeneficiarynoranyoneonhisorherbehalfhasanobligationto

pay. Medicareisnotresponsibleforthefullcostofthereplacedmedicaldeviceifthehospital

receivesapartialorfullcreditfromthemanufacturereitherbecausethemanufacturerrecalled

thedeviceorbecausethedeviceiscoveredunderwarranty. Hospitalsarerequiredtouse

modifiersontheirinpatientandoutpatientclaimswhentheyreceivecreditfromthe

manufacturerof50percentormoreforareplacementdevice.


progress)


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ObservationServicesDuringOutpatientVisitsWewillreviewMedicarepaymentsforobservationservicesprovidedduringoutpatient

visitsinhospitals. TheSocialSecurityAct,1832(a)and1833(t),providesforPartBcoverage

ofhospitaloutpatientservicesandreimbursementforsuchservicesundertheHospital

OutpatientProspectivePaymentSystem(OPPS). CMSsMedicareClaimsProcessingManual,

Pub.No.10004,ch.4,290,providesthebillingrequirements. WewillassesswhetherandtowhatextenthospitalsuseofobservationservicesaffectsthecareMedicarebeneficiariesreceive

andtheirabilitytopayoutofpocketexpensesforhealthcareservices.


HospitalInpatientOutlierPaymentsWewillreviewhospitalinpatientoutlierpayments. Medicaretypicallyreimburseshospitalsfor

inpatientservicesbasedonapredeterminedperdischargeamount,regardlessoftheactual

costsincurred. TheSocialSecurityAct,1886(d)(5)(A)(ii),allowsMedicaretopayhospitals

supplemental,oroutlier,paymentsforpatientsincurringextraordinarilyhighcosts. In2009,

outlierpaymentsrepresentedabout5percentoftotalMedicareinpatientpayments,orabout$6billionperyear. Recentwhistleblowerlawsuitshaveresultedinmillionsofdollarsin

settlementsfromhospitalschargedwithinflatingMedicareclaimstoqualifyforoutlier

payments. Wewillexaminetrendsofoutlierpaymentsnationallyandidentifycharacteristics

ofhospitalswithhighorincreasingratesofoutlierpayments.


InpatientRehabilitationFacilityTransmissionofPatientAssessmentInstrumentsWewilldeterminewhetherinpatientrehabilitationfacilities(IRF)receivedreducedpayments

forclaimswithpatientassessmentinstrumentsthatweretransmittedtoCMSsNational

AssessmentCollection

Database

more

than

27

days

after

the

beneficiaries

discharges.

The

patientassessmentinstrumentisusedtogatherdatatodeterminepaymentforeachMedicare

patientadmittedtoanIRF. FederalregulationsforIRFpaymentsat42CFR412.614(d)(2)

providethatifpatientassessmentsarenotencodedandtransmittedwithindefinedtimelimits,

paymentsbereduced. IfanIRFtransmitstheinstrumentmorethan27calendardaysfrom(and

including)thebeneficiarysdischargedate,theIRFspaymentrate shouldbereducedby

25percent.

(OAS;W001035522;variousreviews;expectedissuedate: FY2011;workinprogress)

Home

Health

Agencies

PartBPaymentsforHomeHealthBeneficiariesWewillreviewPartBpaymentsforservicesandmedicalsuppliesprovidedtobeneficiaries

inhomehealthepisodes. MostservicesandnonroutinemedicalsuppliesfurnishedtoMedicare

beneficiariesduringhomehealthepisodesareincludedinthehomehealthagency(HHA)

prospectivepayments. TheSocialSecurityAct,1832(a)(1)and1842(b)(6)(F),requirethatin


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thecaseofhomehealthservicesfurnishedunderaplanofcareofanHHA,paymentforthose

servicesbetotheHHA,includingpaymentforservicesandsuppliesprovidedunder

arrangementsbyoutsidesuppliers. WewillidentifyPartBpaymentstooutsidesuppliersfor

servicesandmedicalsuppliesthatareincludedintheHHAprospectivepaymentandexamine

theadequacyofcontrolsestablishedtopreventinappropriatePartBpaymentsforservicesand

medicalsupplies.(OAS;W000935418;W001035108;W001135418;variousreviews;expectedissuedate: FY

2011;workinprogress)

HomeHealthAgenciesClaimsforMedicareHomeHealthResourceGroupsWewillreviewMedicareclaimssubmittedbyHHAstodeterminetheextenttowhichthe

claimsmeetMedicarecoveragerequirements. Federalregulationsat42CFR409.42provide

thatbeneficiariesreceivinghomehealthservicesmust(1)behomebound;(2)needintermittent

skillednursingcare,physicalorspeechtherapy,oroccupationaltherapy;(3)beunderthecare

ofaphysician;and(4)beunderaplanofcarethathasbeenestablishedandperiodically

reviewedby

aphysician.

The

Social

Security

Act,

1895,

governs

the

payment

basis

and

reimbursementforclaimssubmittedbyHHAs. Onaprospectivebasis,Medicarereimburses

forhomehealthepisodesusingasystemthatcategorizesbeneficiariesintogroupsthatare

basedoncareandresourceneedsandthatarereferredtoasHomeHealthResourceGroups

(HHRGs). HHRGsarecalculatedusingbeneficiaryassessmentdatacollectedbyanHHA,and

eachHHRGhasanassignedweightthataffectsthepaymentrate. Wewillassesstheaccuracy

ofHHRGssubmittedforMedicarehomehealthclaimsin2008andidentifycharacteristicsof

miscodedHHRGs.


Oversight

of

Home

Health

Agency

Outcome

and

Assessment

Information

Set

Data

WewillreviewCMSsoversightofOutcomeandAssessmentInformationSet(OASIS)data

submittedbyMedicarecertifiedHHAs. Federalregulationsat42CFR484.55requireHHAs

toconductaccuratecomprehensivepatientassessmentsthatincludeOASISdataitemsand

submitthedatatoCMS. OASISdatareflectHHAsperformanceinhelpingpatientstoregain

ormaintaintheirabilitytofunctionandperformactivitiesofdailyliving. OASISdataalso

includemeasuresofphysicalstatusanduseofservices,suchashospitalizationoremergent

care. CMShasusedOASISdataforitsHHAPPSsince2000;beganpostingOASISbased

qualityperformanceinformationonitsHomeHealthCompareWebsiteinthefallof2003;and

conductedahomehealthpayforperformancedemonstrationbasedonOASISdataduring2008

and2009. WewillreviewCMSsprocessforensuringthatHHAssubmitaccurateandcomplete

OASISdata.


HomeHealthProspectivePaymentSystemControlsWewillreviewcompliancewithvariousaspectsofthehomehealthPPS,includingbillingsfor

theappropriatelocationoftheservicesprovided. PursuanttotheSocialSecurityAct,1895,


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thehomehealthPPSwasimplementedinOctober2000. Sincethattime,totalpaymentsto

HHAshaveincreasedsubstantiallyfrom$8.5billionin2000to$16.4billionin2008. Wewill

alsoanalyzevarioustrendsinHHAactivities,includingthenumberofclaimssubmittedto

Medicare,thenumberofvisitsprovidedtobeneficiaries,arrangementswithotherfacilities,

andownershipinformation.

(OAS;W

00

11

35501;

various

reviews;

expected

issue

date:

FY

2011;

new

start)

HomeHealthAgencyProfitabilityWewillreviewcostreportdatatoanalyzeHHAprofitabilitytrendsunderthehomehealth

PPStodeterminewhetherthepaymentmethodologyshouldbeadjusted. TheSocialSecurity

Act,1895,addedbytheBalancedBudgetActof1997(BBA),4603,requiresaPPSfor

homehealthservices. SincethePPSwasimplementedinOctober2000,HHAexpenditures

havesignificantlyincreased. Wewillexaminevarioustrends,includingprofitabilitytrendsin

MedicareandtheoverallprofitabilitytrendsforfreestandingandhospitalbasedHHAs.


MedicareHomeHealthAgencyEnrollmentWewillreviewtheprogramintegrityeffortsofCMS,itscontractors,andStateagencies

duringtheHHAenrollmentprocess. Pursuantto42CFRpart424,subpartP,eachHHA

providermustsubmitanaccurateandcompleteenrollmentapplicationtoCMSandadhereto

aseriesofrequirementstoparticipateintheMedicareprogram. PreviousworkbyOIGfound

thatDMEsuppliersomittedorprovidedinaccurateinformationonenrollmentapplications,

whichresultedinimproperenrollment,andthatthesesupplierswereoftenassociatedwith

HHAsthroughsharedownersand/ormanagers. Wewilldeterminewhethertheprogram

integrityeffortsofCMS,itscontractors,andStatesidentifyandpreventtheenrollmentof

questionable

HHA

applicants.


NursingFacilities

MedicarePartAPaymentstoSkilledNursingFacilitiesWewillreviewtheextenttowhichpaymentstoSNFsmeetMedicarecoveragerequirements.

TheSocialSecurityAct,1888(e),establishestheamountpaidtoSNFsforallcoveredservices.

MedicarepaysPartASNFstaysusingasystemthatcategorizeseachbeneficiaryintoagroup

basedoncareandresourceneeds. ThegroupsarereferredtoasResourceUtilizationGroups

(RUGs). Inapriorreport,OIGfoundthat26percentofclaimshadRUGsthatwerenotsupportedbypatientsmedicalrecords. Thepercentagerepresented$542millioninpotential

overpaymentsforFY2002. Wewillconductamedicalreviewtodeterminewhetherclaims

weremedicallynecessary,sufficientlydocumented,andcodedcorrectlyduringcalendaryear

(CY)2009.



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MedicareRequirementsforQualityofCareinSkilledNursingFacilitiesWewillreviewhowSNFshaveaddressedcertainFederalrequirementsrelatedtoquality

ofcare. WewilldeterminetheextenttowhichSNFs(1)developedplansofcarebasedon

assessmentsofbeneficiaries,(2)providedservicestobeneficiariesinaccordancewiththeplans

ofcare,and(3)plannedforbeneficiariesdischarges. PursuanttotheSocialSecurityAct,

1819(b)(3)and1919(b)(3),nursinghomesparticipatingintheMedicareorMedicaidprogramarerequiredtousetheResidentAssessmentInstrument(RAI)toassesseachnursinghome

residentsstrengthsandneeds. PriorOIGreportsrevealedthataboutaquarterofresidents

needsforcare,asidentifiedthroughtheRAI,werenotreflectedincareplansandthatnursing

homeresidentsdidnotreceiveallthepsychosocialservicesidentifiedincareplans. Wewill

alsoreviewSNFsuseoftheRAItodevelopnursinghomeresidentsplansofcare.


AssessmentandMonitoringofNursingHomeResidentsReceivingAtypical

AntipsychoticDrugs

Wewillreviewtheextenttowhichnursingfacilitiescomplywithassessmentandcareplanningrequirementsforresidentsreceivingatypicalantipsychoticdrugs. Federalregulationsat

42CFR483.20requirenursingfacilitiestodevelopresidentcareplansbasedonperiodic

residentassessments. FacilitiesarerequiredtousetheMinimumDataSet(MDS),a

standardizedassessmenttoolthatincludesmeasuresofaresidentshealthandfunctional

status. PreviousOIGstudieshavefoundthatsomeMDSdataitemswereinaccurate. Wewill

alsoexaminetheextenttowhichnursinghomesusedCMSsResidentAssessmentProtocolfor

PsychotropicDrugstodevelopresidentscareplans.


Oversightof

Poorly

Performing

Nursing

Homes

WewillreviewCMSsandStatesuseofenforcementmeasurestodeterminetheirimpacton

improvingthequalityofcarethatbeneficiariesreceivedinpoorlyperformingnursinghomes

andevaluatetheperformanceofthesenursinghomes. TheSocialSecurityAct,1819(g)and

1864,establishedasurveyandcertificationprocess,includinganenforcementprocess,to

ensurethatnursinghomesmeetFederalstandardsforparticipationintheMedicareand

Medicaidprograms. Wewillexamineenforcementdecisionsresultingfromsurveyand

certification(S&C)inspections,andactionstakenbyCMSandStates. Wewillalsodetermine

theextenttowhichCMSandStatesfollowuptoensurethatpoorlyperformingnursinghomes

implementplansofcorrection.


HospitalizationsofNursingHomeResidentsWewillreviewtheextentofhospitalizationsofMedicarebeneficiariesresidinginnursing

homes. HospitalizationsofnursinghomeresidentsarecostlytotheMedicareprogramand

maybeindicativeofqualityofcareproblemsatnursinghomes. A2007OIGstudyfoundthat

35percentofhospitalizationsduringaSNFstaywerecausedbypoorqualityofcareor


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unnecessaryfragmentationofservices. WewillalsoassessCMSsoversightofnursinghomes

whoseresidentshavehighratesofhospitalization.


NursingHomeEmergencyPreparednessandEvacuationsDuringSelected

NaturalDisastersWewillreviewnursinghomesemergencyplansandemergencypreparednessdeficiencies

citedbyStatesurveyorstodeterminethesufficiencyofthenursinghomesplansandtheir

implementationoftheplans. Federalregulationsat42CFR483.75(m),requirethatMedicare

andMedicaidcertifiednursinghomeshaveplansandprocedurestomeetallpotential

emergenciesandtrainallemployeesintheseemergencyprocedures. In2006,OIGreportedthat

nursinghomesincertainGulfStateshadplansthatlackedanumberofprovisionssuggestedby

emergencypreparednessexpertsandthatstaffmembersdidnotalwaysfollowemergency

plans. Wewilldescribetheexperiencesofselectednursinghomes,includingchallenges,

successes,andlessonslearned,whentheyimplementedtheirplansduringrecentdisasters,

suchashurricanes,floods,andwildfires.(OEI;060900270;expectedissuedate: FY2011;workinprogress)

CriminalBackgroundChecksforNursingFacilityEmployeesWewilldeterminewhetherandtheextenttowhichnursingfacilitieshaveemployed

individualswhohavecriminalconvictions. PursuanttotheSocialSecurityAct,1819(b)(2)

and1919(b)(2),nursingfacilitiesparticipatingintheMedicareandMedicaidprogramsare

requiredtoprovideservicesthatmaintainthedignityandwellbeingofallnursinghome

residents. Wewillcategorizethetypesofcrimes,ifanyarefound,forwhichnursingfacilities

employeeshavebeenconvicted. WewillalsoidentifythenumberofStatesrequiringcriminal

backgroundchecks.


ProgramforNationalandStateBackgroundChecksforLongTermCareEmployeesWewillreviewtheprogramofnationalandStatebackgroundchecksforprospectivelongterm

careemployeesmandatedbythePatientProtectionandAffordableCareActof2010

(AffordableCareAct),6201,whichrequirestheSecretaryofHHStoimplementanationwide

programtoidentifyefficient,effective,andeconomicalproceduresforlongtermcarefacilities

orproviderstoconductbackgroundchecksonprospectiveemployeeswhowillhavedirect

patientaccess. TheAffordableCareActrequiresOIGtoevaluatetheprogram,toincludea

reviewoftheproceduresimplementedbyparticipatingStatesforlongtermcarefacilitiesor

providerstoconductbackgroundchecksandanassessmentofthecostsofconductingsuch

backgroundchecks.



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MedicarePartBServicesDuringNonPartANursingHomeStays: 2008OverviewWewillreviewtheextentofPartBservicesprovidedtonursinghomeresidentswhosestays

arenotpaidforunderMedicaresPartASNFbenefit. UnlikePartBservicesprovidedduringa

PartASNFstay,mostofwhichmustbebilledtoMedicaredirectlybytheSNFinaccordance

withconsolidatedbillingrequirements,mostPartBservicesprovidedduringanonPartAstay

maybebilleddirectlybysuppliersandotherproviders. InrepealingconsolidatedbillingprovisionsthatwouldhaveappliedtononPartASNFstays,CongressdirectedOIGinthe

Medicare,Medicaid,andSCHIPBenefitsImprovementandProtectionActof2000(BIPA),313,

tomonitortheseservicesforabuse. WewillalsoassesspatternsofbillingforPartBservices

amongnursinghomesandproviders.


OtherProvidersandSuppliers

HospiceUtilization

in

Nursing

Facilities

WewillreviewMedicarePartAhospiceclaimsanddatafromtheMDStodescribehospice

utilizationinnursingfacilities. Wewillexaminethecharacteristicsofnursingfacilitieswith

highutilizationpatternsofMedicarehospicecareandthecharacteristicsofthehospicesthat

servethem. TheTaxEquityandFiscalResponsibilityActof1982(TEFRA)createdtheMedicare

hospicebenefitforeligiblebeneficiariesunderMedicarePartA. Inarecentreport,OIGfound

that82percentofhospiceclaimsforbeneficiariesinnursingfacilitiesdidnotmeetMedicare

coveragerequirements. MedPAC,whichisanindependentCongressionalagencyestablished

bytheBalancedBudgetActof1997toadviseCongressonissuesaffectingtheMedicare

program,hasnotedthathospicesandnursingfacilitieshaveincentivestoadmitpatientslikely

tohavelongstays. Wewillalsoassessthebusinessrelationshipsbetweennursingfacilitiesand

hospicesandassessthemarketingpracticesandmaterialsofhospicesassociatedwithhigh

utilizationpatterns.


ServicesProvidedtoHospiceBeneficiariesResidinginNursingFacilitiesWewillreviewtheservicesthathospicesandnursingfacilitiesprovidetohospicebeneficiaries

residinginnursingfacilities,includingservicesbyhospicebasedhomehealthaides. Federal

regulationsaddressMedicareCoPsforhospiceat42CFRpart418,andSNFrequirementsat

42CFR483. Wewillreviewhospiceandnursingfacilitymedicalrecords,includingplansof

care. Wewilldeterminetheextenttowhichhospicesandnursingfacilitiescoordinatecareand

identifyserviceandpaymentarrangementsbetweenthem. Wewillalsoassesstheappropriatenessofhospicesgeneralinpatientcareclaims.



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PlaceofServiceErrorsWewillreviewphysiciancodingofplaceofserviceonMedicarePartBclaimsforservices

performedinambulatorysurgicalcenters(ASC)andhospitaloutpatientdepartments. Federal

regulationsat42CFR414.32providefordifferentlevelsofpaymentstophysiciansdepending

onwheretheservicesareperformed. Medicarepaysaphysicianahigheramountwhena

serviceisperformedinanonfacilitysetting,suchasaphysiciansoffice,thanitdoeswhentheserviceisperformedinahospitaloutpatientdepartmentor,withcertainexceptions,inanASC.

Wewilldeterminewhetherphysiciansproperlycodedtheplacesofserviceonclaimsfor

servicesprovidedinASCsandhospitaloutpatientdepartments.


progress)

AmbulatorySurgicalCenterPaymentSystemWewillreviewtheappropriatenessofthemethodologyforsettingASCpaymentrates

undertherevisedASCpaymentsystem. Section626(b)oftheMMArequirestheSecretaryto

implementarevisedpaymentsystemforpaymentofsurgicalservicesfurnishedinASCs. WewillexaminechangestotherevisedASCpaymentsystemandtheratesettingmethodology

usedtocalculateASCpaymentrates.

(OAS;;W001035423;W001135423;variousreviews;expectedissuedate: FY2011;workin

progress)

CodingofEvaluationandManagementServicesWewillreviewevaluationandmanagement(E&M)claimstoidentifytrendsinthecoding

ofE&Mservices. Medicarepaid$25billionforE&Mservicesin2009,representing19percent

ofallMedicarePartBpayments. PursuanttoCMSsMedicareClaimsProcessingManual,

Pub.No.

100

04,

ch.

12,

30.6.1,

providers

are

responsible

for

ensuring

that

the

codes

they

submitaccuratelyreflecttheservicestheyprovide. E&Mcodesrepresentthetype,setting,and

complexityofservicesprovidedandthepatientstatus,suchasneworestablished. Wewill

reviewE&Mclaimstodeterminewhethercodingpatternsvarybyprovidercharacteristics.


PaymentsforEvaluationandManagementServicesWewillreviewtheextentofpotentiallyinappropriatepaymentsforE&Mservicesandthe

consistencyofE&Mmedicalreviewdeterminations. CMSsMedicareClaimsProcessingManual,

Pub.No.10004,ch.12,30.6.1instructsproviderstoselectthecodefortheservicebasedupon

thecontentoftheserviceandsaysthatdocumentationshouldsupportthelevelofservice

reported. Medicarecontractorshavenotedanincreasedfrequencyofmedicalrecordswith

identicaldocumentationacrossservices. WewillalsoreviewmultipleE&Mservicesforthe

sameprovidersandbeneficiariestoidentifyelectronichealthrecords(EHR)documentation

practicesassociatedwithpotentiallyimproperpayments.

(OEI;041000181;041000182;expectedissuedate: FY2012;workinprogress)


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EvaluationandManagementServicesDuringGlobalSurgeryPeriodsWewillreviewindustrypracticesrelatedtothenumberofE&Mservicesprovidedby

physiciansandreimbursedaspartoftheglobalsurgeryfee. CMSsMedicareClaimsProcessing

Manual,Pub.No.10004,ch.12,40,containsthecriteriafortheglobalsurgerypolicy. Under

theglobalsurgeryfeeconcept,physiciansbillasinglefeeforalloftheirservicesthatareusually

associatedwithasurgicalprocedureandrelatedE&Mservicesprovidedduringtheglobalsurgeryperiod. WewilldeterminewhetherindustrypracticesrelatedtothenumberofE&M

servicesprovidedduringtheglobalsurgeryperiodhavechangedsincetheglobalsurgeryfee

conceptwasdevelopedin1992.


MedicarePaymentsforPartBImagingServicesWewillreviewMedicarepaymentsforPartBimagingservices. Physiciansarepaidfor

servicespursuanttotheMedicarephysicianfeeschedule,whichcoversthemajorcategories

ofcosts,includingthephysicianprofessionalcostcomponent,malpracticecosts,andpractice

expense. TheSocialSecurityAct,1848(c)(1)(B),definespracticeexpenseastheportionoftheresourcesusedinfurnishingtheservicethatreflectsthegeneralcategoriesofexpenses,such

asofficerent,wagesofpersonnel,andequipment. Forselectedimagingservices,wewillfocus

onthepracticeexpensecomponents,includingtheequipmentutilizationrate. Wewill

determinewhetherMedicarepaymentsreflecttheexpensesincurredandwhetherthe

utilizationratesreflectindustrypractices.


BillingofPortableXRaySuppliersWewillreviewprovidersofportablexrayserviceswithunusualclaimspatternsandidentify

Medicareclaims

that

are

questionable.

Payment

for

the

services

provided

by

portable

xray

suppliersaregovernedbyFederalregulationsat42CFR486.100through486.110. CMSs

MedicareClaimsProcessingManual,Pub.10004,ch.13,90,saysthatdiagnosticimaging

servicesfurnishedbyportablexraysuppliershaveasmanyasfourcomponents. Inadditionto

payingsuppliersforthetechnicalandprofessionalcomponentsofatest,Medicarepaysthese

suppliersasetupcomponentandtransportationcomponent. Wewillexaminethebilling

patternsofportablexraysupplierstoidentifythosethatmeritadditionalscrutiny.


ServicesPerformedbyClinicalSocialWorkersWewillreviewservicesfurnishedbyclinicalsocialworkers(CSW)toinpatientsof

MedicareparticipatinghospitalsorSNFstodeterminewhethertheserviceswereseparately

billedtoMedicarePartB. Federalregulationsat42CFR410.73(b)(2)describeservices

performedbyCSWsthatmaynotbebilledasCSWservicesunderMedicarePartBwhen

providedtoinpatientsofcertainfacilities. WewillexamineMedicarePartAandPartB

claimswithoverlappingdatesofservicetodeterminewhetherservicesperformedbyCSWs


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ininpatientfacilitieswereseparatelybilledtoMedicarePartB.


PartialHospitalizationProgramServicesWewillreviewtheappropriatenessofMedicarepaymentsforpartialhospitalization

program(PHP)psychiatricservices. TheSocialSecurityAct,1832(a)(2)(J),providesforcoverageofPHPservices,andconditionsforpaymentareinCMSsMedicareClaimsProcessing

Manual,Pub.No.10004,ch.4,260,andat42CFR410.43and424.24(e). APHPisan

intensiveoutpatientprogramofpsychiatricservicesthathospitalsmayprovidetoindividuals

inlieuofinpatientpsychiatriccare. Theprogramistoprovideindividualswhohavemental

healthconditionswithanindividualized,coordinated,comprehensive,andmultidisciplinary

treatmentinvolvingnurses,psychiatrists,psychologists,andsocialworkers. Medicare

spendingforPHPserviceshasincreasedovertheyears. WewilldeterminewhetherMedicare

paymentsforPHPpsychiatricservicesinhospitaloutpatientdepartmentsandfreestanding

communitymentalhealthcentersmetMedicarerequirementsbasedondocumentation

supportingpsychiatric

services,

including

patient

plans

of

care,

and

physician

supervision

and

certificationrequirements.


OutpatientPhysicalTherapyServicesProvidedbyIndependentTherapistsWewillreviewoutpatientphysicaltherapyservicesprovidedbyindependenttherapists

todeterminewhethertheyareincompliancewithMedicarereimbursementregulations.

TheSocialSecurityAct,1862(a)(1)(A),providesthatMedicarewillnotpayforitemsor

servicesthatarenotreasonableandnecessaryforthediagnosisandtreatmentofillnessor

injuryortoimprovethefunctioningofamalformedbodymember. CMSsMedicareBenefit

Policy

Manual,

Pub.

No.

100

02,

ch.

15,

220.3,

contains

documentation

requirements

for

therapyservices. PreviousOIGworkhasidentifiedclaimsfortherapyservicesprovidedby

independentphysicaltherapiststhatwerenotreasonable,medicallynecessary,orproperly

documented. Focusingonindependenttherapistswhohaveahighutilizationratefor

outpatientphysicaltherapyservices,wewilldeterminewhethertheservicesthattheybilled

toMedicarewereinaccordancewithFederalrequirements.


QuestionableBillingforMedicareOutpatientTherapyServicesWewillreviewpaidclaimsdataforMedicareoutpatienttherapyservicesfrom2009and

identifyquestionablebillingpatterns. Wewillidentifycountieswithhighutilizationand

compareutilizationinthesecountiestonationalaverages. Wewillalsodeterminetheextentto

whichbillingcharacteristicsinhighutilizationcounties,includingquestionablecharacteristics

thatmayindicatefraud,differedfrombillingcharacteristicsnationwide..



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AppropriatenessofMedicarePaymentsforPolysomnographyWewillreviewtheappropriatenessofMedicarepaymentsforsleepstudies. Sleepstudies

arereimbursableforpatientswhohavesymptomsconsistentwithsleepapnea,narcolepsy,

impotence,orparasomniainaccordancewiththeCMSMedicareBenefitPolicyManual,

Pub.No.102,ch.15,70. Medicarepaymentsforpolysomnographyincreasedfrom$62million

in2001to$235millionin2009,andcoveragewasalsorecentlyexpanded. WewillalsoexaminethefactorscontributingtotheriseinMedicarepaymentsforsleepstudiesandassessprovider

compliancewithFederalprogramrequirements.


MedicarePaymentsforSleepTestingWewillreviewtheappropriatenessofMedicarepaymentsforsleeptestproceduresprovided

atsleepdisorderclinics. TheSocialSecurityAct,1862(a)(1)(A),providesthatMedicarewill

notpayforitemsorservicesthatarenotreasonableandnecessaryforthediagnosisand

treatmentofillnessorinjuryortoimprovethefunctioningofamalformedbodymember.

CMSsMedicareBenefit

Policy

Manual,Pub.No.10002,ch.15,70,providesCMSs

requirementsforcoverageofsleeptestsunderPartB. ApreliminaryOIGreviewidentified

improperpaymentswhencertainmodifiersarenotreportedwithsleeptestprocedures. We

willexamineMedicarepaymentstophysiciansandindependentdiagnostictestingfacilitiesfor

sleeptestprocedurestodeterminewhethertheywereinaccordancewithMedicare

requirements.


progress)

ExcessivePaymentsforDiagnosticTests

Wewill

review

Medicare

payments

for

high

cost

diagnostic

tests

to

determine

whether

theyweremedicallynecessary. TheSocialSecurityAct,1862(a)(1)(A),providesthatMedicare

willnotpayforitemsorservicesthatarenotreasonableandnecessaryforthediagnosisand

treatmentofillnessorinjuryortoimprovethefunctioningofamalformedbodymember. We

willdeterminetheextenttowhichthesamediagnostictestsareorderedforabeneficiaryby

primarycarephysiciansandphysicianspecialistsforthesametreatment.


LaboratoryTestUnbundlingbyClinicalLaboratoriesWewillreviewtheextenttowhichclinicallaboratorieshaveinappropriatelyunbundled

laboratoryprofileorpanelteststomaximizeMedicarepayments. PursuanttoCMSsMedicare

ClaimsProcessingManual,Pub.No.10004,ch.16,90,toensuretheaccuracyofpayments,

Medicarecontractorsmustgrouptogetherindividuallaboratoryteststhatclinicallaboratories

canperformatthesametimeonthesameequipmentandthenconsiderthepriceofrelated

profiletests. Paymentforindividualtestsmustnotexceedtheloweroftheprofilepriceorthe

totalpriceofalltheindividualtests. Wewilldeterminewhetherclinicallaboratorieshave

unbundledprofileorpaneltestsbysubmittingclaimsformultipledatesofserviceorby


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drawingspecimensonsequentialdays. Wewillalsodeterminetheextenttowhichthe

Medicarecarriershavecontrolsinplacetodetectandpreventinappropriatepaymentsfor

laboratorytests.


MedicarePartBPaymentsforGlycatedHemoglobinA1CTestsWewillreviewMedicarecontractorsproceduresforscreeningthefrequencyofclinical

laboratoryclaimsforglycatedhemoglobinA1Ctests. CMSsMedicareNationalCoverage

DeterminationsManual,Pub.10003,Ch.1,pt.3,190.21,statesthatitisnotconsidered

reasonableandnecessarytoperformaglycatedhemoglobintestmoreoftenthanevery

3monthsonacontrolleddiabeticpatientunlessdocumentationsupportsthemedicalnecessity

oftestinginexcessofnationalcoveragedeterminationsguidelines. PreliminaryOIGworkat

twoMedicarecontractorsshowedvariationsinthecontractorsproceduresforscreeningthe

frequencyofglycatedhemoglobinA1Ctests. Wewilldeterminetheappropriatenessof

MedicarepaymentsforglycatedhemoglobinA1Ctests.

(OAS;W

00

11

35455;

various

reviews;

expected

issue

date:

FY

2011;

new

start)

TrendsinLaboratoryUtilizationWewillreviewtrendsinlaboratoryutilizationundertheMedicareprogram. Pursuantto

42CFR410.32(a),Medicarepaysonlyforlaboratoryteststhatareorderedbyaphysicianor

qualifiednonphysicianpractitionerwhoistreatingabeneficiary. In2008,Medicarepaidabout

$7billionforclinicallaboratoryservices,whichrepresentsa92percentincreasefrom1998.

Muchofthegrowthinlaboratoryspendingwastheresultofincreasedvolumeofordered

services. Wewillexaminethetypesoflaboratorytestsandthenumberoflaboratorytests

ordered. Wewillalsoexaminehowphysicianspecialty,diagnosis,andgeographicdifference

in

the

practice

of

medicine

affect

laboratory

test

ordering.


LabTestPayments: ComparisonofMedicarewithOtherPublicPayersWewillreviewtheextenttowhichMedicarepaymentratesforlaboratorytestsvaryfrom

otherpublicpayers. ExcessivepaymentratesforlaboratorytestscanbecostlyfortheMedicare

program. In2009,Medicarepaidnearly$10billionforlabtests. WewillcompareMedicare

laboratorypaymentratesforthe10mostutilizedlabtestswiththoseofotherpublicpayers,

includingtheDepartmentofVeteransAffairs(VA)andStateMedicaidprograms.


GeographicAreasWithaHighDensityofIndependentDiagnostic

TestingFacilitiesWewillreviewservicesandbillingpatternsingeographicareaswithhighconcentrationsof

independentdiagnostictestingfacilities(IDTF). IDTFsarefacilitiesthatperformdiagnostic

proceduresandareindependentofphysiciansofficesorhospitals. AnIDTFmayhaveafixed

locationorbeamobileentity,andthepractitionerperformingtheproceduresmaybea


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nonphysician. IDTFsmustmeetregulatoryperformancerequirementsat42CFR410.33to

obtainandmaintainMedicarebillingprivileges. A2006OIGreviewfoundnumerousproblems

withIDTFs,includingnoncompliancewithMedicarestandardsandpotentialimproper

paymentsof$71.5million. Wewillalsoexaminebillingpatternsinareaswithahighdensityof

IDTFs.

(OEI;09

09

00380;

expected

issue

date:

FY

2011;

work

in

progress)

IndependentDiagnosticTestingFacilitiesComplianceWithMedicareStandardsWewillreviewselectedIDTFsenrolledinMedicaretodeterminetheextenttowhichthey

complywithselectedMedicarestandards. IDTFsreceivedpaymentsofabout$860millionin

2009. Federalregulationsat42CFR410.33,requireIDTFstocertifyontheirenrollment

applicationsthattheycomplywith17standards. Suchstandardsincluderequirementsthat

IDTFscomplywithalloftheFederalandStatelicensureandregulatoryrequirementsthatare

applicabletothehealthandsafetyofpatients,providecompleteandaccurateinformationon

theirenrollmentapplications,andhaveondutytechnicalstaffmemberswhoholdappropriate

credentialsto

perform

tests.

We

will

also

identify

billing

patterns

associated

with

IDTFs

that

werenotcompliantwithselectedMedicarestandards.


ComprehensiveOutpatientRehabilitationFacilitiesWewillreviewnationalMedicareutilizationpatternsforComprehensiveOutpatient

RehabilitationFacility(CORF)servicesandidentifyCORFsinhighutilizationareas. Medicare

paidabout$61millionfor35,000beneficiarieswhoreceivedCORFservicesin2009. Previous

OIGworkidentifiedCORFservicesthatdidnotmeetMedicarereimbursementstandards

becausetheywerenotmedicallynecessaryorlackeddocumentationthattheywereprovided.

OIGhas

also

raised

concern

about

potentially

inappropriate

rental

arrangements

between

physicianlandlordsandCORFs. Federalregulationsat42CFR485.62,requirethatCORFs

maintainlocationsthatprovidesafeandsufficientspaceforthescopeofallservicesoffered.

WewillconductsitevisitstodeterminewhetherCORFsinhighutilizationareasmeetbasic

Medicarerequirements. Wewillalsoidentifydiffer

oig 2011 work plan

Documents