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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
FiscalYear2011 IntroductoryMessage
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
FiscalYear2011 IntroductoryMessage
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
FiscalYear2011 IntroductoryMessage
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
FiscalYear2011 MedicarePartAandPartB
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
FiscalYear2011 MedicarePartAandPartB
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
FiscalYear2011 MedicarePartAandPartB
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
FiscalYear2011 MedicarePartAandPartB
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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OfficeofInspectorGeneral I2 WorkPlanPartI
FiscalYear2011 MedicarePartAandPartB
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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OfficeofInspectorGeneral I3 WorkPlanPartI
FiscalYear2011 MedicarePartAandPartB
designationcriteriaintheSocialSecurityAct,1820(c)(2)(B),andconditionsofparticipation
(CoP)at42CFRpt.485,subpartF,andwhetherpaymentstoCAHswereinaccordancewith
Medicarerequirements.
(OAS;W001035101;W001135101;variousreviews;expectedissuedate: FY2011;workin
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.
(OAS;W001135451;variousreviews;expectedissuedate: FY2011;newstart)
DuplicateGraduateMedicalEducationPaymentsWewillreviewproviderdatafromCMSsInternandResidentInformationSystem(IRIS)to
determinewhetherduplicategraduatemedicaleducationpaymentshavebeenclaimed.
Medicarepaysteachinghospitalsfordirectgraduatemedicaleducation(DGME)andindirect
medicaleducation(IME)costs. Federalregulationsat42CFR 413.78(b)and412.105(f)(1)(iii)
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OfficeofInspectorGeneral I4 WorkPlanPartI
FiscalYear2011 MedicarePartAandPartB
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.
(OAS;W001135452;variousreviews;expectedissuedate: FY2011;newstart)
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.
(OAS;W001135317;variousreviews;expectedissuedate: FY2011;newstart)
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.
(OAS;W001135438;variousreviews;expectedissuedate: FY2011;newstart)
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OfficeofInspectorGeneral I5 WorkPlanPartI
FiscalYear2011 MedicarePartAandPartB
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.
(OAS;W001035439;W001135439;variousreviews;expectedissuedate: FY2011;workin
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.
(OAS;W001035500;W001135500;variousreviews;expectedissuedate: FY2011;workin
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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OfficeofInspectorGeneral I6 WorkPlanPartI
FiscalYear2011 MedicarePartAandPartB
ResponsestoAdverseEventsinHospitalsbyMedicareOversightEntitiesWewillreviewresponsesofStatesurveyandcertificationagencies,Medicareaccreditors,
andCMStoallegationsofadverseeventsinhospitals. Anadverseeventisdefinedasharm
toapatientasaresultofmedicalcare. VariousMedicareoversightentitieshaveauthorityto
investigateadverseeventsinhospitalstodeterminewhetherthosehospitalshavetaken
correctiveactionsandareincompliancewithMedicarestandards. Wewillidentifyandanalyzepotentialoverlaps,conflicts,andgapsinresponsesandidentifyopportunitiesforMedicare
oversightentitiestoimprovethequalityofoversightandresponsestoadverseevents.
(OEI;010800590;expectedissuedate: FY2011;workinprogress)
HospitalReportingforAdverseEventsWewillreviewthetypeofinformationhospitalsinternalincidentreportingsystemscapture
aboutadverseevents. Mosthospitalshaveincidentreportingsystemsthatenablemedicaland
hospitalstaffmemberstoreportinformationaboutpatientsafetyincidentswhentheyoccurand
tousereportedinformationtopreventrecurrence,holdstaffmembersaccountable,andnotify
families. Usingdatacollectedfora2010OIGstudyexaminingthenationalincidenceofadverseeventsamonghospitalizedMedicarebeneficiaries,wewilldeterminetheextenttowhich
hospitalsystemscapturedadverseeventsandreportedtheinformationtoexternalpatient
safetyoversightentities.
(OEI;060900091;expectedissuedate: FY2011;workinprogress)
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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OfficeofInspectorGeneral I7 WorkPlanPartI
FiscalYear2011 MedicarePartAandPartB
(OAS;W001035520;W001135520;variousreviews;expectedissuedate: FY2011;workin
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.
(OEI;070900450;expectedissuedate: FY2011;workinprogress)
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.
(OEI;000000000;expectedissuedate: FY2012;newstart)
MedicareInpatientandOutpatientHospitalClaimsfortheReplacementofMedical
DevicesWewilldeterminewhetherhospitalssubmittedinpatientandoutpatientclaimsthatincluded
proceduresfortheinsertionofreplacementmedicaldevicesincompliancewithMedicare
regulations. TheSocialSecurityAct,1862(a)(2),excludesfromMedicarecoverageanitemora
serviceforwhichneitherthebeneficiarynoranyoneonhisorherbehalfhasanobligationto
pay. Medicareisnotresponsibleforthefullcostofthereplacedmedicaldeviceifthehospital
receivesapartialorfullcreditfromthemanufacturereitherbecausethemanufacturerrecalled
thedeviceorbecausethedeviceiscoveredunderwarranty. Hospitalsarerequiredtouse
modifiersontheirinpatientandoutpatientclaimswhentheyreceivecreditfromthe
manufacturerof50percentormoreforareplacementdevice.
(OAS;W001035516;W001135516;variousreviews;expectedissuedate: FY2011;workin
progress)
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OfficeofInspectorGeneral I8 WorkPlanPartI
FiscalYear2011 MedicarePartAandPartB
ObservationServicesDuringOutpatientVisitsWewillreviewMedicarepaymentsforobservationservicesprovidedduringoutpatient
visitsinhospitals. TheSocialSecurityAct,1832(a)and1833(t),providesforPartBcoverage
ofhospitaloutpatientservicesandreimbursementforsuchservicesundertheHospital
OutpatientProspectivePaymentSystem(OPPS). CMSsMedicareClaimsProcessingManual,
Pub.No.10004,ch.4,290,providesthebillingrequirements. WewillassesswhetherandtowhatextenthospitalsuseofobservationservicesaffectsthecareMedicarebeneficiariesreceive
andtheirabilitytopayoutofpocketexpensesforhealthcareservices.
(OEI;000000000;expectedissuedate: FY2012;newstart)
HospitalInpatientOutlierPaymentsWewillreviewhospitalinpatientoutlierpayments. Medicaretypicallyreimburseshospitalsfor
inpatientservicesbasedonapredeterminedperdischargeamount,regardlessoftheactual
costsincurred. TheSocialSecurityAct,1886(d)(5)(A)(ii),allowsMedicaretopayhospitals
supplemental,oroutlier,paymentsforpatientsincurringextraordinarilyhighcosts. In2009,
outlierpaymentsrepresentedabout5percentoftotalMedicareinpatientpayments,orabout$6billionperyear. Recentwhistleblowerlawsuitshaveresultedinmillionsofdollarsin
settlementsfromhospitalschargedwithinflatingMedicareclaimstoqualifyforoutlier
payments. Wewillexaminetrendsofoutlierpaymentsnationallyandidentifycharacteristics
ofhospitalswithhighorincreasingratesofoutlierpayments.
(OEI;061000520;expectedissuedate: FY2011;workinprogress)
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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OfficeofInspectorGeneral I9 WorkPlanPartI
FiscalYear2011 MedicarePartAandPartB
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.
(OEI;010800390;expectedissuedate: FY2011;workinprogress)
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.
(OEI;011000460;expectedissuedate: FY2011;workinprogress)
HomeHealthProspectivePaymentSystemControlsWewillreviewcompliancewithvariousaspectsofthehomehealthPPS,includingbillingsfor
theappropriatelocationoftheservicesprovided. PursuanttotheSocialSecurityAct,1895,
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OfficeofInspectorGeneral I10 WorkPlanPartI
FiscalYear2011 MedicarePartAandPartB
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.
(OAS;W001035428;variousreviews;expectedissuedate: FY2011;workinprogress)
MedicareHomeHealthAgencyEnrollmentWewillreviewtheprogramintegrityeffortsofCMS,itscontractors,andStateagencies
duringtheHHAenrollmentprocess. Pursuantto42CFRpart424,subpartP,eachHHA
providermustsubmitanaccurateandcompleteenrollmentapplicationtoCMSandadhereto
aseriesofrequirementstoparticipateintheMedicareprogram. PreviousworkbyOIGfound
thatDMEsuppliersomittedorprovidedinaccurateinformationonenrollmentapplications,
whichresultedinimproperenrollment,andthatthesesupplierswereoftenassociatedwith
HHAsthroughsharedownersand/ormanagers. Wewilldeterminewhethertheprogram
integrityeffortsofCMS,itscontractors,andStatesidentifyandpreventtheenrollmentof
questionable
HHA
applicants.
(OEI;061000400;expectedissuedate: FY2011;workinprogress)
NursingFacilities
MedicarePartAPaymentstoSkilledNursingFacilitiesWewillreviewtheextenttowhichpaymentstoSNFsmeetMedicarecoveragerequirements.
TheSocialSecurityAct,1888(e),establishestheamountpaidtoSNFsforallcoveredservices.
MedicarepaysPartASNFstaysusingasystemthatcategorizeseachbeneficiaryintoagroup
basedoncareandresourceneeds. ThegroupsarereferredtoasResourceUtilizationGroups
(RUGs). Inapriorreport,OIGfoundthat26percentofclaimshadRUGsthatwerenotsupportedbypatientsmedicalrecords. Thepercentagerepresented$542millioninpotential
overpaymentsforFY2002. Wewillconductamedicalreviewtodeterminewhetherclaims
weremedicallynecessary,sufficientlydocumented,andcodedcorrectlyduringcalendaryear
(CY)2009.
(OEI;020900200;expectedissuedate: FY2012;workinprogress)
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OfficeofInspectorGeneral I11 WorkPlanPartI
FiscalYear2011 MedicarePartAandPartB
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.
(OEI;020900201;expectedissuedate: FY2012;workinprogress)
AssessmentandMonitoringofNursingHomeResidentsReceivingAtypical
AntipsychoticDrugs
Wewillreviewtheextenttowhichnursingfacilitiescomplywithassessmentandcareplanningrequirementsforresidentsreceivingatypicalantipsychoticdrugs. Federalregulationsat
42CFR483.20requirenursingfacilitiestodevelopresidentcareplansbasedonperiodic
residentassessments. FacilitiesarerequiredtousetheMinimumDataSet(MDS),a
standardizedassessmenttoolthatincludesmeasuresofaresidentshealthandfunctional
status. PreviousOIGstudieshavefoundthatsomeMDSdataitemswereinaccurate. Wewill
alsoexaminetheextenttowhichnursinghomesusedCMSsResidentAssessmentProtocolfor
PsychotropicDrugstodevelopresidentscareplans.
(OEI;070800151;expectedissuedate: FY2011;workinprogress)
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.
(OEI;000000000;expectedissuedate: FY2012;newstart)
HospitalizationsofNursingHomeResidentsWewillreviewtheextentofhospitalizationsofMedicarebeneficiariesresidinginnursing
homes. HospitalizationsofnursinghomeresidentsarecostlytotheMedicareprogramand
maybeindicativeofqualityofcareproblemsatnursinghomes. A2007OIGstudyfoundthat
35percentofhospitalizationsduringaSNFstaywerecausedbypoorqualityofcareor
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OfficeofInspectorGeneral I12 WorkPlanPartI
FiscalYear2011 MedicarePartAandPartB
unnecessaryfragmentationofservices. WewillalsoassessCMSsoversightofnursinghomes
whoseresidentshavehighratesofhospitalization.
(OEI;000000000;expectedissuedate: FY2011;newstart)
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.
(OEI;070900110;expectedissuedate: FY2011;workinprogress)
ProgramforNationalandStateBackgroundChecksforLongTermCareEmployeesWewillreviewtheprogramofnationalandStatebackgroundchecksforprospectivelongterm
careemployeesmandatedbythePatientProtectionandAffordableCareActof2010
(AffordableCareAct),6201,whichrequirestheSecretaryofHHStoimplementanationwide
programtoidentifyefficient,effective,andeconomicalproceduresforlongtermcarefacilities
orproviderstoconductbackgroundchecksonprospectiveemployeeswhowillhavedirect
patientaccess. TheAffordableCareActrequiresOIGtoevaluatetheprogram,toincludea
reviewoftheproceduresimplementedbyparticipatingStatesforlongtermcarefacilitiesor
providerstoconductbackgroundchecksandanassessmentofthecostsofconductingsuch
backgroundchecks.
(OEI;071000420;expectedissuedate: FY2012;workinprogress)
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OfficeofInspectorGeneral I13 WorkPlanPartI
FiscalYear2011 MedicarePartAandPartB
MedicarePartBServicesDuringNonPartANursingHomeStays: 2008OverviewWewillreviewtheextentofPartBservicesprovidedtonursinghomeresidentswhosestays
arenotpaidforunderMedicaresPartASNFbenefit. UnlikePartBservicesprovidedduringa
PartASNFstay,mostofwhichmustbebilledtoMedicaredirectlybytheSNFinaccordance
withconsolidatedbillingrequirements,mostPartBservicesprovidedduringanonPartAstay
maybebilleddirectlybysuppliersandotherproviders. InrepealingconsolidatedbillingprovisionsthatwouldhaveappliedtononPartASNFstays,CongressdirectedOIGinthe
Medicare,Medicaid,andSCHIPBenefitsImprovementandProtectionActof2000(BIPA),313,
tomonitortheseservicesforabuse. WewillalsoassesspatternsofbillingforPartBservices
amongnursinghomesandproviders.
(OEI;060700580;expectedissuedate: FY2011;workinprogress)
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.
(OEI;021000070;expectedissuedate: FY2011;workinprogress)
ServicesProvidedtoHospiceBeneficiariesResidinginNursingFacilitiesWewillreviewtheservicesthathospicesandnursingfacilitiesprovidetohospicebeneficiaries
residinginnursingfacilities,includingservicesbyhospicebasedhomehealthaides. Federal
regulationsaddressMedicareCoPsforhospiceat42CFRpart418,andSNFrequirementsat
42CFR483. Wewillreviewhospiceandnursingfacilitymedicalrecords,includingplansof
care. Wewilldeterminetheextenttowhichhospicesandnursingfacilitiescoordinatecareand
identifyserviceandpaymentarrangementsbetweenthem. Wewillalsoassesstheappropriatenessofhospicesgeneralinpatientcareclaims.
(OEI;021000490;expectedissuedate: FY2012;workinprogress)
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OfficeofInspectorGeneral I14 WorkPlanPartI
FiscalYear2011 MedicarePartAandPartB
PlaceofServiceErrorsWewillreviewphysiciancodingofplaceofserviceonMedicarePartBclaimsforservices
performedinambulatorysurgicalcenters(ASC)andhospitaloutpatientdepartments. Federal
regulationsat42CFR414.32providefordifferentlevelsofpaymentstophysiciansdepending
onwheretheservicesareperformed. Medicarepaysaphysicianahigheramountwhena
serviceisperformedinanonfacilitysetting,suchasaphysiciansoffice,thanitdoeswhentheserviceisperformedinahospitaloutpatientdepartmentor,withcertainexceptions,inanASC.
Wewilldeterminewhetherphysiciansproperlycodedtheplacesofserviceonclaimsfor
servicesprovidedinASCsandhospitaloutpatientdepartments.
(OAS;W000935113;W001035113;variousreviews;expectedissuedate: FY2011;workin
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.
(OEI;041000180;expectedissuedate: FY2011;workinprogress)
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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OfficeofInspectorGeneral I15 WorkPlanPartI
FiscalYear2011 MedicarePartAandPartB
EvaluationandManagementServicesDuringGlobalSurgeryPeriodsWewillreviewindustrypracticesrelatedtothenumberofE&Mservicesprovidedby
physiciansandreimbursedaspartoftheglobalsurgeryfee. CMSsMedicareClaimsProcessing
Manual,Pub.No.10004,ch.12,40,containsthecriteriafortheglobalsurgerypolicy. Under
theglobalsurgeryfeeconcept,physiciansbillasinglefeeforalloftheirservicesthatareusually
associatedwithasurgicalprocedureandrelatedE&Mservicesprovidedduringtheglobalsurgeryperiod. WewilldeterminewhetherindustrypracticesrelatedtothenumberofE&M
servicesprovidedduringtheglobalsurgeryperiodhavechangedsincetheglobalsurgeryfee
conceptwasdevelopedin1992.
(OAS;W000935207;variousreviews;expectedissuedate: FY2011;workinprogress)
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.
(OAS;W001135219;variousreviews;expectedissuedate: FY2011;newstart)
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.
(OEI;121000190;expectedissuedate: FY2011;workinprogress)
ServicesPerformedbyClinicalSocialWorkersWewillreviewservicesfurnishedbyclinicalsocialworkers(CSW)toinpatientsof
MedicareparticipatinghospitalsorSNFstodeterminewhethertheserviceswereseparately
billedtoMedicarePartB. Federalregulationsat42CFR410.73(b)(2)describeservices
performedbyCSWsthatmaynotbebilledasCSWservicesunderMedicarePartBwhen
providedtoinpatientsofcertainfacilities. WewillexamineMedicarePartAandPartB
claimswithoverlappingdatesofservicetodeterminewhetherservicesperformedbyCSWs
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OfficeofInspectorGeneral I16 WorkPlanPartI
FiscalYear2011 MedicarePartAandPartB
ininpatientfacilitieswereseparatelybilledtoMedicarePartB.
(OAS;W001135405;variousreviews;expectedissuedate: FY2011;newstart)
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.
(OAS;W001135453;variousreviews;expectedissuedate: FY2011;newstart)
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.
(OAS;W001135220;variousreviews;expectedissuedate: FY2011;newstart)
QuestionableBillingforMedicareOutpatientTherapyServicesWewillreviewpaidclaimsdataforMedicareoutpatienttherapyservicesfrom2009and
identifyquestionablebillingpatterns. Wewillidentifycountieswithhighutilizationand
compareutilizationinthesecountiestonationalaverages. Wewillalsodeterminetheextentto
whichbillingcharacteristicsinhighutilizationcounties,includingquestionablecharacteristics
thatmayindicatefraud,differedfrombillingcharacteristicsnationwide..
(OEI;040900540;expectedissuedate: FY2011;workinprogress)
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OfficeofInspectorGeneral I17 WorkPlanPartI
FiscalYear2011 MedicarePartAandPartB
AppropriatenessofMedicarePaymentsforPolysomnographyWewillreviewtheappropriatenessofMedicarepaymentsforsleepstudies. Sleepstudies
arereimbursableforpatientswhohavesymptomsconsistentwithsleepapnea,narcolepsy,
impotence,orparasomniainaccordancewiththeCMSMedicareBenefitPolicyManual,
Pub.No.102,ch.15,70. Medicarepaymentsforpolysomnographyincreasedfrom$62million
in2001to$235millionin2009,andcoveragewasalsorecentlyexpanded. WewillalsoexaminethefactorscontributingtotheriseinMedicarepaymentsforsleepstudiesandassessprovider
compliancewithFederalprogramrequirements.
(OEI;000000000;expectedissuedate: FY2012;newstart)
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.
(OAS;W001035521;W001135521;variousreviews;expectedissuedate: FY2011;workin
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.
(OAS;W001135454;variousreviews;expectedissuedate: FY2011;newstart)
LaboratoryTestUnbundlingbyClinicalLaboratoriesWewillreviewtheextenttowhichclinicallaboratorieshaveinappropriatelyunbundled
laboratoryprofileorpanelteststomaximizeMedicarepayments. PursuanttoCMSsMedicare
ClaimsProcessingManual,Pub.No.10004,ch.16,90,toensuretheaccuracyofpayments,
Medicarecontractorsmustgrouptogetherindividuallaboratoryteststhatclinicallaboratories
canperformatthesametimeonthesameequipmentandthenconsiderthepriceofrelated
profiletests. Paymentforindividualtestsmustnotexceedtheloweroftheprofilepriceorthe
totalpriceofalltheindividualtests. Wewilldeterminewhetherclinicallaboratorieshave
unbundledprofileorpaneltestsbysubmittingclaimsformultipledatesofserviceorby
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OfficeofInspectorGeneral I18 WorkPlanPartI
FiscalYear2011 MedicarePartAandPartB
drawingspecimensonsequentialdays. Wewillalsodeterminetheextenttowhichthe
Medicarecarriershavecontrolsinplacetodetectandpreventinappropriatepaymentsfor
laboratorytests.
(OAS;W001135222;variousreviews;expectedissuedate: FY2011;newstart)
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.
(OEI;000000000;expectedissuedate: FY2011;newstart)
LabTestPayments: ComparisonofMedicarewithOtherPublicPayersWewillreviewtheextenttowhichMedicarepaymentratesforlaboratorytestsvaryfrom
otherpublicpayers. ExcessivepaymentratesforlaboratorytestscanbecostlyfortheMedicare
program. In2009,Medicarepaidnearly$10billionforlabtests. WewillcompareMedicare
laboratorypaymentratesforthe10mostutilizedlabtestswiththoseofotherpublicpayers,
includingtheDepartmentofVeteransAffairs(VA)andStateMedicaidprograms.
(OEI;000000000;expectedissuedate: FY2012;newstart)
GeographicAreasWithaHighDensityofIndependentDiagnostic
TestingFacilitiesWewillreviewservicesandbillingpatternsingeographicareaswithhighconcentrationsof
independentdiagnostictestingfacilities(IDTF). IDTFsarefacilitiesthatperformdiagnostic
proceduresandareindependentofphysiciansofficesorhospitals. AnIDTFmayhaveafixed
locationorbeamobileentity,andthepractitionerperformingtheproceduresmaybea
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OfficeofInspectorGeneral I19 WorkPlanPartI
FiscalYear2011 MedicarePartAandPartB
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.
(OEI;050900560;expectedissuedate: FY2011;workinprogress)
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