Medicare Payments for Transitional Care Management
The OIG will determine whether payments for transitional care management services (services provided to a patient whose medical and/or psychosocial problems require moderate or high-complexity medical decision making during transitions in care from an inpatient hospital setting, partial hospital, observation status in a hospital or skilled nursing facility/nursing facility to the patient’s community setting) were in accordance with Medicare requirements.
Prolonged Services & the Reasonableness of the Services
The OIG continues to review Medicare claims for additional care provided to a beneficiary after an evaluation and management service was performed to determine whether Medicare payments to a physician were reasonable and made in accordance with Medicare requirements. Monitoring Medicare Payments for Clinical Diagnostic Laboratory Tests—Mandatory Review of Baseline Data Due to a total of $6.8 billion paid for lab tests, accounting for about 2% of all Part B Medicare payments, the OIG plans to analyze clinical diagnostic laboratory tests performed in 2016–2018 and will monitor the Centers for Medicare & Medicaid Services’ establishment of the new Medicare payment system for the top 25 diagnostictests.
As the healthcare industry continues to shift and modify its care delivery and payment models, the OIG Work Plan is a useful tool for providers to get a preview of HHS’s enforcement priorities for 2019 and beyond. It is important for healthcare organizations and provider offices to review the updates and address any applicable items before the expected OIG issue date. It is imperative to monitor areas of potential risk in the work plan for individual practices to ensure compliance. Providers and their staff should familiarize themselves with the Work Plan and use it to help identify potential risk areas in their organizations; it can be useful in maintaining an effective compliance program and may help prevent government scrutiny.
For More Information
For more information, view the complete 2018–19 OIG Work Plan. For questions or additional information on updating or creating a compliance plan for your organization, contact the ACR compliance professionals at [email protected].
