Early last fall, the Department of Health and Human Services (HHS) Office of Inspector General (OIG) released its OIG Work Plan for fiscal year 2018–2019, which is a two-year framework for the audits, inspections, evaluations and investigative activities planned in support of its vision, mission, and strategic goals and objectives to maintain HHS program integrity. The OIG continues to look at key areas that affect quality patient care and outcomes, and determined it would be more beneficial to release their projects work on an ongoing basis instead of biannual updates. The OIG considers several factors when creating Work Plan items, including legal mandates, congressional requests, budgetary concerns, as well as the potential for positive impact. The new format will include an ongoing list of active work plan items, which will comprise newly initiated Work Plan items and notifications of completed items.
Key areas of potential risk that rheumatology practices should be aware of include the following:
Financial Impact of Health Risk Assessments & Chart Reviews on Risk Scores in Medicare Advantage
Payments to Medicare Advantage (MA) organizations are risk adjusted, based on beneficiary information, to determine which MA organizations have higher expected costs. Health risk assessments and chart reviews are an integral part of this process. The OIG seeks to determine which diagnoses solely generated by their integral process correlate with high- and low-risk scores and payments.
Identify Patients at Risk of Opioid Misuse
Because opioid abuse and overdose deaths are at crisis levels in the U.S., the OIG is analyzing data from 2013–2016 on opioid overdose trends from the Centers for Disease Control and Prevention to select multiple states for review. They will review the oversight of opioid prescribing and monitoring of opioid use in the selected states, specifically on policies and procedures, data analytics, programs, outreach, and other efforts. To support HHS’s ongoing efforts to identify and disseminate effective practices to address the opioid epidemic in the U.S., the OIG will highlight these statewide efforts throughout 2019.
Critical Care Evaluation & Management Services
For 2019, the OIG will determine whether Medicare payments for critical care are appropriate and are being paid in accordance with Medicare requirements. Payments for chronic care management services (non-face-to-face services provided to Medicare beneficiaries who have multiple significant chronic conditions that place the patient at significant risk of death, acute exacerbation/decompensation or functional decline where the significant chronic conditions are expected to last at least 12 months or until the death of the patient) will be reviewed to verify if they were in accordance with Medicare requirements.
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 firstname.lastname@example.org.