OIG January 2019 Work Plan Update

PUBLISHED: Jan 16, 2019
Relevant to: All Healthcare Organizations

The Office of the Inspector General (OIG) recently released updates to their Work Plan. As StayAlert! has previously reported, in 2017 OIG transitioned from a yearly to a monthly update. OIG hopes that a monthly update will enhance transparency around OIG's continuous work planning efforts.

For January 2019, OIG has posted the following Work Plan activities of interest to healthcare organizations:

Medicare Payments for Clinical Diagnostic Laboratory Tests in 2018: Year 1 of New Payment Rates:

  • The Protecting Access to Medicare Act of 2014 (PAMA) requires CMS to set payment rates for lab tests using current charges in the private health-care market, under Title XVIII of the Social Security Act. On January 1, 2018, CMS began paying for lab tests under the new system mandated by PAMA. PAMA requires OIG to publicly release an annual analysis of the top 25 laboratory tests by expenditures. OIG will publicly release an analysis of the top 25 laboratory tests by expenditures for 2018, the first year of payments made under the new system for setting payment rates.

States' Compliance with New Requirements to Prevent Medicaid Payments to Terminated Providers:

  • To prevent terminated providers from treating Medicaid enrollees or receiving Medicaid payments, the 21st Century Cures Act (Cures Act) requires CMS to provide information to all States on Medicaid providers that have been terminated for cause. OIG will examine the extent to which terminated providers included in CMS's terminations database have been terminated from all State Medicaid programs and the amount of Medicaid payments for items/services associated with terminated providers.

Medicare Outpatient Outlier Payments for Claims with Credits for Replaced Medical Devices:

  • CMS requires hospitals to submit a zero or token charge when they receive a full credit for a replacement device, but CMS does not specify how charges should be reduced for partial credits. CMS makes an additional payment (an outpatient outlier payment) for hospital outpatient services when a hospital's charges, adjusted to cost, exceed a fixed multiple of the normal Medicare payment. Prior OIG reviews focused on finding unreported credits for medical devices and recommended that CMS recoup Medicare funds for the overstated ambulatory payment classification payment only. This audit focuses on overstated Medicare charges on outpatient claims that contain both an outlier payment and a reported medical device credit. OIG will determine whether Medicare payments for replaced medical devices and their respective outlier payments were made in accordance with Medicare requirements.

Duplicate Payments for Home Health Services Covered Under Medicare and Medicaid:

  • Medicare Home Health Agency (HHA) coverage requirements state that an HHA is responsible for providing all services either directly or under arrangement while a beneficiary is under a home health plan of care authorized by a physician. Consequently, Medicare pays a single HHA overseeing that plan. "Dual eligible beneficiaries" generally describes beneficiaries eligible for both Medicare and Medicaid. Medicare pays covered medical services first for dual eligible beneficiaries because Medicaid is generally the payer of last resort. OIG will determine whether States made Medicaid payments for home health services for dual eligible beneficiaries who are also covered under Medicare.

The OIG Work Plan is a great tool for compliance departments because it provides insight into areas where government enforcement and audit officials are focusing. For more information follow the link below.

Want to read the full alert and receive alert emails?

Browse Additional Alerts