Health Information Management

OIG Work Plan gives insight into areas of focus for compliance

APCs Insider, March 7, 2014

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The Office of the Inspector General (OIG) recently released its 2014 Work Plan, giving providers an idea which CMS policies and regulations the government agency is focusing on for compliance and regulatory review in 2014 and beyond.
Providers can use the Work Plan to identify areas they may want to focus their own compliance and review efforts.
Several of the new initiatives plan to compare the Medicare payments made to different types of facilities, which could result in payment models that are more closely aligned in the future.
One review will compare payments made for physician office visits in provider-based clinics and freestanding clinics for similar procedures. Currently, provider-based clinics receive higher payments for certain services, such as E/M, than freestanding clinics.
The OIG is currently conducting a separate review to determine the impact of provider-based clinics and whether they complied with CMS' criteria.
The Medicare Payment Advisory Commission (MedPAC) said in 2011 that it had "concerns" about the financial incentives for provider-based clinics and recommended Medicare reimburse provider-based clinics at rates similar to freestanding clinics.
The OIG will also review the impact of the 2-midnight rule for determining inpatient status instituted in 2014. CMS introduced the 2-midnight rule after previous OIG reports found "overpayments for short inpatient stays, inconsistent billing practices among hospitals, and financial incentives for billing Medicare inappropriately."
However, the OIG acknowledges the new criteria is a substantial change to the way facilities bill both inpatient and outpatient stays. CMS has already released additional guidance and twice delayed enforcement of the rule due to provider confusion surrounding it.
The OIG will also review claims for new patient E/M clinic visits to determine whether facilities should have reported established patient visits. According to the OIG, "preliminary work identified overpayments that occurred because hospitals used new patient codes when billing for services to established patients."
To read the Work Plan, or for more information about the initiatives planned, visit the OIG's website.

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