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Audit Priorities and Risk Areas identified in the 2015 OIG Work Plan

On October 31, 2014 the United Stated Department of Health and Human Services (HHS) Office of Inspector General (OIG) released its Fiscal Year 2015 Work Plan. The Work Plan is released annually to identify new and ongoing investigative, enforcement and compliance activities the OIG will undertake during that fiscal year.

Here™s a closer look at the plan regarding the determination of audit priorities and identifying risk areas the OIG has stated they will focus on during the 2015 fiscal year.

What™s in the work plan?

In the 2015 Work Plan, the OIG identifies two new focus areas for hospitals and continues to focus on areas that were identified in the 2014 work plan. For hospitals, the two new areas of focus relate to the review of hospital wage data and adverse events in long-term care hospitals. For non-hospital provider/supplier types, the work plan includes one new area of focus " billing by independent clinical laboratories, while remaining focused of areas that were identified in the 2014 Work Plan and previous annual Work Plans. Additionally, the 2015 Work Plan includes efforts such as reviews for Medicare Part D, Medicaid, and the Affordable Care Act (ACA).

For Hospitals

The 2015 OIG Work Plan adds two new compliance risk areas and examines other areas previously identified in the 2014 Work Plan. The new compliance risk areas include the following:

  • Review of Hospital Wage Data " OIG will review hospital controls over the reporting of wage data used to calculate wage indexes for Medicare payments. Prior OIG work in this area identified hundreds of millions of dollars in incorrectly reported wage data, resulting in policy changes by the Centers for Medicare & Medicaid Services (CMS) with regard to how hospitals report deferred compensation costs. Hospitals must accurately report wage data to CMS annually to develop wage index rates.
  • Adverse Events in Long-Term care Hospitals " OIG will examine the national incidence of adverse and temporary harm events for Medicare beneficiaries receiving care in a long-term care hospital. OIG will identify factors contributing to these events, determine the extent to which the events were preventable and estimate the associated costs to Medicare.

Some of the other areas previously identified in 2014 to be aware of include, but are not limited to:

  • Outpatient Dental Claims
  • Reconciliations of Outlier Payments
  • Medicare Oversight of Provider Based Status
  • Review of Selected Inpatient and Outpatient Billing Requirements
  • Hospital Participation in Projects with Quality Improvement Organizations
  • Inpatient Rehabilitation Facilities " Adverse Events in Post-Acute Care for Medicare Beneficiaries

For Providers/Suppliers

The 2015 Work Plan adds priorities for other types of Medicare providers and suppliers.  OIG identified one new focus area in the 2015 Work Plan:

  • Selected Independent Clinical Laboratory Billing Requirements " OIG will review Medicare payments to independent clinical laboratories to determine laboratories™ compliance with selected billing requirements. The results of the reviews will be used to identify clinical laboratories that routinely submit improper claims.  OIG will recommend recovery of overpayments, as appropriate. Prior OIG audits, investigations and inspections have identified independent clinical laboratory areas at risk for noncompliance with Medicare billing requirements. Payments to service providers are precluded unless the provider has, and furnishes upon request, the information necessary to determine the amounts due.

OIG will continue to examine several other provider and supplier compliance risk areas identified in previous years™ Work Plan, including, but not limited to:

  • Physicians " Place-of-Service Coding Errors
  • Physical Therapists " High Use of Outpatient Physical Therapy Services
  • Medicare Part A Billing by Skilled Nursing Facilities
  • Questionable Billing Patterns for Part B Services During Nursing Home Stays
  • Diagnostic Radiology " Medical Necessity of High-Cost Tests
  • Anesthesia Services " Payments for Personally Performed Services

In addition, the 2015 Work Plan states that the OIG is committed to initiating at least five to ten additional reviews addressing ACA programs, which would focus on emerging marketplace issues, Medicaid expansion, new Medicare payment and delivery models or new grant programs.

Conclusion

While this is not an all-inclusive list of everything the Work Plan will focus on, we feel these are important and applicable areas identified in the 2015 Work Plan and in previously submitted Work Plans that determine audit priorities and identify risk areas the OIG will focus on. The Work Plan is a good way to determine what OIG™s new and ongoing investigative, enforcement and compliance activities will include during the coming fiscal year.

If you have any questions about the 2015 OIG Work Plan, or any other compliance related questions, please do not hesitate to contact one of our professional consultants.

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