The U.S. Department of Health and Human Services’ Office of Inspector General (OIG) recently released its Work Plan for Fiscal Year 2013. Annually, OIG releases the plan to identify the projects it intends to undertake and the issues it intends to address in the upcoming year.
In 2013, OIG will review Medicare’s transfer policy to determine whether certain claims were appropriately paid. Specifically, it will investigate payments to hospitals for discharges that should have been submitted as transfers. Similarly, OIG will review claims to determine trends in the number of same-day readmissions. A hospital is entitled to receive only one payment if a same-day readmission occurs for symptoms related to the prior stay’s medical condition. This rule, however, can be overridden in certain situations. OIG plans to test the effectiveness of the override.
OIG also plans to analyze hospital claims data to determine if CMS could save money by expanding the current Diagnosis Related Group (“DRG”) window from three days to 14 days. Currently, Medicare bundles all outpatient services delivered three days prior to an inpatient admission into the one inpatient payment (the DRG window). Medicare does not pay separately for preadmission services when they are delivered by the admitting hospital. OIG has identified improper payments during the DRG window and will investigate what savings could be realized by expanding the window to 14 days.
Other Work Plan highlights include:
Provider Self-Disclosure Protocol: The protocol guides providers in the process of disclosing potential violations of the anti-kickback law. OIG published a Solicitation for Information and Recommendations for revising the protocol in 2012. In 2013, it plans to consider the comments and publish a revised protocol in FY 2013.
Corporate Integrity Agreements: OIG will examine providers that settle fraud cases with CMS but decline to enter a Corporate Integrity Agreement with OIG.
Canceled Surgical Procedures: OIG will review the costs to Medicare associated with inpatient claims for canceled surgical procedures.
Ambulatory Surgical Center Acquisitions: OIG will determine the extent to which hospitals acquire ASCs and convert them to hospital outpatient departments. OIG plans to ascertain the effect this has on Medicare payments and beneficiary cost-sharing.
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