Mid-Atlantic Health Law TOPICS

The Office of Inspector General of the Department of Health and Human Services (OIG), the agency charged with enforcing Medicare fraud and abuse prohibitions, has recently released its Work Plan for 2000. The Work Plan details those activities that are expected to be the focus of the OIG's attention for the upcoming year. The following is a sampling of such items.

A. Hospitals

• Hospital discharges to other facilities will be examined to determine if "double" payments are being made. In other words, is Medicare paying a second facility to provide services that have already been paid for at the first facility?
• Most hospitals, other than Maryland hospitals, are paid a set amount by Medicare based on each patient's diagnosis. However, some non-Maryland hospitals are exempt from this PPS system, and are still paid pursuant to a cost-based reimbursement system. This year the costs of these exempt facilities will be evaluated by the OIG.
• "Stat" characterizations of services will be reviewed. These characterizations generate higher charges to Medicare.

• The activities of nursing home medical directors will be examined.
• The impact of the new Medicare nursing home PPS system on Medicare beneficiaries' access to nursing facility services will be studied. (A preliminary report issued this year found that only minor impediments to access to services have been occurring.)
• The medical necessity of physical and occupational therapy services provided to nursing facility residents will also be evaluated.

• Compliance with billing rules applicable to physician services provided in teaching hospitals will continue to be reviewed.
• The reassignment of billing rights by physicians will also continue to be an OIG focus.

• The OIG will conduct a six state review of outpatient rehabilitation service providers to monitor compliance with Medicare eligibility and reimbursement requirements.
• A national review of Comprehensive Outpatient Rehabilitation Facilities (CORFs) will also be conducted to determine whether services provided meet eligibility and reimbursement requirements.

• Excess payments for ambulance transports will be a Year 2000 focus.

• The OIG will compare the profitability of Medicare business with the operating results from other lines of HMO business, with an eye toward establishing criteria for the profitability of Medicare risk-based HMOs.

• The effectiveness of intermediaries in regard to identifying and recovering Medicare overpayments will also be assessed.