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Watch patient transfers, same-day discharges
Federal investigators will continue to take a close look at payments for related hospital and skilled nursing stays, according to the Work Plan for Fiscal Year 2000 of the Department of Health and Human Services’ (HHS) Office of Inspector General (OIG) in Washington, DC.
The plan outlines the projects OIG sees as most important in its mission of eliminating fraud, abuse, and waste in federally funded health care programs.
Other areas of emphasis in the Work Plan include same-day discharge and readmission, one-day hospital stays, unnecessary skilled nursing stays after a medically unnecessary hospital stay, and upcoding of specific DRGs.
Every hospital should obtain a copy of the Work Plan and should integrate the issues that are identified in the Work Plan directly into its compliance program, advises Robert Jacoby. Jacoby is director of internal audit and compliance services for Healthcare Practice Enhancement Network (HPEN), a health care management consulting firm based in Los Angeles.
"These are the areas that the OIG is going to emphasize during the next 12 months," he says. "You only have a limited number of resources in any compliance plan. Clearly the items on this Work Plan are the areas that you should emphasize — in terms of auditing and monitoring in particular."
In its Work Plan, the OIG outlines 22 projects relating to hospitals, up from 15 in 1999. Here is what the Work Plan states about those projects:
• One-day hospital stays. The OIG will evaluate the reasonableness of Medicare inpatient hospital payments for beneficiaries discharged after spending one day in a hospital.
• Same-day discharge and readmission to same hospital. The OIG will continue to review Medicare claims for beneficiaries discharged and readmitted the same day to the same acute care prospective payment system (PPS) hospital.
With the help of the Health Care Financing Administration (HCFA) in Baltimore, the OIG will see if these claims were appropriately paid. The OIG will review procedures for these readmissions and determine the effectiveness of existing system edits used to identify and review readmissions.
This review may be expanded to include readmissions within several days and readmissions to another PPS and hospital.
• Payments for related hospital and skilled nursing stays. The OIG will determine the extent of Medicare payments for short- and long-stay hospital and skilled nursing facility care when provided sequentially to the same beneficiary. As part of the review, the OIG will assess HCFA’s instructions for identifying and evaluating consecutive beneficiary stays at different providers, including skilled nursing units and PPS-exempt units.
• Skilled nursing facility coverage after unnecessary hospital stays. The OIG will determine whether Medicare pays for skilled nursing care when the qualifying hospital stay was determined to be not medically necessary.
• PPS transfers. The OIG will continue to support the Department of Justice’s assistance in seeking recovery of Medicare overpayments to PPS hospitals that incorrectly reported transfers. The OIG also plans to issue a report recommending recovery of overpayments from hospitals that are not covered by the Justice Department’s projects.
• PPS transfers between chain members. The OIG will review Medicare Part A controls to prevent improper payment of claims for transfers between chain members. The review will include all transfers and all hospitals of selected chains.
• PPS transfers: administrative recovery. The OIG will work with HCFA and the Medicare fiscal intermediaries to administratively recover overpayments resulting from incorrectly reported PPS transfers. The work will focus on the incorrectly reported transfers declined for investigation.
• PPS transfers during hospital mergers. The OIG will review cases in which patients were transferred from acquired PPS hospitals to acquiring PPS hospitals without leaving hospital beds. The OIG will determine whether Medicare paid the acquired hospital under the PPS transfer policy and the acquiring hospital the full diagnosis-related group (DRG) payment.
• Uncollected beneficiary deductibles and coinsurance. The OIG will evaluate the reasonableness of Medicare payments to inpatient hospital providers that fail to collect deductible and coinsurance amounts from beneficiaries.
• Updating DRG codes. The OIG will evaluate the process by which HCFA updates DRGs.
• Medicare payment for DRG 14. The OIG will analyze reasons for miscoding of DRG 14, specific cerebrovascular disorders, except transient ischemia attack.
• DRG payment limits. The OIG will assess the ability of Medicare contractors to limit payments to hospitals for patients who are discharged from a PPS hospital and admitted to one of several post-acute-care settings.
• Outlier payments for expanded services. The OIG will examine the financial impact of outlier Medicare payments made in unusual cases for inpatient care.
• Changes in inpatient case mix index for Medicare. The OIG will examine trends in the case mix of individual hospitals to determine whether historic increases and the recent decline in case mix occurred uniformly across the country.
The OIG will also identify any DRG that significantly influenced national trends or individual hospital variations.
• DRG payment window. This OIG review will:
— determine whether hospitals have complied with settlement agreements with the OIG to preclude duplicate billing for nonphysician outpatient services under the PPS;
— determine the extent of duplicate claims submitted by Part B providers for services such as ambulance, laboratory, or X-ray, provided to hospital inpatients.
• Hospitals exempt from PPS. The OIG will conduct a series of review of hospitals exempt from the PPS. The OIG will evaluate controls at Medicare fiscal intermediaries to review costs at these facilities, as well as the imposition of cost control measures mandated by the Balanced Budget Act of 1997.
• Outpatient hospital psychiatric claims. The OIG will review outpatient psychiatric services rendered by both acute care and psychiatric hospitals to Medicare beneficiaries. The reviews will determine whether the claims were for services actually provided and whether all Medicare billing and reimbursement requirements were met.
• Outpatient hospital revenue centers without common procedure codes. The OIG will examine outpatient hospital claims that contain revenue centers such as an emergency department with no HCFA common procedure code to describe the service. A review of a sample of 1997 claims indicated that nearly 35% of the revenue centers had no associated codes.
• Billing routine services on a "stat" basis. The OIG will analyze billing practices where there are two levels of billing for the same medical procedure depending on whether the services are ordered on a routine basis or on an immediate or "stat" basis.
• Payments for capital items. The OIG will study the financial impact of the PPS on Medicare reimbursement to hospitals for capital items, such as buildings and equipment.
• Graduate medical education payments. The OIG will evaluate the financial impact of the PPS on Medicare payments for graduate medical educational activities.
• Hospital closures: 1998. The OIG will examine the extent, characteristics, reasons for, and impact of hospital closures in 1998. The is the twelfth in a series of annual reports.
(The 2000 Work Plan can be viewed on the Web at http://www.hhs.gov/progorg/oig/wrkpln/2000/ workpl.pdf)