Medicare Compliance & Reimbursement

The annual HHS Office of Inspector General (OIG) work plan not only gives you a preview of what the agency will be focusing on -- it also reflects broader compliance and payment trends. Below experts identify three take-home messages from the OIG's 2011 plan that can help you get a step ahead of what's coming down the pike.

1. Focus on the interplay between your sector and other providers. For example, "a nursing home that just looks at what the OIG is [targeting] related to nursing homes is missing out," cautions attorney Paula Sanders, with Post & Schell in Harrisburg, Pa.

Case in point: The 2011 OIG work plan includes two continuing hospital reviews that nursing homes should watch out for, Sanders says. These are "hospital admissions with conditions coded as being present on admission (POA) and the early implementation of the Medicare policy for hospital-acquired conditions (never events)." The OIG says it will identify whether specific providers transfer a high number of people with POA diagnoses to hospitals, she observes.

Proactive strategy: Nursing homes and hospitals might check with their state Quality Improvement Organization about participating in initiatives focused on preventing pressure ulcers in patients transitioning between the two care settings. (For a free copy of an article on how one QIO has teamed up the two providers, e-mail the editor at SudeepG@elihealthcare.com with "free article" in the subject line.)

The OIG also has an ongoing focus on services provided to hospice recipients in nursing homes, Sanders points out. Among other things, the OIG is determining the characteristics of nursing facilities that have high hospice utilization -- "and the characteristics of hospices that provide services in nursing homes."

Also: The OIG work plan points out that MedPAC "has noted that hospices and nursing facilities have incentives to admit patients likely to have long stays."

"There's some suspicion that nursing homes may be getting hospice to improve their bottom line -- and that hospice may be passing some services off to the nursing homes," observes attorney Robert Markette Jr., with Gilliland & Markette LLP in Indianapolis, Ind. But the OIG is also looking at "hospice, DME, and pharmacy, due to duplication of claims there," he tells Medicare Compliance & Reimbursement.

Proactive strategies: Hospices should consider auditing their claims for patients in nursing homes, suggests Markette in his Home Care Law Blog. They should look for differences in lengths of stay and number of visits as compared to their home patients, he advises.Hospices should also beware sending aides or nurses to "help out" at the facility, Markette cautions in his blog. "You may all it a professional courtesy [but] OIG will call it a kickback."

2. Keep rehospitalization rates are on your radar screen.

The 2011 OIG work plan says the OIG "will review the extent of hospitalizations of Medicare beneficiaries residing in nursing homes," noting that hospitalizations are costly and may signal quality of care issues.

The work plan also says the OIG will examine how CMS is overseeing nursing facilities whose residents show high rates of hospitalization, Sanders points out. And getting back to the first theme where the OIG is connecting the dots, she says: "Again, we're seeing the data mining between what's going on in the hospitals and its impact on nursing homes" and vice versa. The OIG work plan may be targeting rehospitalization of nursing home residents, but you can bet the government has bigger plans for tackling that issue.

The healthcare reform bill includes several billion dollars in savings tied "to fixing rehospitalization," observes Charles Root, PhD, president of CodeMap in Barrington, Ill. He thus predicts the government will "pay more attention to the flow of patients between different providers," and will either focus on preventing rehospitalization -- or look at how people "transition between the hospital and SNFs and even hospice.

The basic motivation will be to save money. And the OIG will recognize that as an important place to look at, hoping they can find some sort of abuse to tack onto it."

In the payment arena, Markette observes, the OIG's focus on rehospitalization dovetails with the Affordable Care Act (ACA)-mandated Medicare payment bundling pilot, which is slated for implementation by January 2013.

The national pilot integrates services for an episode of care for one or more of eight conditions, which the HHS Secretary will select based on suggested criteria in the reform act. An episode of care encompasses three days before a beneficiary's hospital admission, his inpatient stay, and 30 days following discharge from the hospital, notes the ACA. The bundled services run the gamut from acute and outpatient hospital care to physician services to post-acute care.

Bottom line: Markette predicts that if the government finds the bundling pilot produces any cost savings, "the government will jump on it."

3. Brace for more fraud and abuse scrutiny. The "biggest single element" attorney Steve Kern sees in the 2011 OIG work plan and other government-led compliance developments is that "they are looking to further criminalize healthcare."

As one example, Kern points to the Zone Program Integrity Contractors (ZPICs). "The ZPIC movement appears intended to take actions which have been handled in a civil or administrative context and raise them to a level where the government assumes doctors [and other providers] are acting fraudulently," says Kern, with the Bridgewater, N.J. office of Kern Augustine Conroy & Schoppmann PC. And it "puts the burden on them to prove otherwise."

Ultimate irony: At a time when the nation is already facing a "huge shortage" of doctors, Kern fears the trend toward criminalization could dissuade the "best and brightest" from going into medicine.

(Editor's Note: Read the 2011 OIG work plan at http://oig.hhs.gov/publications/workplan/2011/FY11_WorkPlan-All.pdf.)