Why Executives and Physician Leaders Need To Pay Attention to the 2017 Work Plan

The Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently released its fiscal year (FY) 2017 Work Plan. The OIG outlines new and ongoing reviews of HHS programs and operations in its annual Work Plan.

Hospital executives and physician leaders need to pay attention to this document as the OIG continues their efforts in fighting fraud, abuse, and waste with the expectation of more individual accountability. For example, the Department of Justice (DOJ), on Sept. 27, 2016, reported that Tuomey Healthcare’s former president and CEO will have to personally pay $1 million for his involvement in directing the Tuomey into suspect physician arrangements, which led to a Stark settlement of $72 million. In addition to that, he has also been excluded from participation in any federal programs for four years.

The fact that the OIG adds an issue to the Work Plan generally indicates government concern that there are compliance violations in this area. The Work Plan audit process educates government investigators and attorneys, making it much more likely that the issue will become a focus for government enforcement going forward. Moreover, government investigators are much more likely to infer that compliance violations in areas identified in the Work Plan are willful, i.e., the provider should have known this was a high risk area that had to be carefully handled to insure compliance. As a result, hospital executives and physician leaders should be sure to use the 2017 Work Plan as a guide to their compliance activities for the upcoming year.

Of particular interest in the 2017 Work Plan are several new hospital initiatives that the OIG will undertake. One new initiative is the review of provider reimbursement for hyperbaric oxygen (HBO) therapy services.

Prior OIG reports raised three concerns;

(i) beneficiaries had been treated for non-covered conditions,

(ii) the medical documentation did not adequately support HBO treatments, and

(iii) beneficiaries received medically unnecessary treatments.

Another new hospital initiative focuses on outlier payments to inpatient psychiatric facilities, whether freestanding or specialized hospital-based units. Citing a 28% increase in the number of inpatient psychiatric claims with outlier payments from FY 2014 to FY 2015, the OIG plans to conduct a nationwide review to determine if inpatient psychiatric facilities are complying with Medicare documentation, coverage, and coding requirements for stays with outlier payments.

The 2017 Work Plan also describes a revised review for intensity-modulated radiation therapy (IMRT) that will determine whether Medicare outpatient IMRT payments complied with applicable requirements.

In addition to the OIG’s new initiatives, for the second consecutive year, the agency will review hospitals’ use of outpatient and inpatient stays under Medicare’s controversial two-midnight rule.

The OIG also will continue its nationwide review of cardiac catheterizations, endomyocardial biopsies, and anesthesia services which has been on the OIG’s work plan for several years.

The 2017 Work Plan lists a large number of projects under the category of “Other Providers and Suppliers” which involve physicians and suppliers. The new initiatives in this area include an audit related to transitional care management and another related to chronic care management.

The 2017 OIG Work Plan is available at: https://oig.hhs.gov/reports-and-publications/archives/workplan/2017/HHS%20OIG%20Work%20Plan%202017.pdf.